Kuliah Brain Injury Unmuh
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Transcript of Kuliah Brain Injury Unmuh
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Brain Injury
Dr. Krisna Murti SpBSDepartemen Bedah dan Anestesi
RST Soepraoen
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Curriculum Vitae
Nama : Krisna Murti , dr, Sp BSPangkat : Mayor CKM
Jabatan : - Ka Instal Kamar Bedah RST Soepraoen
- Konsultan Bedah saraf RS PantiNirmala dan RKZ
Tempat/ Tgl Lahir : Surakarta , 25 Juli 1970
Agama : Islam
Status : K2
Alamat : Perum Dokter RST Supraun Jl. S.
Supriyadi no. 22
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DIKUM : FK UNDIP 1996 ( Dokter umum)
FK UNPAD 2006 ( Spes Bedah Saraf)
National Neuroscience Institute Singapore 2003Nagoya University Japan, advance training 2006
Berbagai kursus dan seminar DN dan LN
DIKMIL : Sepamilsuk 1993
Sussarcab Kes 1998Sussar selam militer 1998
Selapa TNIAD 2008
Penugasan : Ops Timtim 1998 ,
Maluku 2000Contact : HP 081219040088
EM : [email protected]
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Welcome to Trauma!
First and ForemostABCs!
airway
breathing
circulation
disability
exposure
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Head Injuries:
Account for about one half of all trauma
deaths
Survivors range from baseline function to
severe morbidity
As with most trauma, broken down into
blunt and penetrating
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Anatomy for Head Injuries
Scalp may result in significant bleeding
Skull
well placed fractures place vessels and nerves at risk for injury
protective, but a rigid, fixed space
Dura
Falx separates hemispheres
Tentorium separates cerebrum
Brain
Direct (Primary)
Indirect (secondary)
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Direct (Primary) Brain Injuries
Direct damage done to brain parenchyma
Damage is already done
Irreversible
Damage control (debridement)
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Linear fracture
http://images.google.co.id/imgres?imgurl=http://www.netmedicine.com/xray/img_xr/skul10ax.jpg&imgrefurl=http://xraytamin.blogfa.com/8612.aspx&usg=__PlHU2xmRXdXz5cnNUaagnJdlkHU=&h=379&w=450&sz=14&hl=id&start=48&tbnid=gFoMuAjdeKb9mM:&tbnh=107&tbnw=127&prev=/images%3Fq%3Dlinear%2Bskull%2B%2Bfracture%26gbv%3D2%26ndsp%3D20%26hl%3Did%26sa%3DN%26start%3D40http://images.google.co.id/imgres?imgurl=http://www.medicalfinals.co.uk/joomla/images/stories/medical_finals/headct/skull-case7.jpg&imgrefurl=http://www.medicalfinals.co.uk/joomla/content/view/92/39/&usg=__PE3CFwVBlm9S5Mt4oG2iBZ8ie1I=&h=512&w=512&sz=12&hl=id&start=16&tbnid=4a25UaYvCUD2kM:&tbnh=131&tbnw=131&prev=/images%3Fq%3Dlinear%2Bskull%2B%2Bfracture%26gbv%3D2%26hl%3Did%26sa%3DGhttp://images.google.co.id/imgres?imgurl=http://radiographics.rsnajnls.org/content/vol23/issue4/images/large/g03jl18g18a.jpeg&imgrefurl=http://radiographics.rsnajnls.org/cgi/content-nw/full/23/4/811/F18A&usg=__F-uEfDleITJyFSl0B4ddC-kA2Gs=&h=1800&w=1789&sz=286&hl=id&start=10&tbnid=YtAe9NzRFjO3xM:&tbnh=150&tbnw=149&prev=/images%3Fq%3Dlinear%2Bfracture%26gbv%3D2%26ndsp%3D20%26hl%3Did%26sa%3DGhttp://images.google.co.id/imgres?imgurl=http://medicalimages.allrefer.com/large/infant-skull-fracture.jpg&imgrefurl=http://health.allrefer.com/health/skull-fracture-infant-skull-fracture.html&usg=__murPA2CntLBvAd5Y3q9QTwozxFA=&h=320&w=400&sz=17&hl=id&start=3&tbnid=oTmZelzepsTDWM:&tbnh=99&tbnw=124&prev=/images%3Fq%3Dlinear%2Bfracture%26gbv%3D2%26ndsp%3D20%26hl%3Did%26sa%3DG -
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Depressed fracture
