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Layers of the Meninges : 

Layers of the Meninges

HEAD INJURYin Emergency : 

HEAD INJURYin Emergency

brain : 

brain

Mechanisms of Injury : 

Mechanisms of Injury Motor Vehicle Crashes most common cause of head trauma most common cause of subdural hematoma Sports Injuries Falls common in elderly and in presence of alcohol associated with subdural hematomas Penetrating Trauma missiles more common than sharp projectiles

Categories of Injury : 

Categories of Injury Coup injury directly posterior to point of impact more common when front of head struck Contrecoup injury directly opposite the point of impact more common when back of head struck Diffuse Axonal Injury (DAI) shearing, tearing or stretching of nerve fibers more common with vehicle occupant and pedestrian Focal Injury limited and identifiable site of injury

Slide 7: 

Traumatic Head Injury ALL-NET Pediatric Critical Care Textbook Source: LifeART EM Pro (1998) Lippincott Williams & Wilkins. www.med.ub.es/All-Net/english/neuropage/trauma/head-8htm

Head Injury : 

Head Injury Broad and Inclusive Term Traumatic insult to the head that may result in injury to soft tissue, bony structures, and/or brain injury Blunt Trauma more common dura intact fractures, focal brain injury, DAI Penetrating Trauma less common (GSW most common) dura and cranial contents penetrated fractures, focal brain injury

Brain Injury : 

Brain Injury “a traumatic insult to the brain capable of producing physical, intellectual, emotional, social and vocational changes” Three broad categories Focal injury cerebral contusion intracranial hemorrhage epidural hemorrhage Subarachnoid hemorrhage Diffuse Axonal Injury concussion (mild and classic form)

Major Head Trauma cont. : 

Major Head Trauma cont. Diffuse axonal injury (DAI) Widespread axonal damage Occurs after mild, moderate, or severe TBI Trauma changes the function of the axon Axon swelling (Axonal ballooning) Disconnection 12 to 24 hours to develop Clinical signs Decreased LOC Increased ICP Decerebration or decortication Global cerebral edema

Causes of Brain Injury : 

Causes of Brain Injury Direct (Primary) Causes Impact Mechanical disruption of cells Vascular permeability or disruption Indirect (Secondary or Tertiary) Causes Secondary edema, hemorrhage, infection, inadequate perfusion, tissue hypoxia, pressure Tertiary apnea, hypotension, pulmonary resistance, ECG changes

Pathophysiology of (ICP) IncreasedIntracranial Pressure : 

Pathophysiology of (ICP) IncreasedIntracranial Pressure – Normal ICP 10 mmHg – 80% of head trauma patients have an elevated ICP – Peaks 2-3 days after head trauma – Brain Contents • Brain solids • Brain water • Brain blood • (CSF) Cerebrospinal Fluid

Pathophysiology of Brain Injury : 

Pathophysiology of Brain Injury Levels of Increasing ICP Cerebral cortex and upper brain stem BP rising and pulse rate slowing Pupils reactive Cheyne-Stokes respirations Initially try to localize and remove painful stimuli Middle brain stem Wide pulse pressure and bradycardia Pupils nonreactive or sluggish Central neurogenic hyperventilation Extension

Pathophysiology of Brain Injury : 

Pathophysiology of Brain Injury Levels of Increasing ICP Lower Brain Stem / Medulla Pupil blown (side of injury) Ataxic or absent respirations Flaccid Irregular or changing pulse rate Decreased BP Usually not survivable

Pathophysiology of Brain Injury : 

Pathophysiology of Brain Injury Herniation transtentorial herniation downward displacement of the brain uncal herniation “downward displacement through the tentorial notch by a supratentorial mass exerting pressure on underlying structures including the brain stem”

Head Injuries : 

Head Injuries Scalp Laceration/Avulsion Most common injury Vascularity = diffuse bleeding Can produce hypovolemia in children Generally does not cause hypovolemia in adults

Head Injuries : 

Head Injuries Depressed Linear Stellate Basilar Skull Fractures

Head Injuries : 

