Kasturi - Head Injury CASE

8/12/2019 Kasturi - Head Injury CASE

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MANAGEMENT OF HEADINJURIES AND

PREVENTION OF

SECONDARY BRAIN

DR KASTU

DR ABDU

ABDUL G


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INTRODUCTION

Management of traumatic brain injury focuses on stabilisation of the pprevention of secondary neuronal injury to avoid further loss of neurons

Full neuromonitoring including intracranial pressure measurement areavailable prior to the patients arrival in the intensive care unit.

Significant neurological damage can occur between the time of injury ascanning, accurate measurement of ICP and other parameters.

The acute management of these patients is therefore directed towardsthere is significant intracranial pathology and instituting measures to probrain tissue.


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PATHOPHYSIOLOGICALDISTURBANCE

Head injury can involve the scalp, cranium and/or underlying brain.

Scalp injuries include lacerations, contusions and abrasions, dependinmechanism of injury.

Fractures of the skull can involve the vault or base, be simple or compdepressed or planar. Brain injury can result from the original impact (pri

can result from the development of secondary complications.

Primary brain injury can be focal (i.e. intra-cranial haematoma, contusdiffuse (diffuse axonal injury).


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Diffuse axonal injury occurs as a result of mechanical shearing following decelera

disruption and tearing of axons.Intra-cranial haematomas can be extradural, subdural or intracerebral, while contuoccur adjacent to (coup) or contralateral (contre-coup) to the side of impact.

Secondary brain injury occurs when cerebral oedema, ischaemia, infection, tonsilherniation exacerbates the original injury.

The normal autoregulation of cerebral blood flow is lost in a head injury making anmore susceptible to hypo- or hypervolaemia and hypoxia.

The classical Cushings Reflex is a late event, and often immediately pre-mortem(physiological nervous system response to increased ICP that results in Cushings

a) Increased BP

b) Irregular breathing

c) Reduction of heart rate

- Seen in terminal stages of acute head injury and may indicate imminent brain hern


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CLINICAL ASSESSMENT

Assessment of the head-injured patient begins with the Advanced TraSupport (ATLS) protocol of ensuring patency of the airway with cervicalcontrol whilst maintaining good oxygenation and tissue perfusion.

This aims to prevent the development of secondary brain injury. Of vitaimportance is the need to treat the casualty as if there is an unstable ceinjury before attempting endotracheal intubation, if required.

Between 5 and 10% of head injuries have an associated cervical spineSuch an injury can be excluded in almost all cases with a combination ocomputerised tomography (CT), magnetic resonance imaging (MRI) or extension radiography of the neck, should clinical suspicion indicate it.

Once the clinician is satisfied that the patient is resuscitated with a stacardiorespiratory status, neurological assessment can occur. Neurologiexamination begins with assessment of the patients conscious level us

GCS.


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The severity of the head injury can be based on this initial GCS score.with a GCS of 8 or less is in need of urgent anaesthetic assessment ascompromise and/or reduced lung ventilation is likely.

Pupil size and reaction to light are also assessed. Asymmetrical pupil reduced reaction to light may indicate brain injury from either diffuse injuintra-cranial heamatoma.

It may also, however, indicate an isolated injury to the orbit and assocnerves.

Asymmetry of limb movement may help in diagnosing an underlying inlesion.


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Observations on the blood pressure, pulse and respiratory rate are als

not only to ensure cardiorespiratory stability of the patient, but also to inpossible brainstem compromise.

The mechanism and time of injury, delay in treatment, previous medicthe patient (e.g. epilepsy, diabetes mellitus) and the presence of alcohodrugs that may effect the conscious level are important to ascertain.

Exposure of the patient to examine for any other injuries is then madethorough inspection of the patients scalp for lacerations, compound fracontusions.


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INVESTIGATIONSAll patients with multiple injuries and those with severe head injuries, should

samples analysed for baseline estimations:full blood count (FBC)

electrolytes and urea (RP)

coagulation screen (PT/APTT/INR)

blood gases (ABG)

blood group (GSH/GXM)

Electrolyte abnormalities and haemoglobin deficiencies should be corrected, whilst clotting disorders should be corrected if surgery is anticipated.

With the greater availability of CT, more head-injured patients are being scan

Skull radiography can be used in the absence of CT scans.

But it is by no means comparable as those with head injuries and skull fractuconsidered to have intracranial pathology until proven otherwise.


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MANAGEMENTThe ATLS management of head-injured patients depends on the GCS followin

resuscitation.Patients with a mild head injury (GCS 14-15) should be admitted to a ward whand frequent neurological observations can be ensured.

Should such a patient subsequently deteriorate neurologically (e.g. deterioratincreasing focal neurological deficit) a CT scan of the patients head should bepromptly, and the local neuro-surgical unit contacted.

