traumatic brain injury

87
Traumatic Brain Injury 1.6 million head injuries in US annually 250,000 hospital admissions 60,000 deaths 70,000 - 90,000 permanent neurologic disabilities Causes Motor vehicle accidents Falls

Upload: hosea

Post on 24-Feb-2016

39 views

Category:

Documents


0 download

DESCRIPTION

Traumatic Brain Injury. 1.6 million head injuries in US annually 250,000 hospital admissions 60,000 deaths 70,000 - 90,000 permanent neurologic disabilities Causes Motor vehicle accidents Falls. Primary Survey. Stabilize the spine Establish adequate airway E nsure adequate ventilation - PowerPoint PPT Presentation

TRANSCRIPT

Traumatic Brain Injury

Traumatic Brain Injury1.6 million head injuries in US annually250,000 hospital admissions60,000 deaths70,000 - 90,000 permanent neurologic disabilitiesCausesMotor vehicle accidentsFalls

Primary SurveyStabilize the spineEstablish adequate airwayEnsure adequate ventilationIV access to initiate volume resuscitationAvoid secondary insults to brainHypoxiaHypotensionDetermine level of consciousness examine pupils

Secondary SurveyOnce relatively stableIncludes a complete neurologic examinationSeverity of the head injury is classified clinically by GCS13 to 15 mild 9 to 12 moderate8 or less severeAssess strength, sensation

Overall goal with neurologic injuryPresume injury until proven otherwiseIdentify earlyAllow injured tissue the best chance to repair itselfAdequate delivery of oxygen and glucoseAvoid infectionPreserve residual nervous tissue

Primary Brain InjuryTrauma: concussion, contusion,diffuse axonal injuryIschemia: global, regionalInflammationDirect Injury: hemorrhage,penetrating injuryCompression: tumor, edema,HematomaMetabolic insultsExcitatory toxicity: seizures, illicitdrugs, severe hyperthermia

Secondary Brain InjuryHypoperfusion: hypotension, high intracranial pressure, vasospasmSingle episode SBP 70

CBF is independent of MAP between 50-150AutoregulationWith injury 50% pts lose autoregulation abilityGOAL Normal MAP or MAP >90Treat hypotension with thoughts of causeTreat HTN with B-blockers, nicardipineUse vasodilators with cautionHemodynamic

Marik, P. E. et al. Chest 2002;122:699-711Cerebral autoregulation in normal subjects and patients with chronic hypertension43

Osmotic Agents: MannitolActs within 20-30 minutesDosage: 0.25-1 g/kg bolus Filtered needles! Actions:1) osmotic gradient2) may increase cardiac preload, output and elevate MAP3) improves rheology of red blood cells4) decreases CSF production5) free radical scavengerOsmotic Agents: MannitolSerum osmolality =]3 ft or 5 stairs; an axial load to the head (e.g., diving); a motor vehicle collision at high speed (>100 km/hr) or with rollover or ejection; a collision involving a motorized recreational vehicle; or a bicycle collision. A simple rear-end motor vehicle collision excludes being pushed into oncoming traffic, being hit by a bus or a large truck, a rollover, and being hit by a high-speed vehicle.ImagingCervical spine filmsAP, lateral, and odontoid Additional lateralsIf entire c-spine or C7T1 space not seenAbnormal vertebral alignment, bony structure, intervertebral space, and soft tissue thickeningFlexion and extension filmsSCIWORA (spinal cord injury without radiologic abnormality)CT scan best for bonesIf not adequate visualization by X-rayMRIModality of choice for characterizing acute cord injury Best for edema, hemorrhage, ligamentous injury Neuroresuscitative AgentsHigh dose steroids30mg/kg bolus 5.4mg/kg/hr x 23HGive for 48H if not given within 3H

Effective if given in first 8 hoursInjury classificationStableUnstableSoft tissue or fracture

SurgeryDecompress neural tissuePrevent cord injury by ensuring stabilityOptions includebed rest in traction (rarely done)external immobilizationopen reduction with internal fixation

Order of injury RepairAny open fractures firstThen any closed fractureTibiaFemur within 24hPelvisSpineUpper extremity

Ligamentous injury

Odontoid Fracture

Atlas fracture

C2 Hangmans Fracture

C6 Fracture with retropulsionto cord

Soft tissue swellingsubluxation of C4-C5 with spinal cord compression

Compression fractureLumbarBurst fractureCord Injury SyndromesComplete cord lesion - all sensory and motor function below the lesion is abolishedCentral cord lesion motor function lost upper>lowersuspended sensory loss in cervicothoracic dermatomesPosterior Cord syndrome diminished proprioception and fine touchBrown-Sequard syndrome - cord hemisection ipsilateral loss of pain and proprioception, contralateral pain and temp loss, suspended ipsilateral loss of all sensation

Spinal shock lack of neurologic function after trauma that can last until 4 weeks

Systemic Effects of SCICardiovascularAlmost solely related to interruption of sympathetic pathway at T1-L2BradycardiaResolves with stimulationResolves after 2 monthsRare to need pacemakerHypotensionGive volumeLow dose pressorsRespiratoryRelated to level of injuryThoracic levels eliminates intercostalsDiaphragm alone to inspire phrenic nerve (C3-5)Cervical lesions decreases cough and secretion clearanceDecreased tidal volumesMinimal expiratory helpStatus improves with timeAutonomic hyperreflexiaLoss of central inhibitionhyper-reactive sympathetic reflexes to cord below level of lesionBladder or bowel distention usual causes HTNArrythmiasHeadachesVasodilation above lesion level

In SummaryAppropriate pre-hospital care is essentialAssume injury until proven otherwiseEvaluate as early as possible to prevent unnecessary immobilizationEarlier steroids with spinal injuryFollow clinical exam

ReferencesCzosnyka M. Pickard JD. Monitoring and interpretation of intracranial pressure. Journal of Neurology, Neurosurgery & Psychiatry. 75(6):813-21, 2004 Jun. Gunnarsson T. Fehlings MG. Acute neurosurgical management of traumatic brain injury and spinal cord injury. Current Opinion in Neurology. 16(6):717-23, 2003 Dec.Hutchinson PJ. Kirkpatrick PJ. Decompressive craniectomy in head injury. Current Opinion in Critical Care. 10(2):101-4, 2004 Apr Longhi L. Stocchetti N. Hyperoxia in head injury: therapeutic tool?. Current Opinion in Critical Care. 10(2):105-9, 2004 Apr Marik, PE. Varon, J. and Trask, T Managament of Head Trauma*Chest. 2002; 122: 699 - 711.Marshall LF. Head injury: recent past, present, and future. Neurosurgery. 47(3):546-61, 2000 Sep Patel RV. DeLong W Jr. Vresilovic EJ. Evaluation and treatment of spinal injuries in the patient with polytrauma.Clinical Orthopaedics & Related Research. (422):43-54, 2004 May.