http://images.google.co.id/imgres?imgurl=http://img.medscape.com/pi/emed/ckb/neurosurgery/247017-248108-4158.jpg&imgrefurl=http://emedicine.medscape.com/article/248108-media&usg=__kHRntoRncEwF0FqSxU1YvUyhlF0=&h=1726&w=1485&sz=881&hl=id&start=82&tbnid=nxeyIFKySHY28M:&tbnh=150&tbnw=129&prev=/images%3Fq%3Ddepressed%2Bfracture%26gbv%3D2%26ndsp%3D20%26hl%3Did%26sa%3DN%26start%3D80http://images.google.co.id/imgres?imgurl=http://www.neurosurgery.com.sg/images/photos/neurotrauma/Skullfracture3D.jpg&imgrefurl=http://www.neurosurgery.com.sg/index.php%3Fid%3D69&usg=__ERuaztKapy84qBJsCsFMTrw6S_s=&h=512&w=512&sz=21&hl=id&start=70&tbnid=cLNBDvzj_vQyqM:&tbnh=131&tbnw=131&prev=/images%3Fq%3Ddepressed%2Bfracture%26gbv%3D2%26ndsp%3D20%26hl%3Did%26sa%3DN%26start%3D60http://images.google.co.id/imgres?imgurl=http://anatpat.unicamp.br/minDsc35118%2B.jpg&imgrefurl=http://anatpat.unicamp.br/eradtrauminis.html&usg=__zyxOpJT8lbfkrMFhJEYWYTagghk=&h=219&w=183&sz=12&hl=id&start=63&tbnid=0hQk5djh86TctM:&tbnh=107&tbnw=89&prev=/images%3Fq%3Ddepressed%2Bfracture%26gbv%3D2%26ndsp%3D20%26hl%3Did%26sa%3DN%26start%3D60http://images.google.co.id/imgres?imgurl=http://eforensicmed.googlepages.com/Depressed_skull_fracture.jpg/Depressed_skull_fracture-full.jpg&imgrefurl=http://eforensicmed.googlepages.com/bluntforcetrauma&usg=__tsjCxu_e8-Y4lToSLG4JEAw-0Mg=&h=797&w=1200&sz=77&hl=id&start=46&tbnid=G5G-dUkbuWNUnM:&tbnh=100&tbnw=150&prev=/images%3Fq%3Ddepressed%2Bfracture%26gbv%3D2%26ndsp%3D20%26hl%3Did%26sa%3DN%26start%3D40http://images.google.co.id/imgres?imgurl=http://forensicpathcareers.doodlekit.com/media/AA/AA/forensicpathcareers/images/76284/main/Depressed_Skull_Fracture.jpg&imgrefurl=http://forensicpathcareers.doodlekit.com/home&usg=__fsqF91XzXKjEBn6T89iEyLAlPVE=&h=337&w=450&sz=26&hl=id&start=22&tbnid=T7BJXyZ5PDsdrM:&tbnh=95&tbnw=127&prev=/images%3Fq%3Ddepressed%2Bfracture%26gbv%3D2%26ndsp%3D20%26hl%3Did%26sa%3DN%26start%3D20 -
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Indirect (Secondary) Brain Injury
Damage that occurs after the initial insult
Expanding mass lesions, swelling or
bleeding quickly overwhelm buffers
End result is increased intracranial pressure
(ICP) and/or herniation
Diagnosis and treatments target minimizing
the effects of these indirect insults
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Intracranial Pressure (ICP)
Intracranial space essentially full ofbrain, blood vessels, and a little CSF
In response to an insult, small amount
of CSF can be displaced, can decreaseblood volume, then increase ICP
At higher ICP, loss of autoregulationoccurs
Cerebral perfusion pressure = (MAP-ICP)
Ischemia and neuronal death
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Mechanism 1: Brain Contusion
A brain contusion is defined by celldeath accompanied by hemorrhage(leakage of blood)
The soft brain tissue is vulnerableto contusion in head trauma
The contusion often occurs at a sitedistant from the point of impact
Gross brain image from
http://neuropathology.neoucom.edu/chapter4/chapter4bContusions_dai_sbs.html#contusion
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ec an sm :- Understanding the Determinants of
Intracranial Pressure - The volume of the intracranial vault =
Intracranial Contents:
80% brain tissue 10% blood
10% cerebrospinal fluid
An increase in the volume of any of these intracranial
contents causes increased intracranial pressure
1. The brain can swell (edema)
2. Excess blood can accumulate due to hemorrhage
3. Cerebrospinal fluid can accumulate due to blockage ofoutflow
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Mechanism 2: ICP Key Concept #1: The intracranial vault is a
fixed volume --> Bone does not expand!
