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International Trauma Life Support for Emergency Care Providers CHAPTER seventh edition Head Trauma 10.

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Presentation on theme: "International Trauma Life Support for Emergency Care Providers CHAPTER seventh edition Head Trauma 10."— Presentation transcript:

1 International Trauma Life Support for Emergency Care Providers CHAPTER seventh edition Head Trauma 10

2 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Head Trauma © Edward T. Dickinson, MD

3 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Overview Anatomy of head and brain Pathophysiology of traumatic injury Primary and secondary injury –Mechanisms of secondary brain injury Assessment, management, potential problems Management of cerebral herniation syndrome

4 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Head Trauma Traumatic brain injury (TBI) –Major cause of death and disability –CNS injury in 40% multiple trauma  Death rate twice of non-CNS injury –25% of trauma fatalities Assume spinal injury with serious injury –Potential for altered mental status

5 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Head Anatomy

6 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Brain Injuries Primary –Immediate damage to brain tissue –Direct result of injury force –Little can change injury after it occurs Secondary –Result of hypoxia or decreased perfusion –Prehospital care can help prevent

7 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Brain Injuries Coup –The “3rd collision” –Area of original impact Contracoup –The “4 th collision” –Rebounding hitting the opposite side

8 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Brain Anatomy Intracranial volume Brain CSF Blood vessel volume  Dilatation with high pCO 2  Constriction with low pCO 2 –Slight effect on volume

9 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Brain Physiology Intracranial pressure (ICP) –Pressure of brain and contents in skull Cerebral perfusion pressure (CPP) –Pressure required to perfuse brain Mean arterial pressure (MAP) –Pressure maintained in vascular system

10 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Brain Physiology Cerebral perfusion –CPP = MAP – ICP  MAP constant + ICP increase = CPP decrease  MAP decrease + ICP constant = CPP decrease –Hypotension not tolerated with ICP increase  MAP decrease + ICP increase = CPP critical  Systolic pressure 110–120 mmHg minimum needed to maintain sufficient CPP

11 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Increasing ICP Vital SignChange with Increasing ICP RespirationIncrease, decrease, irregular PulseDecrease Blood pressureIncrease, widening pulse pressure Cushing's response As ICP increases, systolic BP increases As systolic BP increases, pulse rate decreases

12 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians The Injured Brain Cerebral herniation syndrome –Brain forced downward  CSF flow obstructed, pressure on brainstem –Level of consciousness  Decreasing, rapid progression to coma –Associated symptoms  Ipsilateral pupil dilatation, out-downward deviation  Contralateral paralysis or decerebrate posturing  Respiratory arrest, death

13 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Herniation Syndrome Aggressive therapy needed –Hyperventilation is indicated  Ventilate 20 per minute for adult  Ventilate 25 per minute for children  Ventilate 30 per minute for infants  Maintain ETCO 2 30-35 mmHg

14 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Head Injuries Facial injuries –Highly vascular, bleeds briskly  Possible airway compromise  Aspiration  Possible shock –Management  Direct pressure  Airway support –Suction –ET Intubation © Pearson

15 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Head Injuries Scalp wound Highly vascular, bleeds briskly  Shock: child may develop  Shock: adult another cause Management  No unstable fracture: direct pressure, dressings  Unstable fracture: dressings, avoid direct pressure © Edward T. Dickinson, MD

16 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Head Injuries Skull injuries –Linear nondisplaced –Depressed –Compound Suspect fracture –Large contusion or darkened swelling Management –Dressing, avoid excess pressure

17 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Brain Injuries Concussion –No structural injury to brain –Level of consciousness  Variable period of unconsciousness or confusion  Followed by return to normal consciousness –Retrograde short-term amnesia  May repeat questions over and over –Associated symptoms  Dizziness, headache, nausea and/or ringing in ears

18 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Brain Injuries Cerebral contusion –Bruising of brain tissue  Swelling may be rapid and severe –Level of consciousness  Prolonged unconsciousness, profound confusion or amnesia –Associated symptoms  Focal neurological signs  May have personality changes

19 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Brain Injuries Diffuse axonal injury –Diffuse injury  Generalized edema  No structural lesion  Most common injury from severe blunt head trauma –Associated symptoms  Unconscious  No focal deficits

