????(Head Injury)

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????(Head Injury)

• ???
• ??????? ????

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Glasgow Coma Scale
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Classifications of Severity

• Mild head injury (GCS 14-15)
• Moderate head injury (GCS9-13)
• Severe head injury (GCS? 8)

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Immediate Management of Head Injury

• General principles
• Not a single disorder.
• Tailored therapeutic plans for the specific
  lesion and individual patient from time to time.
• No stable hemodynamics, no accurate GCS score.

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Begin at the trauma scene

• Airway with cervical spine control
• Breathing
• Circulation with hemorrhage control
• Stabilizing the cervical and thoracolumbar spine
  (Disability) gt C-spine, CXR, pelvis
• Identifying and stabilizing Extracranial injuries
• Mini-neurologic Examination.
• ?ABCDEE

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Mini-neurological Examination

• Level of consciousness (E4V5M1???)
• Pupillary function (unilateral? L/R? Doll eye
  sign?)
• Lateralized extremity weakness

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Risk Factors (5H-CSI)

• Hypotension ? double mortality rate
• Hypoxia ? add hypotension ? 75 mortality
• Intracranial Hypertension (IICP)
• Hyperthermia
• Electrolyte disturbance (H)
• Coagulopathy
• Seizure
• Infection

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Mild Head Injury (GCS 14-15)

• Brain concussion (initial loss of consciousness)
• All head-injured patients should have a CT scan,
  except the true asymptomatic patients.
• If CT scan is not available ? admission and
  observation for 1-2 days.
• 2-3 serious intracranial insult.
• Abnormal CT scan 18 ? 5 need op

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Mild Head Injury

• Risk factors of neurological deterioration
• Older age and anticoagulant therapy
• CPR
• Alcohol or drug abuse
• Presence of subdural effusion or hematoma at the
  initial CT scan
• Epilepsy
• Previous neurosurgical treatment.
• ? ?????????????????,???????.

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Mild Head Injury

• Admission criteria (?????ER????)
• Penetrating head injuries
• Abnormal CT scan or skull fracture
• Loss of consciousness or amnesia
• Moderate to severe headache or vomiting
• Worsening in GCS score
• Pneumocephalus or CSF leakage
• Associated extracranial injuries
• Alcohol or drug abuse, coagulopathy and other
  risk factors for deterioration
• No reliable assistance at home

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Mild Head Injury

• While being discharged, give a warning sheet
  (??????)
• Within 1-2 weeks, OPD F/U.

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Moderate Head Injury (GCS 9-13)

• CT scan should be done in all cases of moderate
  head injury. (abnormal CT 40)
• Admission criteria
• In non-severe head injury, causes of mortality
  are inadequate observation and extracranial
  injuries.
• Higher risk of deterioration
• Older
• An initial abnormal CT scan
• Lower GCS motor score

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Moderate Head Injury
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Severe Head Injury (GCS lt8)

• First priority (before calling NS Drs)
• Securing airway, breathing, and circulation
  (ABC).
• Emergent intubation !!
• Avoid hypoxia (PaO2lt60mmHg)
• Avoid hypotension (SBPlt90mmHg)
• Avoid electrolyte imbalance Na, K, Glu, Mg
• Other system injury (life threatening) check
  chest and abdomen

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Acute treatment for severe head injury
ABCDE
E
5H-CSI
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To control ICP should be started empirically
even before a CT scan is obtained.

• Comatose patients
• Decline in GCS
• Pupillary asymmetry
• Hemiparesis
• Any signs of presence of a traumatic mass lesion.

• Intubation
• Mild hyperventilation
• IV bolus of mannitol
• Prophylactic phenytoin
• Sedation

CT room
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???????

• ??????,?????????????????
• ????????????,??????????????, ?????,?????????
• ??????????(since 1973),????????????

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???????????

• ?????????????(secondary injury ),?????????????????
  (??????????)???????????????????????,???????????,??
  ?????????????

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???????????

