head injury

HEAD INJURIES – NEURO CRITICARE

By Dr. G. RAJARAMAN

HOD. NEURO SURGERYIGGGH & PGI, PONDICHERRY

Traumatic Brain Injury

INCIDENCE & PREVALENCEINCIDENCE & PREVALENCE In India 1990 4790 (000) 2000 49500 2007 53000 Vehicle 75% - Two Wheeler 14% - Cars Every year 200,00,000 TBI One HI per 15 seconds One Death per 8 MINUTES About 4000 CRORES of Rupees are spent on HI

every year.

Our Hospital Incidence In 2004 – 2009 No of trauma admissions Male - 22, 784 - (5500 / year) Female - 6, 842 - ( 1350 /

year) Deaths - 1, 832 - ( 370 / year) About 20 inpatients per day At least one death per day

COMMON SCENES IN OUR COMMON SCENES IN OUR ROADSROADS

COMMON SCENES IN OUR COMMON SCENES IN OUR ROADSROADS

FREQUENCY OF VARIOUS INJURIESFREQUENCY OF VARIOUS INJURIES(%) (%) IN MOTOR VEHICLE ACCIDENTSIN MOTOR VEHICLE ACCIDENTS

ExtremitiesExtremities 3434

Head and NeckHead and Neck 3232

ChestChest 2525

AbdomenAbdomen 1515

CLASSIFICATION HI

1.Primary Injury2.Secondary InjuryPrimary HI

Impact InjurySkull FracturesFocal Brain InjuriesDiffuse Brain Injury

SECONDARY BRAIN INJURY

Due to increased ICP – Heamatomas, Edema , Hypoxia, Hypotension, Ischemia and electrolytes abnormalities

PRIMARY BRAIN INJURY TO BE AVOIDED

SECONDARY BRAIN INJURY MUST BE PREVENTED

Brain Contusion

A brain contusion is defined by cell death accompanied by hemorrhage (leakage of blood)

The soft brain tissue is vulnerable to contusion in head trauma

The contusion often occurs at a site distant from the point of impact

Gross brain image from http://neuropathology.neoucom.edu/chapter4/chapter4bContusions_dai_sbs.html#contusion

Epidural Hematomas

Slides from Haines:Fundamental Neuroscience for Basic and Clinical Applications 3e -www.studentconsult.com

Sudural Hematomas

Slide from Haines:Fundamental Neuroscience for Basic and Clinical Applications 3e -www.studentconsult.com

Diffuse Brain Swelling

Observe swelling (darker tissue) on brain CT scan of a 7-month-old victim of child abuse. What other injuries are present?

Brain Swelling

Observe diffuse swelling (yellow tissue) and expansion of brain tissue into ventricles

Swelling of the Brain

Brain surface image from www-medlib.med.utah.edu

Observe widening and flattening of gyri on brain surface

Diffuse Axonal Injury

Occurs in up to 1/2 of traumatic brain injuries1

Is a diffuse form of injury, meaning that damage occurs over a more widespread area than in focal brain injury

Involves the shearing of axons in the white matter tracts

Diffuse Axonal Injury

Is one of the major causes of unconsciousness and persistent vegetative state after head trauma.

Over 90% of patients with severe DAI never regaining consciousness (those that do wake up often remain significantly impaired)

Diffuse Axonal Injury

A microscopic view of axonal degeneration

Pathology of brain injury is differernt!

The volume of the intracranial vault =

Intracranial Contents: 80% brain tissue 10% blood 10% cerebrospinal fluid

An increase in the volume of any of these intracranial contents causes increased intracranial pressure

1. The brain can swell (edema)

2. Excess blood can accumulate due to hemorrhage

3. Cerebrospinal fluid can accumulate due to blockage of outflow

The intracranial vault is a fixed volume --> Bone does not expand!