Head Injuries Linear Fracture Usually NOT identified in field 80% of all skull fractures Suspect based on Mechanism of injury Overlying soft tissue trauma Usually NOT emergency Temporal region = ~ Epidural hematoma

Head Injuries : 

Head Injuries Depressed Skull Fracture Segment pushed inward Pressure on brain causes brain injury Neurologic signs and symptoms evident

Head Injuries : 

Head Injuries Basilar Skull Fracture Difficult to detect on x-ray Signs & Symptoms depend on amount of damage Diagnosis made clinically by finding: CSF Otorrhea CSF Rhinorrhea Periorbital ecchymosis Battle’s sign

Head Injuries : 

Head Injuries Basilar Skull Fracture Do NOT pack ears Let drain Do NOT suction fluid Do NOT instrument nose

Head Injuries : 

Head Injuries Open Skull Fracture Cranial contents exposed Manage like evisceration Protect exposed tissue with moist, clean dressing (if possible) Neurologic signs & Symptoms evident

Brain Injuries : 

Brain Injuries Intracranial Hematomas Epidural Subdural Intracerebral

Brain Injuries : 

Brain Injuries Epidural Hematoma Blood between skull and dura Usually arterial tear middle meningeal artery Causes increase in intracranial pressure

Brain Injuries : 

Brain Injuries Epidural Hematoma Unconsciousness followed by lucid interval Rapid deterioration Decreased LOC, headache, nausea, vomiting Hemiparesis, hemiplegia Unequal pupils (dilated on side of clot) Increase BP, decreased pulse (Cushing’s reflex)

Brain Injuries : 

Brain Injuries Subdural Hematoma Between dura mater and arachnoid More common Usually venous bridging veins between cortex and dura Causes increased intracranial pressure

Brain Injuries : 

Brain Injuries Subdural Hematoma Slower onset Increased ICP Headache,decreased LOC, unequal pupils Increased BP, decreased pulse Hemiparesis, hemiplegia

Brain Injuries : 

Brain Injuries Intracerebral Hematoma Usually due to laceration of brain Bleeding into cerebral substance Associated with other injuries DAI Neuro deficits depend on region involved and size repetitive w/frontal lobe Increased ICP

Brain Injuries : 

Brain Injuries Injury to Cerebral Parenchyma Laceration Concussion Contusion

Brain Injuries : 

Brain Injuries Laceration Penetrating wounds GSW Stab Depressed Fracture Severe blunt trauma Sudden acceleration/deceleration

Brain Injuries : 

Brain Injuries Concussion Transient loss of consciousness Retrograde amnesia, confusion Resolves spontaneously without deficit Usually due to blunt head trauma

Cerebral Contusion : 

Cerebral Contusion Signs and Symptoms Personality changes Loss of consciousness Paralysis (one-sided or total) Unequal pupils Vomiting

Head Trauma : 

Head Trauma Concussion Post-concussion syndrome Headaches Depression Personality changes

Diagnostic Studies : 

Diagnostic Studies MRI Brain Scan

Head injury Assessment : 

Head injury Assessment

Head Trauma Assessment : 

Head Trauma Assessment Early Detection Control of Increased ICP Critical

Head Trauma Assessment : 

Head Trauma Assessment Cerebral Perfusion Pressure = Mean Arterial Pressure - Intracranial Pressure CPP = MAP – ICP Target CPP’s Age range Keep greater than Adults 60-70mmHg Children 50-60mmHg Infants 40mmHg

Scene 7 ICP Prevention : 

Scene 7 ICP Prevention Reduce environmental stimuli, rest periods Elevation of head of bed to 30 degrees with head in a neutral position Avoid extreme neck flexion Prevent/treat fever Sedation; restraints avoided if possible Restrict physical activity Intubation and mechanical ventilation if sedated with Propofol

ICP prevention continued : 