• ??????????(neurological examination monitoring)
• ?????((ICP monitor)
• ????????(Transcranial Doppler, TCD)
• ?????????(jugular bulb oxygen saturation , SjvO2)
  
• ??????(brain oxygen saturation monitoring)
• ???????(neurophysiology monitoring)??????(EEG)???
  ??(evoked potential, EP)
• ??????(neurometabolic monitoring)
• ??????(PaO2)??????(PaCO2)?????(pH)???

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??????????

• ????(GCS)?????????????????????????????
• ????????,?????????(SaO2)????(ECG)??????(CVP)??????
  ?????(End tidal CO2)??????????????????
• ??????????????????????????,???????????????????????
  ????????????
• ??????????????,??????(hypotension)???(hypoxia)?

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??????????

• ???????????????????????????
• ?????????,???????????????????????,??????
• ?????????,???????????

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???????

• Monro-Kellie?? ?????????, ??????????????????????,
  ?????1500-1900???
• ?????????????????????????(intracranial pressure,
  ICP)

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Monro-Kellie??
Total 1700ml
???? Blood 150ml
??? CSF 150ml
??? Parenchyma 1400ml
??? Intraventricular space 50ml
?????? Subarachnoid space 100ml
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??????????

• ??????
• ???????,?????????
• ???????????
• ???
• ?????????,??????
• ????
• ???????????

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????????

• ????????(cerebral perfusion pressure,CPP)????
• CBFCPP/CVR
• ????????????(mean arterial pressure,MAP)?????
• CPPMAP-ICP
• ?????????,????????

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???????

• ????????????
• ????????10-15mmHg
• ???????3-7mmHg
• ??????1.5-6mmHg
• ????????? 60-80mmHg

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????

• ??????,???????????????????????(intracranial
  hypertension)?

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??????????

• ???????????,?????????
• ???
• ??????
• ?????(papilledema) ?
• ????--?????????
• ???(herniation)?

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??????????

• Cushing triad ??????
• ???????????????
• ?????,?????????????????

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????????

• Severe head injury with an abnormal admission CT
  scan.
• Severe head injury with a normal CT scan if two
  or more of the following features are noted at
  admission
• Age over 40 years,
• unilateral or bilateral motor posturing
• Systolic blood pressure lt 90mmHg.
• Not routinely indicated in patients with mild or
  moderate head injury.

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ICP monitor techniques

• The gold standard technique for ICP monitoring is
  by means of an intra-ventricular catheter.
  (ventriculostomy, EVD external ventricular
  drainage ?????)
• Alternative techniques
• Parenchymal, subdural, or epidural catheter.
• Complication parenchymal injury, infection,
  hemorrhage, malfunction, or malposition.
• Up to one week and providing prophylactic
  antibiotics.

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??????????

• ?????????
• ??(fluid restriction)
• ???????(??mannito1?glycerol)
• ????(hyper-ventilation)
• ????(hypothermia)?????????

• ????????
• ?????????????(squeezing the oxygenated blood
  through a swollen brain)?
• CPP MAP - ICP

Focus on CPP!!
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????????????

• ??????????,???????????
• ????30?(???????56mmHg)
• ??????(????????56 mmHg)
• ????????
• ?????(PEEP)
• ????(Valsalva maneuvers)
• ???????(???????????)?????????
• ???????
• ?????
• ?????
• ????????(??45mmHg)?????
• ??

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?????????

• ????????70mmHg?
• ???????????? (normovolemia)
• ?????????6-15cmH2O
• ?????12-15mmHg?
• ???????????(isotonic crystalloid)????(colloid)???
  ????????

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??????????????
CBFCPP/CVR CPPMAP-ICP
????

• ??????
• ????? ????
• ???????

???????, ????, ?????
CSF??, ?????
???30?,?????? ??????,??????
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??????,??????????????
CBFCPP/CVR CPPMAP-ICP
????, ??

• ??????
• ????? ????
• ???????

???????, ??????, ?????
??? ???
??????,???? ??????,?????
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?????
?????100??????????(euvolemia)???????? ?6-15cmH2O
????????12-15mmHg??????? 70mmHg,?????????35mmHg
?????????????
??????,??????
?????(mannitol) 0.25-1gm/kg
???????,PaCO2 30-35mmHg ?????????(SjvO2)???
???????????
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?????
???????????(hypothermia)??????? ???????(PaCO2lt30mm
Hg) ?????(decompression craniectomy)
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???(sedation)???????? (neuromuscularblockade)

• ???????????????,???????????
• ???????midazolam, propofo1 ????????atracurium,
  pancuronium, vecuronium?
• ??????20mmHg??24??,???????????