Skull image from www.mnsu.edu
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ec an sm :- Understanding the Physics of Intracranial
Pressure -
Volume (mL)
Pressure
(mmHg)
Intracranial Pressure Rises as Brain+Bood+CSFvolume Increases
ICP > 20 mmHg
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ec an sm :- Understanding the Physics of Intracranial
Pressure -
ICP
CPP
This patient has dangerously high intracranial pressures, which
increase the likelihood of morbidity and mortality
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Mechanism 2: ICP Key Concept #3:
When the brain issqueezed through the
foramen magnum(herniation), the
brainstem is compressed,the patient stops
breathing, and thepatient dies
Herniation schematic from Robbins and Cotran. Pathologic Basis of Disease. 7th ed. Philadelphia: Elselvier; 2005.
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Normal CT
http://images.google.co.id/imgres?imgurl=http://www.southernhealth.com.au/imaging/images/13.jpg&imgrefurl=http://www.southernhealth.com.au/imaging/ct_dh_preps.htm&usg=__JaUzPU7jopDrxzWpY5HbhM7q-pM=&h=483&w=485&sz=24&hl=id&start=3&tbnid=2QhXH8vWjFTIlM:&tbnh=128&tbnw=129&prev=/images%3Fq%3Dnormal%2Bbrain%2BCT%26gbv%3D2%26hl%3Did%26sa%3DGhttp://images.google.co.id/imgres?imgurl=http://neurosun.googlepages.com/headct.jpg/headct-full%3Bcrop:0.12,0.02,0.88,0.94.jpg&imgrefurl=http://neurosun.googlepages.com/normalctbrainfindings&usg=__3fzdhrsRfLHYNsoEhQkIdHmyEwk=&h=444&w=369&sz=35&hl=id&start=15&tbnid=x0PBOv5Mic1w-M:&tbnh=127&tbnw=106&prev=/images%3Fq%3Dnormal%2Bbrain%2BCT%26gbv%3D2%26hl%3Did%26sa%3DGhttp://images.google.co.id/imgres?imgurl=http://thebrain.mcgill.ca/flash/capsules/images/outil_bleu13_img03.jpg&imgrefurl=http://thebrain.mcgill.ca/flash/capsules/outil_bleu13.html&usg=__btDmJWJpzqO74NJ0ynQNH81QFMY=&h=213&w=200&sz=9&hl=id&start=10&tbnid=ETDc9YhrYjUmmM:&tbnh=106&tbnw=100&prev=/images%3Fq%3Dnormal%2Bbrain%2BCT%26gbv%3D2%26hl%3Did%26sa%3DG -
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EDEMA
http://images.google.co.id/imgres?imgurl=http://bestpractice.bmj.com/best-practice/images/bp/688-3_default.jpg&imgrefurl=http://bestpractice.bmj.com/best-practice/monograph/688/resources/image/bp/2.html&usg=__dCvSE3ggciNO-yTUn6u2GP_dAUs=&h=433&w=416&sz=58&hl=id&start=5&tbnid=OK3PAquMv07ibM:&tbnh=126&tbnw=121&prev=/images%3Fq%3Dtraumatic%2B%2Bbrain%2Bedema%26gbv%3D2%26hl%3Did%26sa%3DGhttp://images.google.co.id/imgres?imgurl=http://download.imaging.consult.com/ic/images/S1933033208808749/gr14-midi.jpg&imgrefurl=http://imaging.consult.com/image/chapter/Brain%2520and%2520Spine%3Ftitle%3DVascular%2520Injury%2520and%2520Parenchymal%2520Changes%26image%3Dfig14%26locator%3Dgr14%26pii%3DS1933-0332(08)80874-9&usg=__gQnxDPrYge3kGeNM7sBqRo6QoYo=&h=200&w=173&sz=5&hl=id&start=10&tbnid=Vry757h7BNpQ-M:&tbnh=104&tbnw=90&prev=/images%3Fq%3Dtraumatic%2B%2Bbrain%2Bedema%26gbv%3D2%26hl%3Did%26sa%3DG -
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Categories of Brain Injuries
Diffuse
Concussion (movement to TBI!)