ICP prevention continued Maintain PaO2 Maintain fluid balance and assess osmolality Maintain systolic arterial pressure between 100 and 160 mm Hg Maintain CPP > 70 mm Hg Reduction of cerebral metabolism w/ High-dose barbiturates (decreases metabolic demands of the brain & cerebral blood flow, stabilizes cell membranes, decreases vasogenic edema formation, produces more uniform blood supply)

Treatment : 

Treatment Ventriculostomy - gold standard for ICP monitoring and CSF removal • Other methods include: intraparenchymal monitor, subarachnoid, subdural (bolt) and epidural • none of which are as reliable as the ventriculostomy Ventriculostomy Position

Head Trauma Assessment : 

Head Trauma Assessment LOC = Best Indicator Altered LOC = Intracranial trauma Trauma patient unable to follow commands =25% chance of intracranial injury needing surgery

Head Trauma Assessment : 

Head Trauma Assessment AVPU Scale A = Alert V = Responds to Verbal stimuli P = Responds to Painful stimuli U = Unresponsive

Head Trauma Assessment : 

Head Trauma Assessment Glasgow Scale Eye Opening Motor Response Verbal Response

Glasgow Coma Scale (Pediatric) : 

Glasgow Coma Scale (Pediatric) Eye Opening All Ages • 4 Spontaneous • 3 To voice • 2 To pain • 1 No response Best Motor Response Infant-5 Years >5 Years • 6 Normal movement Obeys commands • 5 Localizes pain Localizes pain • 4 Withdrawals Withdrawals • 3 Abnormal flexion Flexes to pain • 2 Abnormal extension Extends to pain • 1 No response No response Best Verbal Response <1 Year 1-5 Years >5 Years • 5 Coos, babbles Oriented Oriented • 4 Irritable cries Confused Confused • 3 Cries to pain Inappropriate cries Inappropriate words • 2 Moans to pain Incomprehensible sounds Incomprehensible sounds • 1 No response No response No response Note: A total score of <8 indicates severe neurologic injury and requires aggressive intervention including intubation.

Head Trauma Assessment : 

Head Trauma Assessment Eyes Unequal Pupils + Decreased LOC = Compression of oculomotor nerve Probable mass lesion Unequal Pupils + Alert patient = Direct blow to eye, or Oculomotor nerve injury, or Normal inequality

Head Trauma Assessment : 

Head Trauma Assessment Respiratory Patterns Cheyne Stokes Diffuse injury to cerebral hemispheres Central neurological hyperventilation Injury to mid-brain Apneustic Injury to pons

Head Trauma Assessment : 

Head Trauma Assessment Motor Response Is patient able to move all extremities? How do they move? Decorticate Decerebrate Hemiparesis or Hemiplegia Paraplegia or Quadraplegia

Head Trauma Assessment : 

Head Trauma Assessment Motor Response Lateralized/Focal Signs = Lateralized or Focal Deficits Altered motor function may be due to fracture/dislocation

Head Trauma Assessment : 

Head Trauma Assessment Vital Signs Cushing’s Triad Suggests Increased Intracranial Pressure Increased BP Decreased Pulse Irregular respiratory pattern

Head Trauma Assessment : 

Head Trauma Assessment Vital Signs Isolated head injury will NOT cause hypotension in adult Look for another life threatening injury Chest Abdomen Pelvis Multiple long bone fractures

Assessment of Head Injury : 

Assessment of Head Injury Other Indicators of Increased ICP Headache Nausea Vomiting (often projectile) Seizures

Head Trauma Assessment : 

Head Trauma Assessment Summary Most important sign = LOC Direction of changes more important than single observations Importance lies in continued reassessment compared with initial exam altered LOC in trauma = Intracranial injury

Head Trauma Management : 

Head Trauma Management Airway Open Assume C-spine Trauma Jaw Thrust with C-spine Control Clear - Suction As Needed Maintain Intubation if No Gag Reflex, or RSI Rapid -Sequence Intubation (RSI) Avoid nasal intubation

Head Trauma Management : 

Head Trauma Management Breathing Oxygenate - 100% O2 Ventilate No ROUTINE Hyperventilation Hyperventilate at 20 to 24 breaths per minute IF: Glasgow less than 8 Rapid neurologic deterioration Evidence of herniation

