Presentation on theme: "Trauma department Hsinglin Lin"— Presentation transcript:
1 Trauma department Hsinglin Lin Head traumaTrauma departmentHsinglin Lin
2 Introduction Adequate oxygenation Maintenance of sufficient blood pressureAvoid secondary brain damageEarly consultationBCT in hospital cannot treat
3 Consulting neurosurgeon 1.age and mechanism2.Respiratory and cardiovascular status (BP)3.Minineurologic ex., GCS( Motor response), pupillary reactions4.associated injuries5.Result of diagnostic studies (CT)
4 Eye Opening ResponseSpontaneous--open with blinking at baseline 4 pointsTo verbal stimuli, command, speech 3 pointsTo pain only (not applied to face) 2 pointsNo response 1 point
5 Verbal Response Oriented 5 points Confused conversation, but able to answer questions 4 pointsInappropriate words 3 pointsIncomprehensible speech 2 pointsNo response 1 point
6 Motor Response Obeys commands for movement 6 points Purposeful movement to painful stimulus 5 pointsWithdraws in response to pain 4 pointsFlexion in response to pain (decorticate posturing) 3 pointsExtension response in response to pain (decerebrate posturing) 2 pointsNo response 1 point
7 Computed tomographic done in a patient has any of the following features: The patient is eye opening only to pain or does not converse (Glasgow Coma Score 12/15 or less)A deteriorating level of consciousness or progressive focal neurological signsConfusion or drowsiness (Glasgow Coma Score 13 or 14/15) followed by failure to improve within at most four hours of clinical observationRadiological/clinical evidence of a fracture, whatever the level of consciousness
8 New focal neurological signs which are not getting worse Full consciousness (Glasgow Coma Score 15/15) with no fracture but other features, such as:severe and persistent headachenausea and vomitingirritability or altered behavioura seizure
9 AnatomyA: Scalp 1.skin, 2.connective tissure, 3.apponeurosis, 4.losse tissue, 5.pericranium.B:Skull : cranial vault and baseC:Meninges: dura mater, arachnoid and pia mater. Most common injury: Middle meningeal a. in epidural space, Subdural space : bridge veinD:Brain:cerebrum, cerebellum, brainstem
10 E: CSFF: Tentorium:Oculomotor nerve runs along the edge of tentorium. Parasympathetic fibers lie on surface –dilation. Down and out with further compression.Uncal herniation: compression of the corticospinal tract in the midbrain - weakness of opposite sideKenohan’s notch syndrome: Same side
15 Skull fractureSigns of Skull base fx: periobital ecchymosis (raccoon eyes), retroauricular ecchymosis (Battle’s sign), CSF leakage, 7th nerve palsyFragments depressed more than the thickness of the skull require surgical repair.Skull Fx increases the likelihood of intracrainal hematoma.
16 Basilar skull fx are sometimes associated with CSF leakage from nose (rhinorrhea) or the ear (otorrhea). 7th nerve palsy.
17 Intracranial lesions Focal lesions: 1.EDH, often from middle meningeal a., relatively uncommon, treated early prognosis excellent, lucid interval, talk and die2.SDH, tearing of bridging vein, brain damage much sever and prognosis worse than EDH3.Contusion and intracerebral hematomas, associated SDH, frontal and temporal lobes4.diffuse injury- most common type of brain injury
19 Mild concussion consciousness preserved with noticeable degree of temporary neurologic dysfunction Classic cerebral concussion-loss of consciousness , reversible, posttraumatic amnesia
20 Post-concussion syndrome- long-lasting neurologic deficits, include memory difficulties, dizziness, nausea, anosmia and depression.Diffuse axonal injury- prolonged posttraumatic coma not due to mass lesion or ischemia insults. Decortication and decerebration with autonomic dysfunction.
21 Management of mild injury(GCS14-15) CT – a history loss of consciousness, amnesia, or severe headaches.observation at H for hoursSkull X-ray – penetrating head injury, 1.linear or compression fx, 2.midline postion of pineal grand, 3.Air-fluid levels 4.pneumocephalus, 5.facial fx., 6.foreign body
22 Skull base fx.: racoon’s eye, CSF rhinorrhea or ottorhea, hemotympanum, or Battle’s sign – admission for observationC-spine X-ray – signs of tenderness or pain.Mild head-injury patient with normal CT sacn, can be brought back to H promptly, can be dischrged with reliable companion
23 Manageemnt of moderate head injury (GCS 9-13) Able to follow simple commands, but confused or somnolent and have focal neurologic deficits such as hemiparesisCT scanAdmission
24 Management of severe head injury (GCS 3-8) Unable to follow simple commands even cardiopulmonary stabilizationA. Primary survey and resuscitationhypotension, hypoxemia, and anemia1. Airway and breathing: transient respiratory arrest after head injury- death at scene. Early intubation with 100% O2.
25 Hyperventilation with worsening GCS or pupil dilation Hyperventilation with worsening GCS or pupil dilation. Pco2 keep mmHg.2.Circulation: hypotension usually not due to the brain injury itself except terminal medullary failure. Associated spinal cord injury (quadriplegia or paraplegia), cardiac contusion or temponade, and tension pneumpthorax
26 Volume replacement, DPL, ultrasound routinely in the hypotension comatose patient. Hypotensive patient’s neurologic examination is unreliable.B.Secondary surveyMultiple trauma
27 C.Neurologic ex. :After cardiopulmonary stabilized, rapid and directed neurologic exam: GCS, pupillary light response, doll’s eye movement(oculocephalics), calorics(oculovestibulars), corneal responsesObtain a reliable minneurologic ex. Prior sedating or paralyzing P’t
28 Bilaterally dilated and nonreactive pupils can be due to inadequate brain perfusion. Bilateral small pupils suggest drug effects(opiates), metabolic encephalopathies, destructive lesion of pons, Mild dilation of pupil and a sluggish pupillary response of the eye are early signs of temporal hernia.
29 D.Diagnostic procedures: CT within 30 mins Midline shift of >5 mm usually indicates of surgery
30 Medical therapiesA. IV fluids: dehydration is more harmful than beneficial in these patients. Not use hypotonic fluids and glucose-containing fluids. Prevent hyponatremia.B. hyperventilation: aggressive and prolonged hyperventilation impaired cerebral perfusion with ischemia by vasoconstriction. Esp, Pco2 <25mmHg
31 Keep Pco2 above 30 mmHg and 25-30 mmHg with IICP. Mannitol: 1g/kg with bolus without hypotension comatose patient who initially normal, reactive pupils, but develop dilation or bilateral dilation and nonreactive pupil.
32 Lasix: 0.3 to 0.5 mg/kg combined with mannitol. Steroids: not beneficial.Barbiturates: not indicated in the acute injury resusciative phase, effect reduce IICP but cause hypotension.Anticonvulsants: phenytoin reduced the incidence of seizures in the first week but not thereafter.
33 Surgical managementA.Scalp W’d : shave the hair and clear the W’d before suturing. carefully inspect the W’d for fx and foreign material. Open and depression skull fx, consulted neurosurgeon before close.B.Depressed Skull Fx.: depressiom greater than the thickness of adjacent skull.Intracranial mass lesions