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??????(CSF drainage)

• ?????????(ventriculostomy),????????????????
• ????3-5 ml,???????????
• ?????8????75 ml.??????

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?????(osmotic diuretics)

• ??????? mannitol ? glycerol
• ?????????????????,??????????????,???????????????
• ??????????????,????????,??????????,???????????????
  ????
• ????15????????
• ???????????????(bolus, rapid infusion)?

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?????(osmotic diuretics)

• ???????0.25-1 g/4-6hrs,????????????
• ????????,???????320 mOsm/L,????????

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?????(osmotic diuretics)

• ????????????(hypotension)?????(hypovolemia)???????
  ????????????????(CPP protocol)????????????
• ??? lasix ??? mannitol ?????????????20-40mg/3-4hr
  s (0.3 to 0.5 mg/kg),?????????????????????????????
  ?

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Steroids

• Although steroids clearly are useful in reducing
  the perifocal edema associated with brain tumors,
  their value in head injury has not been
  demonstrated.

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Anticonvulsants

• Post-traumatic epilepsy 15-30 of severe H.I.
  5 of mild H.I.
• 90 occur within the first 24 hours
• Indication
• GCS ?10 on admission
• Acute EDH, SDH, ICH (supratentorial)
• Open depressed skull fracture with parenchymal
  injury
• Cortical contusion on CT scan
• Seizure within the first 24 hrs after injury
• Penetrating brain injury
• History of significant alcohol abuse.

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D/C of anticonvulsants

• Taper after 1 week of therapy except in the
  following
• Penetrating brain injury
• Development of late seizure
• Prior seizure therapy
• Patients undergoing craniotomy
• The above four situations maintain for 6-12
  months.

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Indication for Surgery

• Critical factors
• Patients neurological status
• Imaging findings
• Presence and severity of extracranial lesions.
• Time is life.

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Significant Mass Effect

• Displacement of midline structures? 5mm.
• Effacement of basal cisterns on CT scan.

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EDH (epidural hematoma)

• Located in the temporal region tear of the
  middle meningeal vessel, sinus injury
• In 50 of patients there is no radiographic
  evidence of a fracture.
• Small, stable, asymptomatic ? conservative
• All acute traumatic extraaxial hematoma 1cm or
  greater in thickness ? op
• Outcome children better than adult.

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SDH (subdural hematoma)

• 30 of severe head injury
• Bleeding of lacerated brain and cortical vessels
  avulsed bridging vein
• No significant mass effect without brain swelling
  ? conservative
• Larger craniotomy
• Worsen prognosis than EDH
• Golden time 4 hours

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Contusional and intracerebral hematomas (ICH)

• Located in anterior frontal and temporal lobes.
• Awake and alert? conservative
• gt2cm(surface), mass effect, uncontrolled ICP ? op
• Early surgical intervention for temporal and
  posterior fossa lesions.
• Adult with GCS of 3, non-reactive dilated pupil
  without spontaneous respiration ?
  conservative
• Over 75 Y/O, GCS of 5 or less
  ? conservative

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Skull fracture

• Non-op closed, linear, non-depressed skull
  fracture ? heal spontaneously.
• OP
• open fractures or fractures depressed more than
  the thickness of the skull required surgical
  elevation or repair.
• Cosmetic consideration.
• Near a major dural sinus ? non-op, even occluded
  sinus.

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Skull fracture

• There is no evidence to support the theory that
  correction of a depressed skull fracture reduces
  the risk of subsequent seizures.

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Growing skull fracture

• Inspecting the site of injury for a palpable,
  non-tender swelling.
• A linear fracture separated more than 3 mm on CT
  scan suggest an associated dural tear.
• OP or F/U
• They rarely occur in children over 18 months of
  age and rarely show after 6 month from injury.

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Skull Fracture
Raccoons eye sign
Battles sign
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The End!!