Head Trauma Management : 

Head Trauma Management Hyperventilation--Benefits Decreased PaCO2 Vasoconstriction Decreased ICP

Head Trauma Management : 

Head Trauma Management Hyperventilation--Risks Decreased cerebral blood flow Decreased oxygen delivery to tissues Increased edema

Head Trauma Management : 

Head Trauma Management Circulation Maintain adequate BP and Perfusion IV of LR/NS TKO if BP normal or elevated If BP decreased LR/NS bolus titrated to BP ~ 90 mm Hg Consider PASG/MAST if BP below 80 Monitor EKG -- Do NOT treat bradycardia

Head Trauma Management : 

Head Trauma Management Spinal motion restriction If BP normal or elevated, spine board head elevated 300

Head Trauma Management : 

Head Trauma Management Monitor for hyperthermia Vasoconstriction Heat retention Increased cerebral 02 demand

Head Trauma Management : 

Head Trauma Management Drug Therapy Considerations Only after: Management of ABC’s Controlled hyperventilation

Management of Head Injury : 

Management of Head Injury Do NOT apply pressure to open or depressed skull fractures Do NOT attempt to stop flow of blood or CSF from nose, ears Do NOT remove penetrating objects

Head Trauma Management : 

Head Trauma Management Drug Therapy Considerations Mannitol (Osmitrol®) Osmotic diuretic Decreases cerebral edema May cause hypovolemia May worsen intracranial hemorrhage Often reserved for herniation

Head Trauma Management : 

Head Trauma Management Drug Therapy Considerations Dexamethasone (Decadron®) Steroid Decreases cerebral edema Effects delayed Little usage today

Head Trauma Management : 

Head Trauma Management Drug Therapy Considerations Furosemide (Lasix®) Loop diuretic Decreases cerebral edema May cause hypovolemia Often reserved for herniation

Head Trauma Management : 

Head Trauma Management Drug Therapy Considerations Diazepam (Valium®) Anticonvulsant Give if patient experiences seizures May mask changes in LOC May depress respirations May worsen hypotension

Head Trauma Management : 

Head Trauma Management Drug Therapy Considerations Glucose Assess blood glucose Administer only if hypoglycemic Consider thiamine in malnourished

Head Trauma Management : 

Head Trauma Management Transport Considerations Trauma Center GCS < 12 Evidence of herniation Unconscious Multisystem trauma with head trauma Consider comorbid factors

Head Trauma Management : 

Head Trauma Management Helmet Removal Immediate removal if interferes with priorities access to airway or airway management ventilation cervical spine motion restriction May only need to remove face piece to access airway Consider interference with SMR Technique requires adequate assistance training in the procedure padding if shoulder pads left on

SUMMARY : 

SUMMARY • Trauma is the leading cause of unintentional death in those patients between the ages 1-34. • Trauma assessment is a Basic Life Support skill and requires that you have a well organized approach. Patient survival depends on your assessment skills. • Blunt abdominal trauma from an MVA has a high incidence of injuries to the spleen and liver. Rapid evaluation and transport are a must! • Chest trauma is the second leading cause of all trauma mortality, accounting for 20% of all trauma deaths. • Severe traumatic head injury is the leading cause of trauma deaths with as many as 450,000 patients per year requiring hospitalization for their head injury. • Don’t forget your ABC’s in evaluating trauma patients!

Slide 72: 

?????????? ??? ??? ???? 22 ?? case Ambulance ??.???????????? refer ?????.?????????? CC: ???????????? ??????????????? ????????????????????????????????????????????????????? PI: 30 ???????????????? ????????????????????????????????.?????????? ?????????????? ???????????????????????? ????????????????????? ?????????????????????????? ?????? 2 ???????????????????????????? ????????????????????????????????????