20 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Brain Injuries Anoxic brain injury –Small cerebral artery spasms due to anoxia –No-reflow phenomenon  Cannot restore perfusion of cortex after 4–6 minutes of anoxia  Irreversible damage occurs >4–6 minutes –Hypothermia seems protective

21 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Brain Injuries Intracranial hemorrhage –Epidural  Between skull and dura –Subdural  Between dura and arachnoid –Intracerebral  Directly into brain tissue –Subarachnoid  Between the arachnoid and pia mater

22 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Intracranial Hemorrhage Acute epidural hematoma –Arterial bleed  Temporal fracture common  Onset: minutes to hours –Level of consciousness  Initial loss of consciousness  “Lucid interval” follows –Associated symptoms  Ipsilateral dilated fixed pupil, signs of increasing ICP, unconsciousness, contralateral paralysis, death

23 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Intracranial Hemorrhage Acute subdural hematoma –Venous bleed  Onset: hours to days –Level of consciousness  Fluctuations –Associated symptoms  Headache  Focal neurologic signs –High-risk  Alcoholics, elderly, taking anticoagulants

24 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Intracranial Hemorrhage Intracerebral hemorrhage –Arterial or venous  Surgery is often not helpful –Level of consciousness  Alterations common –Associated symptoms  Varies with region and degree  Pattern similar to stroke  Headache and vomiting

25 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Brain Injuries Subarachnoid hemorrhage –Blood in subarachnoid space  Intravascular fluid “leaks” into brain  Fluid “leak” causes more edema –Associated symptoms  Severe headache  Vomiting  Coma  Cerebral herniation syndrome possible

26 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Head Trauma Assessment ITLS Primary Survey –Every trauma patient initially evaluated in the same sequence

27 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Head Trauma Assessment ITLS Primary Survey –Limit patient agitation, straining  Contributes to elevated ICP –Airway  Vomiting common within first hour  Endotracheal intubation –Preoxygenation –Nasotracheal or RSI or sedation facilitated

28 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Head Trauma Assessment Rapid Trauma Survey –Head  Lacerations  Depressed or open skull fractures  Stability of skull  Signs of basilar skull fracture

29 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Basilar Skull Fracture Battle's signRaccoon eyes Photo courtesy of David Effron, MD, FACEP

30 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Pupils –3 rd cranial nerve –Bilateral dilated, unreactive probable brain stem injury –Unilateral dilated, reactive may be ICP –Other causes  Hypothermia  Drugs  Anoxia  Ocular trauma

31 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Extremities Decorticate –Arms flexed and legs extended Decerebrate –Arms extended and legs extended © Pearson

32 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Glasgow Coma Scale Suspect severe brain injury < GCS 9

33 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Vital Signs –Extremely important –Obtain & record often

34 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians The Injured Brain Hypotension –Single instance increases mortality  Adult (systolic <90 mmHg) 150%  Child (systolic < age appropriate) worse Fluid administration for TBI GCS <9 –Titrate to 110–120 mmHg systolic with or without penetrating hemorrhage to maintain CPP

35 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Secondary Survey & Ongoing Exam Secondary Survey –Do not delay scene time if load-and-go Ongoing Exam –Record  Level of consciousness  Pupil size & reaction  GCS  Weakness or paralysis

36 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Management Hypoxia –Perfusion decrease causes cerebral ischemia –Hyperventilation increases hypoxia significantly more than it decreases ICP Assist ventilation –High-flow oxygen –One breath every 6–8 seconds –SpO 2 >95% –Maintain ETCO 2 at 35 mmHg –Endotracheal intubation

37 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Management –Spinal Motion Restriction –Consider sedation if aggitated or combative –Record baseline observations vital signs –Continuously monitor –IV access avoid hypotention –Hyperventilate if cerebral herniation

38 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Hyperventilation Rates Capnography Maintain ETCO 2 30-35 mmHg Age GroupNormal RateHyperventilation Adult8–10 per minute20 per minute Children15 per minute25 per minute Infants20 per minute30 per minute

39 International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell Alabama College of Emergency Physicians Summary Knowledge of central nervous system Essential for assessment and management Key actions Rapid assessment, airway management, prevent hypotension, frequent Ongoing Exams Serious head injury has spinal injury until proven otherwise Altered mental status common


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