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Trauma CNS Injury - Concussion

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Presentation on theme: "Trauma CNS Injury - Concussion"— Presentation transcript:

1 Trauma CNS Injury - Concussion



4 Cranial Injury Trauma must be extreme to fracture Basal Skull Linear
Depressed Open Impaled Object Basal Skull Unprotected Spaces weaken structure Relatively easier to fracture

5 Cranial Injury Basal Skull Fracture Signs Battle’s Signs Raccoon Eyes
Retroauricular Ecchymosis Associated with fracture of auditory canal and lower areas of skull Raccoon Eyes Bilateral Periorbital Ecchymosis Associated with orbital fractures

6 Cranial Injury Basilar Skull Fracture May tear dura
Permit CSF to drain through an external passageway May mediate rise of ICP Evaluate for “Target” or “Halo” sign

7 Brain Injury As defined by the National Head Injury Foundation
“a traumatic insult to the brain capable of producing physical, intellectual, emotional, social and vocational changes.” Classification Direct Primary injury caused by forces of trauma Indirect Secondary injury caused by factors resulting from the primary injury

8 Direct Brain Injury Types
Coup Injury at site of impact Contrecoup Injury on opposite side from impact

9 Direct Brain Injury Categories
Focal Occur at a specific location in brain Differentials Cerebral Contusion Intracranial Hemorrhage Epidural hematoma Subdural hematoma Intracerebral Hemorrhage Diffuse Concussion Moderate Diffuse Axonal Injury Severe Diffuse Axonal Injury

10 Focal Brain Injury Cerebral Contusion
Blunt trauma to local brain tissue Capillary bleeding into brain tissue Common with blunt head trauma Confusion Neurologic deficit Personality changes Vision changes Speech changes Results from Coup-contrecoup injury

11 Focal Brain Injury Intracranial Hemorrhage
Epidural Hematoma Bleeding between dura mater and skull Involves arteries Middle meningeal artery most common Rapid bleeding & reduction of oxygen to tissues Herniates brain toward foramen magnum

12 Focal Brain Injury Intracranial Hemorrhage
Subdural Hematoma Bleeding within meninges Beneath dura mater & within subarachnoid space Above pia mater Slow bleeding Superior sagital sinus Signs progress over several days Slow deterioration of mentation

13 Focal Brain Injury Intracranial Hemorrhage
Intracerebral Hemorrhage Rupture blood vessel within the brain Presentation similar to stroke symptoms Signs and symptoms worsen over time

14 Diffuse Brain Injury Due to stretching forces placed on axons
Pathology distributed throughout brain Types Concussion Moderate Diffuse Axonal Injury Severe Diffuse Axonal Injury

15 Diffuse Brain Injury Concussion
Mild to moderate form of Diffuse Axonal Injury (DAI) Nerve dysfunction without anatomic damage Transient episode of Confusion, Disorientation, Event amnesia Suspect if patient has a momentary loss of consciousness Management Frequent reassessment of mentation ABC’s

16 Diffuse Brain Injury Moderate Diffuse Axonal Injury
“Classic Concussion” Same mechanism as concussion Additional: Minute bruising of brain tissue Unconsciousness If cerebral cortex and RAS involved May exist with a basilar skull fracture Signs & Symptoms Unconsciousness or Persistent confusion Loss of concentration, disorientation Retrograde & Antegrade amnesia Visual and sensory disturbances Mood or Personality changes

17 Diffuse Brain Injury Severe Diffuse Axonal Injury
Brainstem Injury Significant mechanical disruption of axons Cerebral hemispheres and brainstem High mortality rate Signs & Symptoms Prolonged unconsciousness Cushing’s reflex Decorticate or Decerebrate posturing

18 Intracranial Perfusion
Review Cranial volume fixed 80% = Cerebrum, cerebellum & brainstem 12% = Blood vessels & blood 8% = CSF Increase in size of one component diminishes size of another Inability to adjust = increased ICP


20 ETCO2 Monitoring

21 Physiology of the Respiratory System

22 Respiration and Ventilation
Respiration is the exchange of gases between a living organism and its environment. Ventilation is the mechanical process that moves air into and out of the lungs.

23 The Respiratory Cycle Pulmonary ventilation depends upon changes in pressure within the thoracic cavity. Coordinated interaction among the respiratory system, the central nervous system, and the musculoskeletal system.

24 The Respiratory Cycle Inspiration
Thoracic cavity is closed except for the tracheal opening Respiratory centers stimulate nerves which stimulate muscle Changes in pressure occur with diaphragmatic contraction and intercostals contract and air is drawn inward Active process

25 The Respiratory Cycle Expiration
Receptors signal the respiratory center by way of the vagus nerve to inhibit inspiration. Expiration occurs Normally passive Use of accessory muscles

26 Pulmonary Circulation
Respiration also requires an intact circulatory system. Venous system carries deoxygenated blood to the right side of the heart, and the right ventricle pumps it into the pulmonary circulation.