Diffuse Axonal Injury Focal
Laceration (blunt) and penetrating
Contusions
Intracerebral hematomas
Epidural and subdural
Subarachnoid hemorrhage
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Diffuse Brain Injuries
Concussion
Mild traumatic brain injury
No significant imaging findingsDoes not mean no injury
Diffuse Axonal Injury
Severe injury globally caused by sheering ofaxons
Often neurologically devastated
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http://images.google.co.id/imgres?imgurl=http://www.learningradiology.com/caseofweek/caseoftheweekpix2008-2/cow315-1arr.jpg&imgrefurl=http://www.learningradiology.com/archives2008/COW%2520315-Diffuse%2520Axonal%2520Injury/daicorrect.htm&usg=__l47i9x1D8gCJ_ak5cSqacON7dYg=&h=522&w=400&sz=57&hl=id&start=98&tbnid=gCg1_WOail1dEM:&tbnh=131&tbnw=100&prev=/images%3Fq%3Ddiffuse%2Binjury%26gbv%3D2%26ndsp%3D20%26hl%3Did%26sa%3DN%26start%3D80http://images.google.co.id/imgres?imgurl=http://img.medscape.com/pi/emed/ckb/emergency_medicine/756148-810904-784.jpg&imgrefurl=http://emedicine.medscape.com/article/810904-overview&usg=__LawVYAt__XGDbX7dBodgSpxj2zE=&h=504&w=410&sz=29&hl=id&start=14&tbnid=9sjWJA-Yv9yRqM:&tbnh=130&tbnw=106&prev=/images%3Fq%3Ddiffuse%2Binjury%26gbv%3D2%26hl%3Did%26sa%3DG -
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Mechanism : Diffuse Axonal Injury
A microscopic view of axonal degeneration
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Focal Brain Injuries
Penetrating injuries often intuitively
obvious
Contusions (including contrecoup)
Hematomas
Epidural
Subdural
Subarachnoid hemorrhage
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Contusions
Focal areas ofhemorrhage within the
parenchyma
Contrecoup injuriesoccur from awhiplash effect ofthe brain against theskull on the oppositeside of the initial pointof impact or injury
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Subarachnoid hemorrhage
Subarachnoid blood vessels ruptured
May be the most common finding on
moderate to severe brain injuries
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Penetrating Brain Injury (GSW)
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Epidural Hematoma
Blood between inner
table of the skull and the
dura
Usually a tear of the
MMA Lens shaped hematomas
that do not cross suture
lines on CT
Rare in elderly
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Epidural hematoma (EDH)
http://images.google.co.id/imgres?imgurl=http://www.med.mun.ca/anatomyts/radioanat/radiology/ken/epidural02.JPG&imgrefurl=http://www.med.mun.ca/anatomyts/radioanat/radiology/ken/bonk.htm&usg=__MRw-SmYsp6IJ53bUpZCpQVT5bI8=&h=421&w=360&sz=50&hl=id&start=1&tbnid=s3yLOTdWnVmTSM:&tbnh=125&tbnw=107&prev=/images%3Fq%3Depidural%2Bhematoma%26gbv%3D2%26hl%3Didhttp://images.google.co.id/imgres?imgurl=http://www.nebraskabraininjurylawyer.com/images/brainoverviews/hematomas/hematoma.subdural2.JPG&imgrefurl=http://www.nebraskabraininjurylawyer.com/how.html&usg=__gX6J29X21xpAVoaWEalxFLlO740=&h=272&w=300&sz=25&hl=id&start=172&tbnid=unIAWtcEWhU2OM:&tbnh=105&tbnw=116&prev=/images%3Fq%3Depidural%2Bhematoma%26gbv%3D2%26ndsp%3D20%26hl%3Did%26sa%3DN%26start%3D160http://images.google.co.id/imgres?imgurl=http://www.binglixue.com/image/images/cns/CNS020.jpg&imgrefurl=http://www.binglixue.com/image/cns/cns1.htm&usg=__Z3PP-eRh2bR6-kI7aBzAqU12Kmo=&h=330&w=504&sz=41&hl=id&start=60&tbnid=8eN-ERaMIlS6KM:&tbnh=85&tbnw=130&prev=/images%3Fq%3Depidural%2Bhematoma%26gbv%3D2%26ndsp%3D20%26hl%3Did%26sa%3DN%26start%3D40http://images.google.co.id/imgres?imgurl=http://www.uth.tmc.edu/radiology/test/er_primer/skull_brain/brct/b15.JPG&imgrefurl=http://www.uth.tmc.edu/radiology/test