BRAIN HERNIATIONS

Pre-arrival

Resource identification and allocation

1o Survey 2o Survey

Basic Studies Specialty Studies

Reevaluation

Resuscitation

1o Therapy Definitive Therapy

Trauma:Initial Management Priorities Components of Management

1 Hour

• Establish leadership - Involved leader- Remote leader

Anesthesiologist

CRNA1o Nurse

Tray

Line person

Chest tube person

Bystander

Bystander

Tray

CPR person

Bystander

Tray

Tray

Team Leader

Examining person2o Nurse

BystanderTray

Line person

Chest tube person

Bystander

Tray

Coffee maker

Trauma:Initial Management Priorities

• Organize team - Number / type of personnel

- Assess competency levels

- Assign tasks

Pre-arrival

• Multiple medical teams and specialties

• Isolation and Precautions

• Machines

• Confined Space

• Access to ICU

• “Waiting Room Dynamics”

The ICU Culture

• Personnel - Primary team- Specialty teams

• Facilities - Admitting area - 1o & 2o treatment areas

• Materials - “tubes”, “lines”, “trays”- Familiarity w. equipment

Assess:

Trauma:Initial Management Priorities

1 hour

Pre-arrival 1o Survey

Resuscitation

2o Survey

Basic Studies Specialty Studies

Reevaluation

1o Therapy Definitive Therapy

Pre-arrival

Pre-arrival

• Can the Institution handle this patient?

• … at this time?

• Are there alternative facilities nearby?

Assess:

1o Survey

Resuscitation

2o Survey

Basic Studies Specialty Studies

Reevaluation

1o Therapy Definitive Therapy

1 hour

Pre-arrival

Airway:- assess- establish- maintain

Breathing:- assess- support

Circulation:- assess- access- stop hemorrhage- resuscitate

Trauma:Initial Management Priorities

Assess: • Immediate risk for loosing limb or life?

• Potential for (rapid) deterioration?

Primary Survey

Difficult Airway Management

WHAT IS THIS ?!

TO KEEP IT OPEN- OPA

BenefitsBenefits and and

LimitatioLimitationsns

IndicatioIndications and ns and

ContrainContraindicationdication

ss

CERVICAL SPINE FRACTURE

AWESOME Tube Dude!Now what?

Trauma patients usually do not die from lack of Hb but from hypovolaemia.

Parameters Class I Class II Class III Class IV

Blood loss%ml

0 - 15750

15 - 30750-1500

30 - 401500-2000

>40>2000

Blood pressure Normal Normal Decreased Decreased

Pulse rate <100 >100>120

Thready

>140

Very thready

Capillary refill

Normal(<2 sec)

Slow >2 sec

>2 sec Undetectable

Respiratory rate

14 - 20 20 - 30 30 - 40 >35

HEAD INJURY - MANAGEMENTGolden Hour: It is the FIRST 60 mts. Which decides the life or death4 Hour Rule4hrs – 30%4-24 hrs – 70 - 90%After24 hrs – 90 - 100% or PVS

Head Trauma Usually signifies craniocerebral

trauma Includes alteration in consciousness High potential for poor outcome

Death at injury Death within 2 hours after injury Death 3 weeks after injury

TIME

Time was gold Time was moneyTime is life

E.R. MANAGEMENTCONTINUE THE BRAIN RESUSCITATION

INITIATED IN THE FIELD & TRANSPORT.

IMAGING FOR CEREBRAL AND SPINAL INJURIES.

EMERGENCY ROOM TREATMENT BEGINS WITH THE PATIENT ARRIVAL AND ENDS WITH TRANSFER TO THE OT (OR) NICCU.

