neurologic trauma.pptx

8/9/2019 Neurologic Trauma.pptx

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Neurologic TraumaNeurologic Trauma

Bryan E. Bledsoe, DO, FACEPBryan E. Bledsoe, DO, FACEP


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Suppose you were anidiot. And suppose you

were a member ofCongress.

But I repeat myself.

Mark Twain


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Traumatic Brain n!ury "TB #Traumatic Brain n!ury "TB #

De$ined as a %low or !olt to t&e &ead or a'enetrating &eadin!ury t&at disru'tst&e $unction o$ t&e%rain.

De$ined as a %low or !olt to t&e &ead or a'enetrating &eadin!ury t&at disru'tst&e $unction o$ t&e%rain.


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(tatistics(tatistics

).* million 'eo'lesustain a TB eac& year

in t&e +nited (tates- , die,/0-, are &os'itali1ed,

).) million are treatedand released $rom t&eED.

).* million 'eo'lesustain a TB eac& year

in t&e +nited (tates- , die,/0-, are &os'itali1ed,

).) million are treatedand released $rom t&eED.


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CausesFalls "/23#

M4Cs "/ 3#(truck %y5against e6ents ")73#Assaults "))3#

Blasts are t&e leading cause o$ TB $or acti6eduty military 'ersonnel in war 1ones.

CausesFalls "/23#

M4Cs "/ 3#(truck %y5against e6ents ")73#Assaults "))3#

Blasts are t&e leading cause o$ TB $or acti6eduty military 'ersonnel in war 1ones.


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(tatistics(tatisticsMales are a%out ).-times more likely tosustain a TB as a$emale.

Males are a%out ).-times more likely tosustain a TB as a$emale.


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8ig&est risk $or TB9* years

)-9)7 years

A$rican Americans&a6e t&e &ig&estdeat& rate $rom TB .

8ig&est risk $or TB9* years

)-9)7 years

A$rican Americans&a6e t&e &ig&estdeat& rate $rom TB .


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Estimated :; %illionlost $rom TB "medicalcosts and lost'roducti6ity#.uent ty'e o$ TB

Most common in(u%$rontal corte?Frontal lo%eTem'oral lo%e

Occi'ital "less common#O$ten associated wit& (A8.

Cere%ral contusionMost $re>uent ty'e o$ TB

Most common in(u%$rontal corte?Frontal lo%eTem'oral lo%e

Occi'ital "less common#O$ten associated wit& (A8.


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Trauma Ty'esTrauma Ty'es


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ContusionContusion


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(u%arac&noid&emorr&age

Disru'tion o$su%arac&noid 6essels.)50 o$ all 'atients wit&moderate to se6ere TB

&a6e traumatic (A8.

(u%arac&noid&emorr&age

Disru'tion o$su%arac&noid 6essels.)50 o$ all 'atients wit&moderate to se6ere TB

&a6e traumatic (A8.


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E'idural &ematomaCollection o$ %lood %etween t&e dura and t&eskull.Arterial %leed.

ncidence.-9). 3 o$ all &ead9in!ured 'atients.

H) 3 o$ &ead9in!ured 'atients w&o are comatose.Almost all associated wit& skull $racture.2 3 will 'rogress to uncal &erniation.

E'idural &ematomaCollection o$ %lood %etween t&e dura and t&eskull.Arterial %leed.

ncidence.-9). 3 o$ all &ead9in!ured 'atients.

H) 3 o$ &ead9in!ured 'atients w&o are comatose.Almost all associated wit& skull $racture.2 3 will 'rogress to uncal &erniation.


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E'idural 8ematomaE'idural 8ematoma


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E'idural 8ematomaE'idural 8ematoma

(igns and (ym'tomsClassis syndrome "H/ 3 o$ cases#

mmediate =OC.Patient awakens and &as a Llucid inter6al.=oses consciousness as &ematoma e?'ands.

Most commonly

Most 'atients eit&er ne6er lose consciousness orne6er regain consciousness.

(igns and (ym'tomsClassis syndrome "H/ 3 o$ cases#

mmediate =OC.Patient awakens and &as a Llucid inter6al.=oses consciousness as &ematoma e?'ands.

Most commonly

Most 'atients eit&er ne6er lose consciousness orne6er regain consciousness.


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(u%dural &ematomaCollection o$ %lood%etween t&e dura andt&e (AM.4enous %leed.Associated wit&

sudden accelerationand5or deceleration.Tears %ridging 6eins.

