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Head Trauma. Objectives: A- Review specific of anatomy and physiology as related to head injuries. B- Identify the principles of general management of.

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Presentation on theme: "Head Trauma. Objectives: A- Review specific of anatomy and physiology as related to head injuries. B- Identify the principles of general management of."— Presentation transcript:

1 Head Trauma

2 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.

3 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.

4 Head Trauma Neurosurgical consult essentialNeurosurgical consult essential Early transfer reduces morbidity and mortalityEarly transfer reduces morbidity and mortality CardiorespiratoryCardiorespiratory Level of consciousnessLevel of consciousness Pupillary reactionPupillary reaction Vital signsVital signs Associated injuriesAssociated injuries Skull film resultsSkull film results

5 Cranial Nerve Assessment Pupils occulomotor nerve ( IIIrd )Pupils occulomotor nerve ( IIIrd ) Others- lower assessment priorityOthers- lower assessment priority Alteration of Consciousness is The Hallmark of Brain InjuryAlteration of Consciousness is The Hallmark of Brain Injury

6 Unconsciousness Injury Bilateral cerebral corticesBilateral cerebral cortices Brain stem RASBrain stem RAS Increased ICPIncreased ICP Decreased CBFDecreased CBF Increased ICP Results in:Increased ICP Results in: Decreased perfusionDecreased perfusion Altered level of consciousnessAltered level of consciousness

7 History Determine cause and effectDetermine cause and effect Pre- and post injury statusPre- and post injury status Document communicateDocument communicate ReassessReassess Vital signs Identifies status neurologically and systemically. Identifies status neurologically and systemically. Respiratory AssessmentRespiratory Assessment Assess and correct deficienciesAssess and correct deficiencies Increased ICP - slower RRIncreased ICP - slower RR Increased ICP – noisy tachypneaIncreased ICP – noisy tachypnea Asses for other etiologyAsses for other etiology

8 Blood Pressure Increased ICP Increased BP & widened pulse pressureIncreased ICP Increased BP & widened pulse pressure Assess for other etiologyAssess for other etiology Treat shock vigorouslyTreat shock vigorouslyPulse Increased ICP bradycardiaIncreased ICP bradycardia Tachycardia grave signTachycardia grave sign Assess for etiologyAssess for etiology

9 Temperature TemperatureTemperature Weather extremesWeather extremes Control hyperthermiaControl hyperthermia Eye Opening Response Spontaneous – already open with blinking (normal) : four (4) pointsSpontaneous – already open with blinking (normal) : four (4) points To speech – not necessarily to request eye opening : three (3) pointsTo speech – not necessarily to request eye opening : three (3) points To pain – stimulus should not be to face : two (2) pointsTo pain – stimulus should not be to face : two (2) points None – make note if eyes are swollen shut : one (1) pointNone – make note if eyes are swollen shut : one (1) point

10 Verbal Response Oriented - knows name, age, etc. : five (5) pointsOriented - knows name, age, etc. : five (5) points Confused conversation - still answers questions: four (4) pointsConfused conversation - still answers questions: four (4) points Inappropriate words - speech is either exclamatory or random : three (3) pointsInappropriate words - speech is either exclamatory or random : three (3) points Incomprehensible sounds - do not confuse with partial respiratory obstruction : two (2) pointsIncomprehensible sounds - do not confuse with partial respiratory obstruction : two (2) points None – make note if intubation prevents speech: one (1) pointNone – make note if intubation prevents speech: one (1) point

11 Best Motor Response Obeys - moves limb to command and pain is not required: six (6) pointsObeys - 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) pointsLocalizes - changing the location of the pain stimulus causes the limb to follow: five (5) points Withdraws - pulls away from painful stimulus: four (4) pointsWithdraws - pulls away from painful stimulus: four (4) points Abnormal flexion - three (3) pointsAbnormal flexion - three (3) points Extensor response - two (2) pointsExtensor response - two (2) points No movement - one (1) pointNo movement - one (1) point

12 C-spine Assessment High index for suspicionHigh index for suspicion Reflex assessmentReflex assessment Sensory assessmentSensory assessment X-raysX-rays