27 Pulmonary Circulation
Diffusion occurs in the pulmonary capillaries. Blood returns to the left side of the heart for systemic circulation.

28 Diffusion Movement of a gas from an area of higher concentration to an area of lower concentration Transfers gases between the lungs and the blood and between the blood and peripheral tissues

29 Measuring Oxygen and Carbon Dioxide Levels
The partial pressure of a gas is its percentage of the mixture’s total pressure. Four major respiratory gases: Nitrogen (N2) Oxygen (O2) Carbon dioxide (CO2) Water (H2O)

30 Normal Arterial Partial Pressures
Oxygen (PaO2) = 100 torr (average = 80 – 100) Carbon dioxide (PaCO2) = 40 torr (average = 35 – 45)

31 Factors Affecting Oxygen Concentration in the Blood
Decreased hemoglobin concentration Inadequate alveolar ventilation Decreased diffusion across the pulmonary membrane Ventilation/perfusion mismatch occurs when a portion of the alveoli collapses

32 Factors Affecting Carbon Dioxide Concentrations in the Blood
Hyperventilation Lowers CO2 levels due to increased respiratory rates or deeper respiration Increased CO2 production include: Fever, muscle exertion, shivering, and metabolic processes Decreased CO2 elimination results from decreased alveolar ventilation

33 Respiratory Rate Involuntary; however, can be voluntarily controlled
Chemical and physical mechanisms provide involuntary impulses to correct any breathing irregularities

34 Nervous Impulses from the Respiratory Center
Main respiratory center is the medulla Apneustic center assumes respiratory control if the medulla fails to initiate impulses Pneumotaxic center controls expiration Stretch receptors prevent overexpansion of the lungs Hering-Breuer reflex

35 Chemoreceptors Located in carotid bodies, arch of the aorta, and medulla Stimulated by decreased PaO2, increased PaCO2, and decreased pH Cerebrospinal fluid (CSF) pH is primary control of respiratory center stimulation

36 Hypoxic Drive Hypoxemia is a profound stimulus of respiration in a normal individual. Hypoxic drive increases respiratory stimulation in people with chronic respiratory disease.

37 Measures of Respiratory Function
Respiratory rate Factors influencing rate include: Fever, emotion, pain, hypoxia, acidosis, stimulant drugs, depressant drugs, sleep Age Rate per Minute Adult 12–20 Children 18–24 Infants 40–60

38 Measures of Respiratory Function
Respiratory capacities and measurements Total lung capacity Total volume of air at maximum inhalation Average adult male TLC- 6 liters Tidal Volume Average volume of gas inhaled or exhaled in one respiratory cycle Approximately 500 cc

39 Measures of Respiratory Function
Respiratory capacities and measurements Dead-space Amount of gases in tidal volume that remains in the airway Alveolar volume The alveolar volume is the amount of gas in the tidal volume that reaches the alveoli for gas exchange Minute volume The amount of gas moved in and out of the respiratory tract in 1 minute

40 Measures of Respiratory Function
Respiratory capacities and measurements Alveolar minute volume Amount of gas that reaches the alveoli for gas exchange in one minute Inspiratory reserve volume The amount of air that can be maximally inhaled after a normal inspiration Expiratory reserve volume The amount of air that can be maximally exhaled after a normal expiration

41 Measures of Respiratory Function
Respiratory capacities and measurements Residual volume The amount of air remaining in the lungs at the end of maximal expiration Functional residual volume The volume of gas that remains in the lungs at the end of normal expiration Forced expiratory volume The amount of air that can be maximally expired after maximum inspiration

42 Non-Invasive Respiratory Monitoring
Devices will assist your measurement of the effectiveness of oxygenation and ventilation. Pulse oximetry, capnography, esophageal detection, and peak flow measurements

43 Non-Invasive Respiratory Monitoring
Pulse Oximeter Measures hemoglobin oxygen saturation in peripheral tissues The “fifth vital sign” Normal SpO2 varies between 95 and 99 percent 85 percent or lower indicates severe hypoxia © Scott Metcalfe

44 SPO2 and waveform Plethysmograph
Optically measures bloodflow to an organ

45 Non-Invasive Respiratory Monitoring
Capnography Recordings or displays of exhaled CO2 measurements are called capnography. When perfusion decreases, as occurs in shock or cardiac arrest, ETCO2 levels reflect pulmonary blood flow and cardiac output, not ventilation.

46 Non-Invasive Respiratory Monitoring
Capnography (cont.) A normal partial pressure of end-tidal CO2 (PETCO2) is approximately mmHg. Increased ETCO2 levels are found with hypoventilation, respiratory depression, and hyperthermia. Decreased ETCO2 levels can be found in shock, cardiac arrest, pulmonary embolism, bronchospasm, and with incomplete airway obstruction.