(u%dural &ematomaCollection o$ %lood%etween t&e dura andt&e (AM.4enous %leed.Associated wit&

sudden accelerationand5or deceleration.Tears %ridging 6eins.


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(u%dural 8ematoma(u%dural 8ematoma


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(u%dural 8ematoma(u%dural 8ematoma

+sually more %rain 'arenc&ymal in!uryt&an e'idurals.

Classi$ied asAcute "H 0 days#(u%acute "09)* days#C&ronic "I )* days#

+sually more %rain 'arenc&ymal in!uryt&an e'idurals.

Classi$ied asAcute "H 0 days#(u%acute "09)* days#C&ronic "I )* days#


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Di$$use A?onal n!ury "DA #nterru'tion o$ a?onal $i%ers in t&e w&ite

matter and %rain stem.(&earing $orces "usually deceleration# causein!ury.

Adults M4Cs

Ba%ies L(&aken %a%y syndromen!ury occurs immediately and is usually

irre6ersi%le.

Di$$use A?onal n!ury "DA #nterru'tion o$ a?onal $i%ers in t&e w&ite

matter and %rain stem.(&earing $orces "usually deceleration# causein!ury.

Adults M4Cs

Ba%ies L(&aken %a%y syndromen!ury occurs immediately and is usually

irre6ersi%le.


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Di$$use A?onal n!uryDi$$use A?onal n!ury


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ntracere%ral8emorr&age

+sually caused %ys&earing $orces.(e6erity de'ends u'onlocation and si1e.

(econdary in!urycommon.

ntracere%ral8emorr&age

+sually caused %ys&earing $orces.(e6erity de'ends u'onlocation and si1e.

(econdary in!urycommon.


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Pro%a%ly mortal.Pro%a%ly mortal.


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TB (igns and (ym'tomsTB (igns and (ym'toms

An?iety5ner6ousnessBe&a6ioral c&anges

Disin&i%itionm'ulsi6enessna''ro'riate laug&ter rrita%ility

Di'lo'iaDe'ressionTrou%le concentrating

An?iety5ner6ousnessBe&a6ioral c&anges

Disin&i%itionm'ulsi6enessna''ro'riate laug&ter rrita%ility

Di'lo'iaDe'ressionTrou%le concentrating

A'&asiaDys'&agiaDi11iness8eadac&e+ncoordination o$mo6ements

=ig&t&eadednessAta?iaAmnesia

A'&asiaDys'&agiaDi11iness8eadac&e+ncoordination o$mo6ements

=ig&t&eadednessAta?iaAmnesia


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Musclesti$$ness5s'asm(ei1ures(lee' disorders(lurred or sloweds'eec&

TinglingNum%nessPain

Musclesti$$ness5s'asm(ei1ures(lee' disorders(lurred or sloweds'eec&

TinglingNum%nessPain

4ertigo=ocali1ed weaknessNausea4omitingBody tem'eraturec&anges

ComaPosturingPu'illary a%normality

4ertigo=ocali1ed weaknessNausea4omitingBody tem'eraturec&anges

ComaPosturingPu'illary a%normality


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( N( AND ( MPTOM(

N TBA E E T EME=

4A AB=E


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Assessment5TreatmentAssessment5Treatment

Airway "wit& c9s'ine control#

Breat&ingCirculationDisa%ility

E?'osure

Airway "wit& c9s'ine control#

Breat&ingCirculationDisa%ility

E?'osure


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Pal'ate skull, $acial %ones and neckAssess rate, de't& and >uality o$

res'irations.Consider tac&y'nea at t&e $ollowing rates asign o$ deterioration

n$ant * %reat&s 'er minute

C&ild 0 %reat&s 'er minuteAdult / %reat&s 'er minute

Pal'ate skull, $acial %ones and neckAssess rate, de't& and >uality o$

res'irations.Consider tac&y'nea at t&e $ollowing rates asign o$ deterioration

n$ant * %reat&s 'er minute

C&ild 0 %reat&s 'er minuteAdult / %reat&s 'er minute


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Assess 'u'ils care$ullyPu'il si1e

(ymmetryeacti6ity to lig&t

Assess 'u'ils care$ullyPu'il si1e(ymmetry

eacti6ity to lig&t


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Pu'illary assessmentBilateral symmetry "asymmetric 'u'ils di$$ermore t&an ) mm#.

eacti6ity to lig&t "a $i?ed 'u'il s&ows H)mmc&ange in res'onse to %rig&t lig&t#.Dilation "greater t&an or e>ual to *mm

diameter in adults#

Pu'illary assessmentBilateral symmetry "asymmetric 'u'ils di$$er more t&an ) mm#.