E.R. MANAGEMENT

A AIRWAYB BREATHINGC CIRCULATIOND DRUGSE EXAMINATIONF FLUIDS

AIRWAY

POSITIONINGTHROAT CLEARINGMETALIC AIRWAYET TUBEEMERGENCY TRACHEOSTOMY

OUR AIM : Air should go into both the lungs EQUALLY AND ADEQUATELY

and to maintantain Spo2 > 90%

BREATHING

HYPO VENTILATION – less than 10HYPERVENTILATION – more than 35ABNORMAL VENTILATIONS

- chyne stokes- Apneustic- Ataxic- Paradoxical

CIRCULATION AIM is to maintain CPP > 70 ( at

least above 50 mm Hg )

CPP CPP = MAP - ICP

MAP MAP = DIASTOLIC + 1/3 PULSE

PRESSURE MAP = 2/3 diastolic + 1/3 systolic MAP = CO X PVR - CVP

Autoregulation of Cerebral Blood Flow Blood vessels alter their diameter to ensure

a constant cerebral blood flow Lower limit for MAP is 50mm Hg. Below this, cerebral flow decreases and

there is risk of ischemia Upper limit is MAP of 150mmHg. Above this

the cerebral blood vessels are maximally constricted. Blood vessels cannot constrict more to control high pressure. Blood brain barrier is disrupted and cerebral edema and ICP results

MAP= DBP + 1/3 Pulse Pressure

NORMAL ICP 8 – 12 mm Hg 10 – 15 cm of water

Intracranial Pressure Monro-Kellie hypothesis (applies

only to children with a rigid skull and not neonates) Skull is an enclosed space with three

variables Brain tissue Blood Cerebrospinal fluid

Volume (mL)

Pressure

(mmHg)

Intracranial Pressure Rises as Brain+Bood+CSF volume Increases

ICP > 20 mmHg

CPP 100 – 20 = 80 90 – 20 = 70 90 – 50 = 40

Intracranial Pressure -

ICP

CPP

This patient has dangerously high intracranial pressures, which increase the likelihood of morbidity and mortality

Cerebral Perfusion Pressure (CPP)

Pressure needed to maintain blood flow to the brain

MAP-ICP=CPP Normal CPP is 60-100 CPP>100 is hyperperfusion and IICP CPP< 60 hypoperfusion CPP<30 incompatible with life

ICP - MANAGEMENT Keep HOB elevated 30 degrees if BP is

normal If BP is low will need to put HOB flat Keep head in alignment to prevent

cutting off venous flow from the head Don’t elevate knees – this will increase

intrathoracic pressure Turn gently from side to side – if turning

raises ICP, pt will need to stay on back

Drug Therapy Mannitol – Rapid short acting

diuretic that decreases ICP. Decreases total brain water content

Watch fluids and electrolytes closely (I and O and labs)

Don’t give in cases of renal failure or if serum osmolality increased

Drug Therapy Loop diuretics – reduce blood

volume and tissue volume Corticosteroids – Decadron most

common steroid used. Watch for side effects. Should be on antacids or H2 receptor blockers to prevent ulcers.

DRUGSANITIBIOTICSANALGESICANTIEPILEPTIC

EPSOLIN – Loading dose for patients having 2 or more fits - 15 mg / kg over ½ hour in

100 ml/NSProphylaxis and maintenance 5mg/kg/24

hrs in 2 to 3 divided dose.

ANTIEDEMALASIX (Freusemide) 20mg/IV/B.D. for adultMANNITOL 100ml IV TDS

Acute Medical evaluation: CT Physical and neurological exam

Serial assessment

EXAMINATION

Glasgow Coma Scale Best Eye Response. (4)

• No eye opening. • Eye opening to pain. • Eye opening to verbal command. • Eyes open spontaneously

Best Verbal Response. (5) • No verbal response • Incomprehensible sounds. • Inappropriate words. • Confused • Oriented

 Best Motor Response. (6) • No motor response. • Extension to pain. • Flexion to pain. • Withdrawal from pain. • Localizing pain. • Obeys Commands.

