Extradural Epidemiology: All ages but more common if <40yrs and males The most common site in children Symptoms and signs: Lucid period. Pupils dilate late. 75% have skull # Prognosis: 10% mortality usually due to diffuse axonal injury
Acute Subdural Epidemiology Mostly over 40yrs with significant trauma Small brains, coagulopathies, 3 days from injury Types Diffuse, multiple collections (more common) One big bleed Usually associated with axonal injury Prognosis-30% mortality
Subacute and Chronic Subdural Frequently no history of trauma Present as raised ICP, sometimes weeks after cause Associated with underlying brain trauma. Frequently (approx 20%) recollect (osmotic/rebleed)
Traumatic Subarrachnoid Not raised ICP, presents like ordinary SAH Which came first the accident or the headache? If in doubt - needs arteriography to exclude aneurysm Nimodipine and hydration are effective Prognosis better than aneuysmal SAH
Intracerebral Haematoma Cerebral contusions and haematomas are different Treatment may involve surgery if Signs of raised ICP CT suggests that raised ICP will develop! Posterior fossa bleeds Otherwise treat as diffuse injury
Criteria for admission Skull fracture Persistent GCS < 15 Persistent vomiting Epileptic fit Abnormal neurological signs Mastoid bruising Orbital bruising Lack of supervision at home IF IN DOUBT ADMIT!
Treatments Resuscitation..Resuscitation.. THINK ABC Consider early ventilation Treat space occupying lesions with surgery Treat Fits »Diazepam »Phenytoin ( 5-10mg/kg at 50mg/min) »Thiopentone infusion Mannitol? 0.5-1g/kg over 15-20 mins Good secondary survey
Mannitol Buys time Osmotic gradient between plasma /brain 1g/Kg (5ml/Kg) 0.5g/100mls of 20% over 15mins 50ml aliquots of 20% over 10 mins Equilibration, fully osmolised at 310 mOSM, don’t give if >320 May cause ATN, Hypertension & high intracellular osmotic pressure, phlebitis
From the following list which patients need to be admitted?: A 25 year old with a parietal skull fracture. A 43 year old who keeps on asking what happened. A fully alert 37 year old with an aortic valve replacement and normal skull X-ray. A 19 year old student who lives in a bed sitter.
Which of the following would you X-ray? A 3 month old baby who has "rolled off a couch". An 18 month old who has run into a door sustaining a large right sided forehead swelling. An 18 year old struck over the head with a billiard cue. A 25 year old in a 3 metre fall from scaffolding. A 43 year old intoxicated man who had fallen backwards from a bar stool onto a concrete floor. A 72 year old who struck her head on an open cupboard door.