eacti6ity to lig&t "a $i?ed 'u'il s&ows H)mmc&ange in res'onse to %rig&t lig&t#.Dilation "greater t&an or e>ual to *mm

diameter in adults#


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(ingle $i?ed and dilated 'u'il*-3 'oor outcome

Bilateral $i?ed and dilated 'u'ils2/3 'oor outcome

(ingle $i?ed and dilated 'u'il*-3 'oor outcome

Bilateral $i?ed and dilated 'u'ils2/3 'oor outcome


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Mid9'osition $i?ed anddilated 'u'il

(uggests %rain stem

&erniation.ndicati6e o$ mass on

same side.Treat &y'o?ia and

&y'otension, i$ 'resent.Treat increased CP 'er'ractice 'arameters.

Mid9'osition $i?ed anddilated 'u'il

(uggests %rain stem

&erniation.ndicati6e o$ mass on

same side.Treat &y'o?ia and

&y'otension, i$ 'resent.Treat increased CP 'er'ractice 'arameters.


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ndications o$ &erniation+nilateral or %ilateral dilated, nonreacti6e'u'ils.Asymmetric 'u'ils.Decere%rate 'osturing.No motor res'onse to 'ain$ul stimuli.

ndications o$ &erniation+nilateral or %ilateral dilated, nonreacti6e'u'ils.Asymmetric 'u'ils.Decere%rate 'osturing.No motor res'onse to 'ain$ul stimuli.


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Monitor ('O / and ETCO / .Maintain ('O / I 7 3

Maintain ETCO / %etween 0-90@ mm 8gnitiate 4 line wit& salineMaintain adult systolic BP I 7 mm 8g

Pediatric 6alues are lower.+tili1e lasgow Coma (cale

Monitor ('O / and ETCO / .Maintain ('O / I 7 3

Maintain ETCO / %etween 0-90@ mm 8gnitiate 4 line wit& salineMaintain adult systolic BP I 7 mm 8g

Pediatric 6alues are lower.+tili1e lasgow Coma (cale


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lasgow Coma (cale "Adult#lasgow Coma (cale "Adult#

Eye O'ening "E# 4er%al es'onse "4# Motor es'onse "M#O !"# $6

Or&!'(!) $5 Lo*al&+!# $5

S,o'(a'!o-# $4 Co'.-#!) $4 /&( )ra # $4

R!a*(&o' (o S,!!* $3 I'a,,ro,r&a(! /or)# $3 D!*or(&*a(! $3

R!a*(&o' (o a&' $2 I'*om,r! !'#& l!So-')# $2

D!*!r! ra(! $2

No R!#,o'#! $1 No R!#,o'#! $1 No R!#,o'#! $1

O AL E M


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lasgow Coma (cale " n$ant#lasgow Coma (cale " n$ant#

Eye O'ening "E# 4er%al es'onse "4# Motor es'onse "M#O !"# $6

Coo# Ba l!# $5 Lo*al&+!# $5

S,o'(a'!o-# $4 Irr&(a l! Cr" $4 /&( )ra # $4

R!a*(&o' (o S,!!* $3 Cr&!# (o a&' $3 D!*or(&*a(! $3

R!a*(&o' (o a&' $2 Ma'# r-'(# $2 D!*!r! ra(! $2

No R!#,o'#! $1 No R!#,o'#! $1 No R!#,o'#! $1

O AL E M


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Assess %loodglucose le6el.Assess %loodglucose le6el.


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Treat AirwayTreat Airway

Protect C9s'ine alignment, consider$acial trauma.

Airway su''ort 'er sco'e o$ 'ractice.ntu%ate se6ere TB 'atients.Correct &y'o?ia.

Protect C9s'ine alignment, consider$acial trauma.

Airway su''ort 'er sco'e o$ 'ractice.ntu%ate se6ere TB 'atients.Correct &y'o?ia.


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J&en to ntu%ateJ&en to ntu%ate

C( H 7 "se6ereTB #.

All 'atients wit&res'iratory $ailure o$a'nea.

C( H 7 "se6ereTB #.

All 'atients wit&res'iratory $ailure o$a'nea.


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Treat Breat&ingTreat Breat&ing

O?ygenation.Administer su''lemental o?ygen %y non9re%reat&er or B4M as a''ro'riate.

