CASUALTY UNIT Management of Head InjuryBy Dr. Akinniyi O.T
Clinical Services Dept- NOH Dala
OutlineIntroduction Epidemiology Clinical presentation Management Complications Prevention Conclusion
Introduction Definition: Injury to the cranial vault, content or covering in isolation or combination.Associated injuries: Facial, Cervical spineM:F==2:1, 80% of victims are 15-25yrs75% of fatalities following motorbike accidents.Causation: RTA, domestic violence/assault. industrial/occupational hazard.Major disability in patients with moderate/severe injuries.
Goal of treatment Control and treat 10 injury while preventing development of 20 injury.
Apparently trivial but potentially fatal injuries.
Apparently hopeless but potentially. salvageable injuries.
Hopeless injuries.
Clinical presentationHx: Altered or loss consciousness following trauma
Examination: vitals, GCS, head, ears, nostrils, eyes, pupillary size, light rxn, fundoscopy, face focal/lateralizing signs.
SpinePosturing: decorticate, decerebrate Chest, abdomen, pelvis, extremities
Investigations Skull: AP, Lateral, Townes
CT, MRI, Transfontanell scan(
Treatment: At the scene Quarantine and extraction to safetyAir way and cervical control
Breathing Control of haemorrhage
AVPU, semi-prone (Lt)Associated injuries
Transport Communication with receiving facility
Treatment: In Hospital CareResuscitation + primary surveySecondary survey
Indication and timing of surgical treatmentSurgical options
Management of complicationsSupportive care/care of the unconscious
Rehabilitation
Resuscitation + primary survey:Airway + cervical control: Breathing: supplemental intranasal O2, 300 head-up
Circulation: (Anyawu 2000,Richards 2001, P.Singh 2005) Choice of fluidAmount of fluidDuration of fluid therapyHypovolaemia at presentationHypertension at presentation
Disability: GCSExposure
Secondary surveyHx: medical conditions, lucid interval
Examination: GCS(30min-1hrly), pupils, lateralizing signs
Review of results: skull x-ray, brain ct, mri
Assessment
Mild +Moderate head injuryGrouping: i-iv based on GCSi: 9-12
ii: 13-14
iii: 15 with neurologic deficit/ skull fracture
iv: 15 no deficits of fracture
Severe Head injuryGCS 3-8
ICU
Supportive care
Supportive careHDU/ICU: Continuous Invasive monitoring Respiration/ Air wayPressure areasEyes Nutrition BladderBowelDVT prophylaxisSurveillance for nosocomial infection
Conditions complicating head injuryCerebral oedema: elevation, hyperventilation, mannitol.
Seizures.
Raised intracranial pressure: muscle relaxation, paralysis, controlled csf drainage, propofol.
Indication and timing of surgical RxtScalp: Laceration (6hrs).
Skull: Open/ significant depressed fracture.
Brain: intracranial collection, penetrating injury, persistent csf leakage, lateralizing signs.
Surgical optionsScalp: 10 closure, flaps, cortical drilling and 20 closure.
Skull: Elevation of depressed skull fractures, bone grafting, titanium plating, bone cement
Haematoma: Burr Hole(diagnostic/theraputic) drainageDura: 10 suturing, dural patch (water tight)
Brain injury: Debridement, lobotomy
Rehabilitation:Re-integration into the society
Head injury advice
ComplicationsEarly: seizures, amnesisa, abscess, encephalitis, meningitis, haematomas
Late: seizures, personality change, hemiplegias/hemiparesis, vegetative state, skull osteomyelitis
cosmetic
PrognosisSeverity of initial injury at presentation
Secondary brain injury
Adequacy of treatment
Age
Prevention:Primary: re-education, sit belts, helmets, pedestrian
Secondary: diagnosis, timely definitive intervention Tertiary: Re-engineering
Conclusion For those of us still writing exams coupled with the paucity of updated literature we should avoid disdain for that which is old while embracing the new.While controversies rage on we should give our patients the best within the context of current knowledge and evidence.
THANK YOU ALL
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