Head Trauma

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Head Trauma
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Objectives

• A- Review specific of anatomy and physiology as
  related to head injuries.
• B- Identify the principles of general management
  of the unconscious traumatized patient and the
  delayed complications.
• C- Outline the method of evaluating head injuries
  using a mininurological examination.

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• D- Explain the management techniques to be used
  in specific types of head injuries.
• E- Demonstrate the ability to assess various
  types of head, maxillofacial and neck injuries
  using a head-trauma model.
• F- Explain clinical signs and outline priorities
  for initial management of injuries identified in
  the assessment.

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Head Trauma

• Neurosurgical consult essential
• Early transfer reduces morbidity and mortality
• Cardiorespiratory
• Level of consciousness
• Pupillary reaction
• Vital signs
• Associated injuries
• Skull film results

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• Cranial Nerve Assessment
• Pupils occulomotor nerve ( IIIrd )
• Others- lower assessment priority
• Alteration of Consciousness is The Hallmark of
  Brain Injury

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Unconsciousness Injury

• Bilateral cerebral cortices
• Brain stem RAS
• Increased ICP
• Decreased CBF
• Increased ICP Results in
• Decreased perfusion
• Altered level of consciousness

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• History
• Determine cause and effect
• Pre- and post injury status
• Document communicate
• Reassess
• Vital signs
• Identifies status neurologically and
  systemically.
• Respiratory Assessment
• Assess and correct deficiencies
• Increased ICP - slower RR
• Increased ICP noisy tachypnea
• Asses for other etiology

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• Blood Pressure
• Increased ICP Increased BP widened pulse
  pressure
• Assess for other etiology
• Treat shock vigorously
• Pulse
• Increased ICP bradycardia
• Tachycardia grave sign
• Assess for etiology

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• Temperature
• Temperature
• Weather extremes
• Control hyperthermia
• Eye Opening Response
• Spontaneous already open with blinking (normal)
  four (4) points
• To speech not necessarily to request eye
  opening three (3) points
• To pain stimulus should not be to face two
  (2) points
• None make note if eyes are swollen shut one
  (1) point

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• Verbal Response
• Oriented - knows name, age, etc. five (5)
  points
• Confused conversation - still answers questions
  four (4) points
• Inappropriate words - speech is either
  exclamatory or random three (3) points
• Incomprehensible sounds - do not confuse with
  partial respiratory obstruction two (2) points
• None make note if intubation prevents speech
  one (1) point

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• Best Motor Response
• Obeys - moves limb to command and pain is not
  required six (6) points
• Localizes - changing the location of the pain
  stimulus causes the limb to follow five (5)
  points
• Withdraws - pulls away from painful stimulus
  four (4) points
• Abnormal flexion - three (3) points
• Extensor response - two (2) points
• No movement - one (1) point

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C-spine Assessment

• High index for suspicion
• Reflex assessment
• Sensory assessment
• X-rays

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Hints to Cervical Cord Injury

• Flaccid areflexia, especially with flaccid rectal
  sphincter
• Diaphragmatic breathing
• Ability to flex forearms but not extend them
• Facial grimaces in response to pain above the
  clavicle but not below
• Hypotension without other evidence of shock (ie,
  hypotensive with warm extremities)
• Priapism is an uncommon but characteristic sign

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• Brain stem responses Neurosurgeon to perform
  occulocephalic occulovestibular cranial nerve
  test.
• Skull X-rays
• Do not delay primary assessment management to
  obtain skull X-rays.

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Management Reassessment, O2 and Airway

• Concussion
• No significant brain injury or localizing signs
• History amnesiac of event
• Admit individualize
• Contusion
• Significant alterations in consciousness and
  localizing signs
• Countercoup injury
• Admit and observe 48 hours

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Intracranial Hemorrhage

• Meningeal or brain
• CT - precise or diagnose
• Clinical findings similar
• Acute epidural
• Middle meningeal artery tear
• Rapidly fatal
• Hallmark ipsilateral, dilated fixed pupil
• Immediate surgery
• Prognosis good

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• Acute Subdural
• Venous hemorrhage
• life- threatening gradual onset
• severe underlying brain injury
• Prognosis poor
• Subarachnoid
• Bloody CSF, meningeal irritation
• Headache, photophobia
• Nuchal rigidity, R/O C-spine injury
• High index of suspicion
• Admit

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• Closed Brain Hemorrhages
• Occur at any location
• CT- precise diagnosis
• Neurological deficits- region and size of
  hemorrhage
• Increased ICP Complications
• Cerebral edema
• Vasospasm
• Loss of autoregulation( Neurosurgical consult )

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Fluid Restriction Prevent Overhydration

• Diuretics
• Neurological consult
• Mannitol 50 gms IV
• Furosemide 40-80 mg IV
• Urinary catheter
• Deliberate Hypocapnia
• Maintain PCO2 at 26-28 torr
• Intubation
• Latrogenic paralysis
• Monitor ABGs ( Neurosurgical consult )

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• Convulsions
• Intracranial hemorrhage
• Treatment
• Diazepam 10mg IV
• Diphenylhydantoin 1 gm IV
• Phenobarbital or anaesthesia
• Restlessness
• Identify etiology
• Correct cause
• Hyperthermia
• Potential disastrous
• Reversible neurologic findings
• Vigorous intervention
• Scalp Wounds
• Blood loss
• Inspection
• Repair

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Surgical Management

• Obtain necessary tests early
• Emergent surgeries for hematomas
• Transfer to neurosurgeon
• Avoid delays

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Summary

• A- Obtain and maintain an open airway
• B- Ventilate to avoid hypercarbia
• C- Treat shock, if present and look for cause
• D- Except for shock, restrict fluid intake to
  maintenance levels
• E- Establish baseline parameters
• F- Search for associated injuries
• G- Obtain X-rays as needed, but only after the
  patient is stable
• H- Consult a neurosurgeon and consider early
  transfer

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• I- Should the patient's condition show a change
  for the worse, consider other diagnoses and forms
  of treatment.
• Consult with a neurosurgeon and consider
  transfer.
• J- Reassess continually to identify changes
  necessitates neurosurgical intervention.