POINTS BEST EYE OPENING

BEST VERBAL RESPONSE

BEST MOTOR RESPONSE

6 - - OBEYS

5 - ORIENTED LOCALIZES PAIN

4 SPONTANEOUS

CONFUSED WITHDRAWS TO PAIN

3 TO SPEECH IN APPROPRIATE FLEXION RESPONSE

2 TO PAIN INCOMPREHENSIVE

EXTENSION RESPONSE

1 NONE NONE NONE

GLASGOW COMA SCALE (FOR AGE ≥ 4 YEARS)

E4 V5 M6 Minimum 3, Maximum 15

POINTS BEST EYE OPENING

BEST VERBAL RESPONSE BEST MOTOR RESPONSE

6 - - OBEYS

5 - SMILES, FOLLOWS OBJECTS

LOCALIZES PAIN

4 SPONTANEOUS

CRYINGCONSOLABLE

INTERACTION

WITHDRAWS TO PAIN

3 TO SPEECH

INCONSISTENTLY CONSOLABLE

MOANING FLEXION

2 TO PAIN INCONSOLABLE

RESTLESS EXTENSION

1 NONE NONE NONE NONE

GLASGOW COMA SCALE (FOR AGE < 4 YEARS)

ANY CHANGE OF SCORE MORE THAN TWO IS IMPORANT

Skull Fracture Locations Frontal Orbital fracture Temporal fracture Parietal fracture Posterior fossa fracture Basilar skull fracture

Occurs at base of the skull Watch for rhinorrhea and otorrhea Test fluid leaking from nose or ear for

glucose and watch for halo If the drainage is CSF then the fracture has

crossed the dura

PUPILS

Bilateral Equal

> 1mm difference is significant

Change in size of pupils is indicative of III cranial nerve paralysis and coning on the side of DILATED PUPIL

PULSE

TACHYCARDIA-PainHypotensionCardiac Causes

BRADYCARDIA- Increased in ICPHypoxiaCardiac Causes

PUPILLARY DILATATION WITH BRADICARDIA

INCREASED INTRACRANIAL PRESSURE

Battle’s sign

FLUIDS

CRYSTALLOIDS AND COLLOIDSCRYSTALLOIDS

ISOTONIC – NS / RLHYPOTONIC – 5% DexHYPERTONIC - DNS

FLUIDS

RL IS BETTER- Sodium - Na+- Potassium - K+- Calcium - Ca+- Bicarbonate as lactate

SECONDARY SURVAY and Laboratory EEG Evoked potentials Lumbar puncture CT scan MRI scan Functional imaging Arteriography

Evalution – CT Scan

EDH SDH

Thick - Hyperdense Thin

Localised Diffuse

Lens Sickle

Only Blood CSF Mic

Fracture Skull No

No Brain Injury Brain cont.

No SAH SAH

What is this ?

EXTRA DURAL HEMATOMA

AcuteSkull Fracture 65 – 90%< 2 > 60 years rare

85% Arterial Bleeding70% Vault – Epicentre @ PTERION

ACUTE EXTRADURAL HAEMOTOMA

Left fronto temporal EDH

TREATMENT

Surgical Evacuation after craniotomyHaemostasisDural Hitch stichesDrainage

SUB DURAL HEMATOMA

SDHVenous Brain LaceAcute, SA, Chronic.0-3 day 3 days to 3 week to

3 week 3 monthsPresentation: LOC – No LIMortality : 50-90%

ACUTE SUBDURAL HAEMOTOMA

Treatment: summary Protect the airway & oxygenate Ventilate to normocapnia Correct hypovolaemia and

hypotension Prevent herniation Surgery for hemorrhage, edema,

skull repair Medications for edema, infection,

agitation, coagulants, anticonvulsives, etc.

Rehabilitation

The Value of Serial Observation

Looking to the future…

Will new imaging technologies and TREATMENT lead to advances in patient care?

Thanks for Your Attention

Questions, / discussion

?

THANK YOU

THANK YOU

VERYMUCH