13 Hints to Cervical Cord Injury Flaccid areflexia, especially with flaccid rectal sphincterFlaccid areflexia, especially with flaccid rectal sphincter Diaphragmatic breathingDiaphragmatic breathing Ability to flex forearms but not extend themAbility to flex forearms but not extend them Facial grimaces in response to pain above the clavicle but not belowFacial grimaces in response to pain above the clavicle but not below Hypotension without other evidence of shock (ie, hypotensive with warm extremities)Hypotension without other evidence of shock (ie, hypotensive with warm extremities) Priapism is an uncommon but characteristic signPriapism is an uncommon but characteristic sign

14 Brain stem responses :Neurosurgeon to perform occulocephalic & occulovestibular cranial nerve test. Brain stem responses :Neurosurgeon to perform occulocephalic & occulovestibular cranial nerve test. Skull X-raysSkull X-rays Do not delay primary assessment & management to obtain skull X-rays.Do not delay primary assessment & management to obtain skull X-rays.

15 Management Reassessment, O2 and Airway Concussion No significant brain injury or localizing signsNo significant brain injury or localizing signs History : amnesiac of eventHistory : amnesiac of event Admit : individualizeAdmit : individualizeContusion Significant alterations in consciousness and localizing signsSignificant alterations in consciousness and localizing signs Countercoup injuryCountercoup injury Admit and observe 48 hoursAdmit and observe 48 hours

16 Intracranial Hemorrhage Meningeal or brainMeningeal or brain CT - precise or diagnoseCT - precise or diagnose Clinical findings similarClinical findings similar Acute epiduralAcute epidural Middle meningeal artery tearMiddle meningeal artery tear Rapidly fatalRapidly fatal Hallmark : ipsilateral, dilated fixed pupilHallmark : ipsilateral, dilated fixed pupil Immediate surgeryImmediate surgery Prognosis : goodPrognosis : good

17 Acute Subdural Venous hemorrhageVenous hemorrhage life- threatening gradual onsetlife- threatening gradual onset severe underlying brain injurysevere underlying brain injury Prognosis : poorPrognosis : poorSubarachnoid Bloody CSF, meningeal irritationBloody CSF, meningeal irritation Headache, photophobiaHeadache, photophobia Nuchal rigidity, R/O C-spine injuryNuchal rigidity, R/O C-spine injury High index of suspicionHigh index of suspicion AdmitAdmit

18 Closed Brain Hemorrhages Occur at any locationOccur at any location CT- precise diagnosisCT- precise diagnosis Neurological deficits- region and size of hemorrhageNeurological deficits- region and size of hemorrhage Increased ICP Complications Cerebral edemaCerebral edema VasospasmVasospasm Loss of autoregulation( Neurosurgical consult )Loss of autoregulation( Neurosurgical consult )

19 Fluid Restriction Prevent Overhydration Diuretics Neurological consultNeurological consult Mannitol 50 gms IVMannitol 50 gms IV Furosemide 40-80 mg IVFurosemide 40-80 mg IV Urinary catheterUrinary catheter Deliberate Hypocapnia Maintain PCO2 at 26-28 torrMaintain PCO2 at 26-28 torr IntubationIntubation Latrogenic paralysisLatrogenic paralysis Monitor ABGs ( Neurosurgical consult )Monitor ABGs ( Neurosurgical consult )

20 Convulsions Intracranial hemorrhageIntracranial hemorrhageTreatment Diazepam 10mg IVDiazepam 10mg IV Diphenylhydantoin 1 gm IV Diphenylhydantoin 1 gm IV Phenobarbital or anaesthesiaPhenobarbital or anaesthesia RestlessnessRestlessness Identify etiologyIdentify etiology Correct causeCorrect causeHyperthermia Potential disastrousPotential disastrous Reversible neurologic findingsReversible neurologic findings Vigorous interventionVigorous intervention Scalp Wounds Blood lossBlood loss InspectionInspection RepairRepair

21 Surgical Management Obtain necessary tests earlyObtain necessary tests early Emergent surgeries for hematomasEmergent surgeries for hematomas Transfer to neurosurgeonTransfer to neurosurgeon Avoid delaysAvoid delays

22 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

23 I- Should the patient's condition show a change for the worse, consider other diagnoses and forms of treatment.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.Consult with a neurosurgeon and consider transfer. J- Reassess continually to identify changes necessitates neurosurgical intervention.J- Reassess continually to identify changes necessitates neurosurgical intervention.


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