4entilation.Assess rate, de't&, >uality, to determine t&ee$$ecti6eness o$ res'irations.As necessary, assist 6entilations wit& B4Mand su''lemental O / .

O?ygenation.Administer su''lemental o?ygen %y non9re%reat&er or B4M as a''ro'riate.

4entilation.Assess rate, de't&, >uality, to determine t&ee$$ecti6eness o$ res'irations.

As necessary, assist 6entilations wit& B4Mand su''lemental O / .


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Treat Breat&ingTreat Breat&ing

Adult normal4entilation rate

) 9)/ 'er minute


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8y'er6entilation8y'er6entilation

8y'er6entilationa'id PaCO /

Cere%ral 6asoconstrictionDecreased CBF CP

But, &y'er6entilation can CBF to t&e'oint o$ isc&emia.Monitor ETCO / Q

8y'er6entilationa'id PaCO /

Cere%ral 6asoconstrictionDecreased CBF CP

But, &y'er6entilation can CBF to t&e'oint o$ isc&emia.Monitor ETCO / Q


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Potential &arm in 'atients wit&oute6idence o$ %rain &erniation.

(&ort9term measure used in s'eci$ic TB'atients "&erniation# until de$initi6ediagnostic or t&era'eutic can %e'ro6ided.

Potential &arm in 'atients wit&oute6idence o$ %rain &erniation.

(&ort9term measure used in s'eci$ic TB'atients "&erniation# until de$initi6ediagnostic or t&era'eutic can %e'ro6ided.


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atesAges 79Adult / %reat&s 'er minute

"ETCO / K 0- mm 8g#.

Ages )92 years 0 %reat&s 'er minute"ETCO / K 0/90- mm 8g#.

Ages H ) year * %reat&s 'er minute"ETCO / K 0/90- mm 8g#.

atesAges 79Adult / %reat&s 'er minute

"ETCO / K 0- mm 8g#.

Ages )92 years 0 %reat&s 'er minute"ETCO / K 0/90- mm 8g#.

Ages H ) year * %reat&s 'er minute"ETCO / K 0/90- mm 8g#.


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FluidsFluids

Fluids to maintain (BPI 7 mm 8g.Normal saline8y'ertonic saline

Fluids to maintain (BPI 7 mm 8g.Normal saline8y'ertonic saline


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Brain9Targeted T&era'iesBrain9Targeted T&era'ies

lucose $or &y'oglycemia(edati6es $or agitation

Analgesics $or 'ainParalytics $or ET intu%ationContro6ersial

Mannitol=idocaine8y'ertonic (aline

lucose $or &y'oglycemia(edati6es $or agitationAnalgesics $or 'ainParalytics $or ET intu%ationContro6ersial

Mannitol=idocaine8y'ertonic (aline


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DestinationsDestinations

Mild " C( )*9)-# Emergency De'artmentModerate " C( 79)0# Trauma Center

(e6ere " C( H 7# Trauma Center wit&se6ere TB management ca'a%ilities.

Mild " C( )*9)-# Emergency De'artmentModerate " C( 79)0# Trauma Center

(e6ere " C( H 7# Trauma Center wit&se6ere TB management ca'a%ilities.


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Take 8ome MessagesTake 8ome Messages

Clinical 'ractice s&ould %e e6idence9%ased.

Do early and re'eated neurologicalassessments.denti$y 'atients wit& se6ere TB " C( H

7#.

Clinical 'ractice s&ould %e e6idence9%ased.

Do early and re'eated neurologicalassessments.denti$y 'atients wit& se6ere TB " C( H

7#.


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Take 8ome MessagesTake 8ome Messages

A6oid &y'o?ia, kee' ('O / I 7 3.A6oid &y'otension, kee' (BP I 7 mm

8g.8y'er6entilate only $or clinical signs o$&erniation.

Triage and trans'ort TB to a''ro'riate$acilities %ased on se6erity.

A6oid &y'o?ia, kee' ('O / I 7 3.A6oid &y'otension, kee' (BP I 7 mm

8g.8y'er6entilate only $or clinical signs o$&erniation.

Triage and trans'ort TB to a''ro'riate$acilities %ased on se6erity.


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T&e FutureT&e Future

T&era'ies to 'rotect against secondaryin!ury

8y'ot&ermia.(edati6e9induced coma.Meta%olic t&era'ies.Antio?idant t&era'ies.

T&era'ies to 'rotect against secondaryin!ury

8y'ot&ermia.(edati6e9induced coma.Meta%olic t&era'ies.Antio?idant t&era'ies.

neurologic trauma.pptx

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