Download Head Trauma

Head Trauma
Objectives:
A- Review specific of anatomy and physiology
as related to head injuries.
B- Identify the principles of general
management of the unconscious
traumatized patient and the delayed
complications.
C- Outline the method of evaluating head
injuries using a mininurological
examination.
D- Explain the management techniques to be
used in specific types of head injuries.
E- Demonstrate the ability to assess various
types of head, maxillofacial and neck
injuries using a head-trauma model.
F- Explain clinical signs and outline priorities
for initial management of injuries identified
in the assessment.
Head Trauma
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Neurosurgical consult essential
Early transfer reduces morbidity and mortality
Cardiorespiratory
Level of consciousness
Pupillary reaction
Vital signs
Associated injuries
Skull film results
Cranial Nerve Assessment
• Pupils occulomotor nerve ( IIIrd )
• Others- lower assessment priority
• Alteration of Consciousness is The
Hallmark of Brain Injury
Unconsciousness Injury
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Bilateral cerebral cortices
Brain stem RAS
Increased ICP
Decreased CBF
• Increased ICP Results in:
• Decreased perfusion
• Altered level of consciousness
History
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Determine cause and effect
Pre- and post injury status
Document communicate
Reassess
Vital signs
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Identifies status neurologically and systemically.
Respiratory Assessment
Assess and correct deficiencies
Increased ICP - slower RR
Increased ICP – noisy tachypnea
Asses for other etiology
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Blood Pressure
Increased ICP Increased BP & widened
pulse pressure
Assess for other etiology
Treat shock vigorously
Pulse
Increased ICP bradycardia
Tachycardia grave sign
Assess for etiology
Temperature
• Temperature
• Weather extremes
• Control hyperthermia
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Eye Opening Response
Spontaneous – already open with blinking
(normal) : four (4) points
To speech – not necessarily to request eye opening
: three (3) points
To pain – stimulus should not be to face : two (2)
points
None – make note if eyes are swollen shut : one (1)
point
Verbal Response
• Oriented - knows name, age, etc. : five (5) points
• Confused conversation - still answers questions:
four (4) points
• Inappropriate words - speech is either
exclamatory or random : three (3) points
• Incomprehensible sounds - do not confuse with
partial respiratory obstruction : two (2) points
• None – make note if intubation prevents speech:
one (1) point
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Best Motor Response
Obeys - moves limb to command and pain
is not required: six (6) points
Localizes - changing the location of the
pain stimulus causes the limb to follow: five
(5) points
Withdraws - pulls away from painful
stimulus: four (4) points
Abnormal flexion - three (3) points
Extensor response - two (2) points
No movement - one (1) point
C-spine Assessment
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High index for suspicion
Reflex assessment
Sensory assessment
X-rays
Hints to Cervical Cord Injury
• Flaccid areflexia, especially with flaccid rectal
sphincter
• Diaphragmatic breathing
• Ability to flex forearms but not extend them
• Facial grimaces in response to pain above the
clavicle but not below
• Hypotension without other evidence of shock (ie,
hypotensive with warm extremities)
• Priapism is an uncommon but characteristic sign
• Brain stem responses :Neurosurgeon to
perform occulocephalic & occulovestibular
cranial nerve test.
• Skull X-rays
• Do not delay primary assessment &
management to obtain skull X-rays.
Management Reassessment, O2 and
Airway
Concussion
• No significant brain injury or localizing signs
• History : amnesiac of event
• Admit : individualize
Contusion
• Significant alterations in consciousness and
localizing signs
• Countercoup injury
• Admit and observe 48 hours
Intracranial Hemorrhage
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Meningeal or brain
CT - precise or diagnose
Clinical findings similar
Acute epidural
Middle meningeal artery tear
Rapidly fatal
Hallmark : ipsilateral, dilated fixed pupil
Immediate surgery
Prognosis : good
Acute Subdural
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Venous hemorrhage
life- threatening gradual onset
severe underlying brain injury
Prognosis : poor
Subarachnoid
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Bloody CSF, meningeal irritation
Headache, photophobia
Nuchal rigidity, R/O C-spine injury
High index of suspicion
Admit
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Closed Brain Hemorrhages
Occur at any location
CT- precise diagnosis
Neurological deficits- region and size of
hemorrhage
Increased ICP Complications
Cerebral edema
Vasospasm
Loss of autoregulation( Neurosurgical
consult )
Fluid Restriction Prevent Overhydration
Diuretics
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Neurological consult
Mannitol 50 gms IV
Furosemide 40-80 mg IV
Urinary catheter
Deliberate Hypocapnia
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Maintain PCO2 at 26-28 torr
Intubation
Latrogenic paralysis
Monitor ABGs ( Neurosurgical consult )
Convulsions
• Intracranial hemorrhage
Treatment
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Diazepam 10mg IV
Diphenylhydantoin 1 gm IV
Phenobarbital or anaesthesia
Restlessness
Identify etiology
Correct cause
Hyperthermia
Potential disastrous
Reversible neurologic findings
Vigorous intervention
Scalp Wounds
Blood loss
Inspection
Repair
Surgical Management
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Obtain necessary tests early
Emergent surgeries for hematomas
Transfer to neurosurgeon
Avoid delays
Summary
A- Obtain and maintain an open airway
B- Ventilate to avoid hypercarbia
C- Treat shock, if present and look for cause
D- Except for shock, restrict fluid intake to
maintenance levels
E- Establish baseline parameters
F- Search for associated injuries
G- Obtain X-rays as needed, but only after the
patient is stable
H- Consult a neurosurgeon and consider early
transfer
• I- Should the patient's condition show a
change for the worse, consider other
diagnoses and forms of treatment.
• Consult with a neurosurgeon and consider
transfer.
• J- Reassess continually to identify changes
necessitates neurosurgical intervention.