CASE STUDY : 

CASE STUDY ?????????? 01.50 ?.???????????????????? GCS: E2M5V1 pupill 3 m. RTBE ????? ??.????????????????????????????????? No.7.5 Fix. 21. - On Bird’ s respirator Vt. : 500 ml. FiO2 :0.4 Rate 16 /m. On philaderphea On NG –tube feeding Bandage stop bleeding ????????????????? On LRS 1000 ml. IV rate 80 cc/hr. On foley’s cath with bag . urine output ?????????? flow?? CT – brain without contrast : CXR: contusion both upper lung , no fracture rib. Both pelvic Ap,lat : no fracture U/S whol Abdomen : normal study

Slide 74: 

?????????? 03.50 ?. ??????????????????????????????????????????? ?? refer ????.??????? ??????????????? ?????????? 05.00 ?. Ambulance ??.??????? ?????.?????????? ????????????????????????????????????? ??????????????????? Ambulance ?????? Unconsciousness. GCS: E1M5Vt pupill 3 m. RTBE On ET – tube No.7.5 Fix 22 On Bird’ s respirator Vt. : 500 ml. FiO2 :0.4 Rate 16 /m. On philaderphea On NG –tube feeding ?? Gastric content ??????????????????? ?????????????????????? Bandage stop bleeding ????????????????? ?? bleeding ??? gauze ???????? On 0.9% nss. 1000 ml. IV. rate 80 cc/hr. ??????????????? 900 ml. On foley’s cath with bag . urine output ~ 50 cc.?????????? flow??

Slide 75: 

?????????? 05.20 ?. ??????????????????????????????????? ???????????????? Ambulance ????????????????? ????????(?????-??????) ???????case ?????? consult Sx. ??????????? ??????????????????????????????? CT – chest, CT- whol abdomen, CT – Cspine ????????? ?????????? 05.30 ?. ????????? Ambulance Pt. On ventrilater CMV mode Vt. : 650ml. FiO2 :0.4 Rate 16 /m. ??????????? ~ 30 ???? , On 0.9% nss. 1000 ml. IV. rate 80 cc/hr. ??? BP 99/60 mmHg, PR 110 /min. ???????????? order Dopamine 2 mcq./kg./min. IV. ??????????????????????????? 10 ???? ??? BP.??? BP 118/72 mmHg, PR 104 /min. O2 sat 100 %

Slide 76: 

?????????? 05.50 ?. BP 108/97 mmHg, PR 110 /min. O2 sat 100 % ?????????? 06.00 ?. BP 140/67 mmHg, PR 107 /min. O2 sat 100 % ?????.??????? ??????????????????? X-RAY ??????? CT – chest, CT- whol abdomen, CT – Cspine ???????????? stable ?? ?????????????????????????????? ???????????????????????????????? ????????????????????? ??? Monitor O2 sat 100 % BP 136/90 mmHg ,PR 102 /min. ?????????? secretion ?? ET- tube

Slide 77: 

?????????? 06.30 ?. ??????????????? ????ICU1 ???????????????????????????????? ??????????? ????????????????????????????? ?? secretion ?? ET- tube ?????????????????????? ???????????????????????? X-RAY ??????????????????????? ???????? suction secretion ???????ICU1 HPI: ????????????????? ??????????????

Slide 78: 

Physical examination GA: Unconsciousness. GCS: E2M5Vt pupill 3 m. RTBE V/S: BP 140/90mmHg, PR 100 /min. Rate 16 /m. O2 sat 100 % HEAD : Multiple lacered wound with forieng body ??????????????? ???? bleeding ??? gauze Heart: tachycardia Lung: Equal brest sound, secretion sound ABD: Soft, not tender, Multiple abration wound and contusion wound EXT: respond to deep pain all ext.

