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Committee on Trauma Presents ©ACS Head Trauma Head Trauma.

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Presentation on theme: "Committee on Trauma Presents ©ACS Head Trauma Head Trauma."— Presentation transcript:

1 Committee on Trauma Presents ©ACS Head Trauma Head Trauma

2 Objectives  Describe basic intracranial physiology.  Recognize the importance of limiting secondary brain injury.  Perform a focused neurologic exam.  Stabilize and arrange for definitive care. ©ACS

3 Key Questions  What are the unique features of brain anatomy and physiology and how do they affect patterns of brain injury?  What is a focused neurologic exam?  What is optimal management of the brain-injured patient?  How do I diagnose brain death? ©ACS

4  Rigid, nonexpansile skull filled with brain, CSF, and blood  CBF autoregulation  Autoregulatory compensation disrupted by brain injury  Mass effect of intracranial hemorrhage ©ACS Anatomy and physiology effects?

5 Monro-Kellie Doctrine ©ACS Ven. Vol. Art. Vol. BrainCSFMass Arterial Volume BrainCSF 75 mL Mass 75 mL Venous Volume Art. Vol. Brain CSF

6 Volume – Pressure Curve ©ACS Volume of Mass ICP (mm Hg) Compensation Herniation Point of Decompensation

7 Intracranial Pressure (ICP)  10 mm Hg=Normal  > 20 mm Hg=Abnormal  > 40 mm Hg=Severe  Many pathologic processes affect outcome  Sustained  ICP leads to  brain function and outcome ©ACS

8 Cerebral Perfusion Pressure* ©ACS * CPP  Cerebral Blood Flow MBPICPCPP Normal Cushing’s Response Hypotension – =

9 Autoregulation  If autoregulation is intact, CBF is maintained with a mean BP of 50 to 160 mm Hg.  Moderate or severe brain injury: Autoregulation often impaired  Brain more vulnerable to episodes of hypotension  secondary brain injury ©ACS

10 Mild Brain Injury ©ACS  GCS Score = 14–15  History  Exclude systemic injuries  Neurologic exam  X-rays as indicated  Alcohol / drug screens as indicated  Liberal use of head CT Observe or discharge based on findings

11 Moderate Brain Injury ©ACS  GCS Score = 9–13  Initial evaluation same as for mild injury  CT scan for all  Admit and observe  Frequent neurologic exams  Repeat CT scan  Deterioration: Manage as severe head injury

12 Severe Brain Injury  GCS Score = 3–8  Evaluate and resuscitate  Intubate for airway protection  Focused neurologic exam  Frequent reevaluation  Identify associated injuries ©ACS

13 Classification of Brain Injury ©ACS By Mechanism  Blunt: High and low velocity  Penetrating: GSW and other

14 Classification of Brain Injury ©ACS By Morphology: Skull Fractures Vault Basilar  With / without CSF leak  With / without cranial palsy  Depressed / nondepressed  Open / closed

15 Classifications of Brain Injury ©ACS By Morphology: Brain Focal Diffuse  Epidural (extradural)  Subdural  Intracerebral  Concussion  Multiple contusions  Hypoxic / ischemic injury

16 Diffuse Brain Injury  Mild concussion  Severe, ischemic insult ©ACS Normal CT Diffuse Injury

17 Contusion / Hematoma  Coup / contracoup injuries  Most common: Frontal / temporal lobes  CT changes usually progressive  Most conscious patients: No operation ©ACS

18 Contusion / Hematoma ©ACS Large frontal contusion with shift

19 Epidural Hematoma  Associated with skull fracture  Classic: Middle meningeal artery tear  Lenticular / biconvex  Lucid interval  Can be rapidly fatal  Early evacuation essential ©ACS

20 Epidural Hematoma Uncal herniation Temporal Epidural Hematoma ©ACS

21 Subdural Hematoma  Venous tear / brain laceration  Covers cerebral surface  Morbidity / mortality due to underlying brain injury  Rapid surgical evacuation recommended, especially if > 5 mm shift of midline ©ACS

22 Subdural Hematoma ©ACS

23 Priorities  ABCDE ©ACS  Minimize secondary brain injury  Administer O 2  Maintain blood pressure (systolic > 90 mm Hg)

24 Focused Neurologic Exam?  GCS Score ©ACS Consult neurosurgeon early  Pupils  Lateralizing signs

25 Indications for CT Scan? ©ACS All patients with suspicion of brain injury

26 Medical Management  Controlled ventilation ©ACS  Intravenous fluids  Euvolemia  Isotonic  Goal: Paco 2 at 35 mm Hg

27 Medical Management ©ACS  Mannitol  Use with signs of tentorial herniation  Dose: 1.0 g / kg IV bolus  Consult with neurosurgeon first

28 Medical Management  Other medications ©ACS  Anticonvulsants  Sedation  Paralytics

29 Surgical Management ©ACS Scalp Injuries  Possible site of major blood loss  Direct pressure to control bleeding  Occasional temporary closure

30 Surgical Management ©ACS Intracranial Mass Lesion  May be life-threatening if expanding rapidly  Immediate neurosurgical consult  Hyperventilation / Mannitol  Damage control craniotomy: Transfer to neurosurgeon (rural / austere areas)

31 Diagnose brain death? ClinicalAncillary Studies ©ACS  GCS Score = 3  Nonreactive pupils  Absent brainstem reflexes  No spontaneous ventilatory effort  EEG: No activity  Brain scan: No flow  ICP > MAP x 3 hours  No cardiac response to atropine Remember, organ donation

32 ©ACS

33 Summary: What should I do?  Maintain mean BP > 90 mm Hg  Maintain Paco 2 near / at 35 mm Hg  Use isotonic solution for euvolemia  Frequent neurologic exams  Liberal use of CT scans  Early neurosurgical consult ©ACS

34 Summary: What should I not do?  Allow patient to become hypotensive  Over-aggressively hyperventilate  Use hypotonic IV fluids  Use long-acting paralytics  Paralyze before performing complete exam  Depend on clinical exam alone ©ACS


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