PTC HEAD TRAUMA By Dr. Vashdev FCPS, Consultant Neuro and Spinal Surgeon & DEPARTMENT OF...
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Transcript of PTC HEAD TRAUMA By Dr. Vashdev FCPS, Consultant Neuro and Spinal Surgeon & DEPARTMENT OF...
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PTCPTC
HEAD TRAUMAHEAD TRAUMA
By
Dr. Vashdev
FCPS ,
Consultant Neuro and Spinal Surgeon &
DEPARTMENT OF NEUROSURGERY
LIAQUAT UNIVERSITY OF MEDICAL AND HEALTH SCIENCES.
JAMSHORO
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PTCPTC
Head TraumaHead Trauma
Objectives• To understand the structured approach
to the patient with head trauma• To learn how to identify serious and life-
threatening head injuries
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PTCPTC
Head TraumaHead Trauma
• 1/3-1/2 of trauma deaths• Good outcomes possible without
CT scans and neurosurgeons• Aim to avoid secondary brain injury• Hypoxia and hypotension double
mortality
121
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PTCPTC
Head TraumaHead TraumaApproachApproach
Airway
Breathing
Circulation
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PTCPTC
Head TraumaHead TraumaPhysiologyPhysiology
CPP = MAP - ICP
CPP = cerebral perfusion pressureMAP = mean arterial pressure
ICP = intracranial pressure
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PTCPTC
Cerebral Blood FlowCerebral Blood FlowDepends on:Depends on:
• CPP (MAP-ICP)
• PaCO2
• PaO2
• Local metabolites
124
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PTCPTC
Head TraumaPathophysiology
• Primary Injury
• occurs at time of injury
• Secondary Injury
• occurs after injury
• may be preventable
125
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PTCPTC
Head TraumaPrimary injury
Diffuse axonal injury Acceleration deceleration
Cerebral contusion Penetrating injury
126
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PTCPTC
Head Trauma Secondary injury
Hypoxia Hypoperfusion (↑ ICP, ↓ MAP) Hypoglycaemia Hyperthermia (fever) Seizures
127
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PTCPTC
Head TraumaHead TraumaInitial assessmentInitial assessment
Airway (+ C-spine)
Breathing
Circulation
Disability ( pupils)
Exposure
128
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PTCPTC
Head TraumaHead TraumaExaminationExamination
• Glasgow Coma Score• Pupils• Corneal reflex• Eye position • Fundi
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PTCPTC
Head TraumaHead TraumaExaminationExamination
• Tympanic membrane• Scalp and skull
(Raccoon eyes, Battle sign)• Respiratory Pattern• Muscle tone• Posture• Tendon reflexes
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PTCPTC
Head Trauma Head Trauma GCS Eye openingGCS Eye opening
Open spontaneously 4
Open to command 3
Open to pain 2
None 1
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PTCPTC
Head Trauma Head Trauma GCS Best Verbal Response GCS Best Verbal Response
Oriented 5
Confused 4
Inappropriate words 3
Inappropriate sounds 2
None 1
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PTCPTC
Head TraumaHead TraumaGCS Best Motor ResponseGCS Best Motor Response
Obeys command 6Localises to pain 5Withdraws to pain 4Abnormal flexion 3Extensor response 2None 1
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PTCPTC
Head Trauma Head Trauma Severity of Head InjurySeverity of Head Injury
Severe GCS <8
Moderate GCS 9-12
Mild GCS 13-15
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PTCPTC
Head Trauma Head Trauma Pupillary signsPupillary signs
• Size• Reactivity• Equality
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PTCPTC
Head Trauma Head Trauma Pupillary responsesPupillary responses
Fixed, dilated,
unresponsive
• Severe hypoxia• Severe brain Injury• Hypothermia• Seizures
137
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PTCPTC
Head Trauma Head Trauma Pupillary responsesPupillary responses
Unilateral, dilated,
unresponsive
• Expanding lesion on same side
• Tentorial herniation
• Seizures
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PTCPTC
Head TraumaHead TraumaAcute extradural or subduralAcute extradural or subdural
• Potentially life-threatening• Immediate recognition essential• Require burr-hole decompression
139
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PTCPTC
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PTCPTC
Head TraumaHead TraumaAcute extraduralAcute extradural
• LOC → lucid interval → deterioration• Middle meningeal artery bleed• Overlying skull fracture• Contralateral hemiparesis• Fixed pupil on side of injury
140
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PTCPTC
Head TraumaHead TraumaAcute subduralAcute subdural
• Tearing of bridging vein between cortex and dura
• Underlying brain injury• Usually no lucid interval• Worse prognosis than extradural
haematoma
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PTCPTC
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PTCPTC
Head TraumaHead TraumaOther injuriesOther injuries
• Base-of-skull fractures• Cerebral concussion• Depressed skull fracture• Intracerebral haematoma
Usually do not require urgent neurosurgery consultation
142
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PTCPTC
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PTCPTC
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PTCPTC
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PTCPTC
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PTCPTC
AirwayBreathing (ventilation)Circulation + Avoid ↑ ICP
Aim to prevent secondary injury
Head TraumaHead TraumaManagementManagement
143
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PTCPTC
Head TraumaHead TraumaSevere (GCS<8)Severe (GCS<8)
• Intubate• Normal CO2
• Treat hypotension with fluid • Sedation +/- paralysis
144
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PTCPTC
Head TraumaHead TraumaSevere (GCS<8)Severe (GCS<8)
• Nurse head up 20o
• Prevent hyperthermia• Complete secondary survey• Reassess frequently
145
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PTCPTC
FINDINGS WITH LOW FINDINGS WITH LOW RISK OF ICIRISK OF ICI- asymptomatic
- headache- dizzines- scalp hematoma- skull x-ray normal- DISCHARGE on instructions- change in level of consiousness- severe headache- persistent vomiting- bradycardia
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PTCPTC
FINDINGS WITH FINDINGS WITH MODERATE RISK ICI MODERATE RISK ICI
h/o loss of cons. progressing headache post traumatic seizures age <2 years post traumatic amnesia vomiting signs of BSF multiple trauma severe facial injuries
CRITERIA FOR OBSERVATION AT HOME
normal C.T scan GCS - >14 reasonable access to hospital
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PTCPTC
FINDING WITH HIGH RISK FINDING WITH HIGH RISK OF ICIOF ICI
- Depressed level of Con.
- Focal Neurologic Findings
- Penetrating skull injuries
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PTCPTC
Head TraumaHead TraumaBewareBeware
• Deteriorating conscious state• Penetrating injury• Focal neurological signs
- unequal, dilated pupils
- seizures
- posturing
146
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PTCPTC
Head TraumaHead Trauma
??147
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PTCPTC
Head TraumaHead Trauma
Summary• ABCs• Prevent secondary injury• Isolated head trauma doesn’t cause
hypotension • Look for other injuries• Deterioration → reassess
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PTCPTC