Patients with a mild head injury should be observed until they make a comple

neurological recovery and are only discharged if a responsible adult can superhome for a further few days.

All patients with a GCS of 13 or less should receive a CT scan of their head aauthorities would advocate a CT scan on all whose GCS is not normal.

Those with an acute lesion on CT scan or evidence of diffuse cerebral oedemurgently discussed with the local neurosurgical unit, with the CT images transfeimmediately, either by computer image-link or courier..


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All CT scans should be accompanied by a provisional radiology report frreferring hospital.

Other indications for neurosurgical referral include:

a) compound depressed skull fracture

b) severely depressed fracture

c) deteriorating GCS score even with a normal scand) cerebrospinal fluid otorrhoea and rhinorrhoea


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The following details are necessary when making a neurosurgical referral:

Name

Age

Sex

Date, time and mechanism of injury

Initial GCS on scene (documented by paramedics)

GCS following resuscitation (before administration of anaesthetic agents should they be required)

Evidence of deteriorating GCSPupil reaction

Vital observations

Previous medical and drug history

Previous functional ability and mobility in the case of elderly patients,

Other injuries and management of the patient since injury


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INDICATION FOR SURGERThe decision to operate on a head-injured patient is based on a number of fa

including premorbid state, the severity of initial injury, the onset and rapidity of deterioration and patient assessment on arrival at the centre.

Important radiological features on CT scan include size of focal lesion(s) togeassociated surrounding oedema and midline shift.

Also to be considered, in particular in the case of elderly dependant patients, wishes of the relatives.

Before embarking on a neurosurgical procedure, it is important to correct anydeficiencies and order the required amount of cross-matched blood.

With the aid of the CT scans, the operation is then planned in consultation wiconsultant neurosurgeon-on-call, and the appropriate theatre staff informed. Incircumstances, neurosurgical intervention, in the form of exploratory burr holesmade at the tertiary centre or the referring hospital.


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CONCLUSION

Modern management of head injuries at the neurosurgical unit involvcontinued ventilation, surgery, intensive care unit management of intracranial pressure and cerebral perfusion pressure, oxygenation.

The aim of all of the above is to minimise any potential for secondaryand to present the neurosurgeon with a patient who is alive and has achance of good quality survival.


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CASE PRESENTATION

18 YEARS OLD BOY WITH NO KNOWN MEDICAL ILLNES

ALLEDGED MVA ( MB SKIDDED )

PATIENT WAS MOTORBIKE RIDER NOT WEARING HELMETUNSURE MECHANISM OF INJURY+LOC,+RETROGRADE AMNESIA, NO ENT BLEED ,BUT REGAINED

CONCIOUSNESS ON THE WAY TO HOSPITALLEFT SIDED HEADACHE AND SWELLINGLEFT SHOULDER PAIN WITH LIMITED ROMNO VOMITING NO BLURRING OF VISION


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ON EXAMINATION

GCS 15/15, PUPIL 3/3 REACTIVE

,NOT TACHYPNIC

VITAL STABLE, NO HYPOTENSIVE EPISODE

LUNGS CLEAR,EQUAL AIR ENTRY

CVS DRNM

P/A:SOFT NON TENDER, NO GUARDING

HEAD EXAMINATION NOTED THERE IS SCALP SWELLING OVER LFRONTO-TEMPORO-PARIETAL

FAST SCAN-NO FREE FLUID

CHEST X-RAY: NO PNEUMOTHORAX, NO RIB FRACTURE


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CT BRAIN DONE:

-ACUTE EXTRA DURAL BLEED IN LEFT FRONTAL REGION(6X3X4

-ACUTE SUBDURAL BLEED RIGHT FRONTO-PARIETAL-TEMPOROOCCIPITAL LOBE( MAXIMUM THICKNESS IS 0.8CM)

-ACUTE BLEED IN INTERHEMISPHERIC FISSURE AND BILATERALTENTORIUM CEREBELLI

-LEFT LATERAL VENTRICLES IS COMPRESSED

-EXTENSIVE HEMATOMA OF LEFT FRONTO-PARIETO TEMPORO-OCCIPITAL.


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EMERGENCY CRANIOTOMY DONE

POST OP PATIENT SENT TO ICU FOR CEREBRAL PROTECTION ACONTINUATION OF CARE

CT BRAIN REPEATED THE NEXT DAY.


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REPEATED CT BRAIN

-RESOLVING LEFT FRONTAL EXTRADURAL BLEED

AFTER COMPLETED CEREBRAL PROTECTION,PATIENT WASEXTUBATED AND SENT TO GENERAL WARD

PATIENT PROGRESS IS WELL, AMBULATING AND TOLERATINGORALLY WELL

NO FEVER, NO HEADACHE , BLURRING OF VISION.

DISCHARGED WELL.


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THANK Y

Kasturi - Head Injury CASE

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