/er_primer/skull_brain/brct/brct15.html&usg=__AsAyqlV233gxodoF8UYm794Z8C4=&h=288&w=296&sz=20&hl=id&start=8&tbnid=ZmunD1Vn18RCxM:&tbnh=113&tbnw=116&prev=/images%3Fq%3Depidural%2Bhematoma%26gbv%3D2%26hl%3Didhttp://images.google.co.id/imgres?imgurl=http://www.med.mun.ca/anatomyts/radioanat/radiology/ken/epidural02.JPG&imgrefurl=http://www.med.mun.ca/anatomyts/radioanat/radiology/ken/bonk.htm&usg=__MRw-SmYsp6IJ53bUpZCpQVT5bI8=&h=421&w=360&sz=50&hl=id&start=1&tbnid=s3yLOTdWnVmTSM:&tbnh=125&tbnw=107&prev=/images%3Fq%3Depidural%2Bhematoma%26gbv%3D2%26hl%3Did -
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Subdural Hematoma
Blood beneath the dura,
overlying the brain and
arachnoid, resulting from
tears to bridging vesselsCrescent shaped density that
may run length of skull
Very common in the elderly
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Subdural hematoma(SDH)
h i l f d j d
http://images.google.co.id/imgres?imgurl=http://wpcontent.answers.com/wikipedia/commons/thumb/3/38/Trauma_subdural_arrow.jpg/190px-Trauma_subdural_arrow.jpg&imgrefurl=http://www.answers.com/topic/subdural-hematoma&usg=__58WRTdd_lyTFsQ8WPj9tdZ8Qi3g=&h=232&w=190&sz=11&hl=id&start=91&tbnid=4m0Xz3PiuDA_cM:&tbnh=109&tbnw=89&prev=/images%3Fq%3Dsubdural%2Bhematoma%26gbv%3D2%26ndsp%3D20%26hl%3Did%26sa%3DN%26start%3D80http://images.google.co.id/imgres?imgurl=http://www.neurosurgery.com.sg/images/photos/neurotrauma/LtSDHpre2.jpg&imgrefurl=http://www.neurosurgery.com.sg/index.php%3Fid%3D72&usg=__V-uRrpZV6WUnVCvSnCkxXz3IcPc=&h=512&w=512&sz=32&hl=id&start=6&tbnid=o5gxLHlV1M0-LM:&tbnh=131&tbnw=131&prev=/images%3Fq%3Dsubdural%2Bhematoma%26gbv%3D2%26hl%3Did%26sa%3DGhttp://images.google.co.id/imgres?imgurl=http://brighamrad.harvard.edu/Cases/bwh/images/15/DR25Arrow74.GIF&imgrefurl=http://brighamrad.harvard.edu/Cases/bwh/hcache/15/full.html&usg=__ZjaGSxZDHI0RSOOE6UB69WPSfWk=&h=365&w=288&sz=90&hl=id&start=4&tbnid=O3As6o6-5T59GM:&tbnh=121&tbnw=95&prev=/images%3Fq%3Dsubdural%2Bhematoma%26gbv%3D2%26hl%3Did%26sa%3DG -
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Prehospital Care of Head Injured
Patient
Historically, most patients were
hyperventilated (bad!)
ABCs
Spinal immobilization
Initial resuscitation
Rapid transport
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Head Injury Management
Management overall goal is to prevent or
minimize secondary injuries to the brain
Prevent hypoxia
Prevent hypotension
Prevent hemorrhage (anemia)
Prevent or limit increasing pressure
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ED Assessment of Head Injured
Patient
ABCs (again)
History (think alternate sources)
Clues to brain injury (examples: Cushings
reflex, raccoon eyes, etc)
Physical examtreat prioritized life threats
first
The D of the ABCs (neuro exam)
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Glasgow Coma Scale (GCS)MOTOR VERBAL EYES
6 follow commands 5 conversant +
oriented
4 open
spontaneously
5 localizes 4 conversant +
disoriented
3 open to
command4 flexion/withdrawal 3 inappropriate
words
2 open to pain
3 decorticate post 2 incomprehensible
sounds
1 doesnt open
2 decerebrate post 1 no sounds
1 no movement
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GCS Scores
GCS 13-15 Mild head injury
GCS 9-12 Moderate head
injury
GCS < 8 Severe head injury
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Management Principles
ABCs (Get used to it)
Protect spine as well (C spine injury
assumed until proved otherwise)
Stop blood loss elsewhere
Maintain perfusion (why hyperventilation is
detrimental!)
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Thank You !
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