Slide 79: 

CBC WBC 13.7 X 10 9/L (4.8-19)mm3 RBC 5.15 X 10 12/L (4.2-5.4) HGB 16.3 gm% (14-18) Hct 49 % (42-52)MCV 95 fl. ( 80-96)MCH 31.7 pg (26-34) MCHC 33.3 % (32-36) RDW 12.2 % (11-14.5) Plt 298 X10 9/L (140-440) N Plt Smear Adequate NE% 52.1 % (45.0-70.0) LY% 39.0 % (25.0-40.0) MO% 7.9 % (2.0-12.0) EO% 1.0% (1.0-8.0) BA% 0.0% (0-1.0) Normochromia Yes Normocytosis Yes

Slide 80: 

CHEMISTRYBUN 11.0 mg/dL (7-18) Creatinine 1.0 mg/dL (0.6-1.3) Sodium 143 mmol/L (136-145) Potassium 3.7 mmol/L (3.5-5.1) Cl P. 104 mmol/L (98-107) CO2 P. 22.1 mmol/L (21-32) Prothrombin time PT control 11.9 Sec. PT 11.9 Sec (N 10.0-15.0) INR 1.00 APTT PTT control 26.7 Sec. PTT 24.9 Sec. (N 30.0-42.0) PTT Ratio 0.93

Slide 81: 

Diagnosis & Treatment Car Accident with Intraventricular Hemorrhage with Multiple Organ injury R/O lung contusion and Multriple lacered wound at maxillofacial

Slide 82: 

Treatment ??.?????????? - On ET – tube No.7.5 Fix 21 On Bird’ s respirator Vt. : 500 ml. FiO2 :0.4 Rate 16 /m. - On philaderphea On NG –tube feeding ?? Gastric content ??????????????????? ?????????????????????? Bandage stop bleeding ????????????????? ?? bleeding ??? gauze ???????? On LRS 1000 ml. IV rate 80 cc/hr. ?????????????? 0.9% nss. 1000 ml. IV. rate 80 cc/hr. On foley’s cath with bag . urine output ~ 50 cc.?????????? flow??

Slide 83: 

Ambulace On ventrilater CMV mode Vt. : 650ml. FiO2 :0.4 Rate 16 /m. On 0.9% nss. 1000 ml. IV. rate 80 cc/hr. Dopamine 2 mcq./kg./min. IV. Monitor EKG : sinus tachycardia , O2 sat , BP ??.??????? CT – chest, CT- whol abdomen, CT – Cspine

????????????????? : 

????????????????? ???????? 1 ???????????????????????????????????????? ???????????????????????????????????????????????????? ?????????????? ???????   Hydrocephalus ??????????????????????????? ?????????????? 1. ???????????? ???? Glasgow Coma Scale = 11 ????? (E4V2M5) 2. ??????????????? 1 ????????? ???????? 2 ????????? ????????????????????? ???? 2 ???? 3. ????????????????? 170/100 mmHg 4. CT- brain ???? Intraventricular Hemorrhage

Slide 85: 

???????????? ????????????????????????????? ???????????????????????????????       ??????????????? 1. ???????????????????????????????? 2. ????????????????????????????????????????????????? 11 ????? 3. ?????????????????????????????????????????????????? 2 ???? 4. ???????????????????????? ??? ????????????????????????? 37.5 ???????????? ??????? ??????????????? 90/60 ????????????? ?????????? 140/90 ????????????? ??????????????? 60-100 ?????/???? ??????????????????????? 12-20 ?????/????

Slide 86: 

???????????????     1.??????? Vital sign , Neurosign ????????????????????????????????     2.??????????????????????????????????????? 30 ????     3. ???????????????????????????????????????? ????????????????????????????????????????????????????????????????????????? , on philaderphai     4. ??????????????????????????????????????????????? ???? ?????????? ???????     5. ???????????????????????????????????????????? ???? Isometric exercise     6. ???????????????????????????????????90/60 – 140/90 mmHg

Slide 87: 

7. ??????????????????????? ???????????????????? ??????????????????????????????????? ???????????????????????????? 10-15 ???? ??????????????????????????????????????????????? ?????????????????????????????????????? 8. ???????????????????????????????????????? ??? 0.9 % NSS 1,000 ????????? IV drip 80 ??????????????????? ??? ?????????????????????????????????????????????????????????????????????????????????? 9. ????????????????????????? ?????????????     10. ????????????????????????????????????