47 Non-Invasive Respiratory Monitoring
Capnography Colorimetric Device Contains pH-sensitive paper Causes a color change in the paper Electronic Devices Use an infrared technique to detect CO2 May be either qualitative or quantitative Reprinted by permission of Nellcor Puritan Bennett LLC, Pleasanton, California © Scott Metcalfe

48 Non-Invasive Respiratory Monitoring
Capnography (cont.) Clinical application Allows continuous monitoring of airway placement and ventilation for intubated patients Monitoring non-intubated patients Useful in CPR Rise with the onset of effective CPR © Scott Metcalfe

49 Non-Invasive Respiratory Monitoring
Esophageal Detector Device May be either a rigid syringe or a bulb syringe © Wolfe Tory Medical

50 IV Therapy

51 Catheters Sizes 24-14ga Varies in model types

52 Components Iv lock Saline Heparin Iv tubing Medication bag

53 Fluid Administration Administer up to 250ml of saline.
Medical control option for 250ml or more Indicators Excessive bleeding Blood pressure below 100mm HG Suspected dehydration Suspected internal bleeding

54 Field Triage & Patient Assessment

55 Priority Determination
Once the initial assessment is completed, determine the patient’s priority. If serious injury or illness is indicated by the initial assessment, conduct rapid head-to-toe assessment for other potential life-threats and initiate transport.

56 Top Priority Patients Poor general impression Complicated childbirth
Unresponsive Conscious but cannot follow commands Difficulty breathing Hypoperfusion Complicated childbirth Chest pain and BP below 100 systolic Uncontrolled bleeding Severe pain Multiple injuries

57 Expedite transport for a high-priority patient and continue assessment and care en route.
© Glen Jackson

58 The Focused History and Physical Exam

59 Types of Patients Trauma patient with significant mechanism of injury
Trauma patient with isolated injury Responsive medical patient Unresponsive medical patient

60 The Major Trauma Patient
Sustained significant injury Exhibits altered mental status from the incident

61 Evaluate the trauma scene to determine the mechanism of injury.
© Robert J. Bennett

62 Predictors of Serious Internal Injury
Ejection from vehicle Death in same passenger compartment Fall from higher than 20 feet Rollover of vehicle High-speed motor vehicle collision Vehicle-passenger collision Motorcycle crash Penetration of the head, chest, or abdomen

63 MOI Considerations for Infants and Children
Fall from higher than ten feet Bicycle collision Medium-speed vehicle collision with resulting severe vehicle deformity

64 A bent steering wheel indicates potentially serious injuries.
Courtesy of Edward T. Dickinson, MD

65 Rapid Trauma Assessment
Not a detailed physical exam Fast, systematic assessment for other life-threatening injuries Findings may influence transport decision

66 DCAP-BTLS Deformity Contusion Burns Abrasion Tenderness Penetration
Lacerations Swelling

67 Deformity

68 Contusion

69 Abrasions

70 Penetrations

71 Burns Superficial: Partial thickness: Full thickness:

72 Tenderness

73 Laceration

74 Swelling

75 Hemorrhage & Tourniquets

76 Hemorrhage Assessment
Scene Size-up Standard precautions are essential Evaluate the mechanism of injury Time elapsed since injury Determine the amount and rate of blood loss © Jeff Forster

77 Hemorrhage Assessment
Primary Assessment General Impression Obvious Bleeding Mental Status ABC Interventions Manage as you go O2 Bleeding control Shock BLS before ALS!

78 Hemorrhage Assessment
Secondary Assessment Rapid Trauma Assessment Full head to toe Consider air medical if stage 2+ blood loss Focused Physical Exam Guided by c/c Vitals, SAMPLE, and OPQRST Additional Assessment Search for signs of internal bleeding Bleeding from body orifice, melena, hematochezia Orthostatic hypotension

79 Hemorrhage Assessment
Ongoing Assessment Reassess vitals and mental status: Q 5 min: UNSTABLE patients Q 15 min: STABLE patients Reassess interventions: Oxygen ET IV Medication actions Trending: improvement vs. deterioration Pulse oximetry End-tidal CO2 levels

80 Hemorrhage Management
Assure that the airway is patent and breathing is adequate. Maintain the airway and provide the necessary ventilatory support. Administer high-flow oxygen. Carotid pulse. CaAssure that the patient has a palpable re for serious (arterial and heavy venous) hemorrhage, immediately after you correct airway and breathing problems.

81 Hemorrhage Management
Direct Pressure Controls all but the most persistent hemorrhage If bleeding saturates the dressing, cover it with another dressing If ineffective, may be necessary to visualize wound to apply pressure directly to site

82 Hemorrhage Management
Tourniquet Consider using a tourniquet only as a last resort when hemorrhage is prolonged and persistent. Apply a blood pressure cuff just proximal to the hemorrhage site. Inflate to apply pressure 20-30mmHg greater than the systolic blood pressure

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