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Head Trauma

Head Trauma. Artun KIRKER. MVA FALLING OF HEIGHTS VIOLENCE SPORTS PENETRATING WOUNDS INDUSTRIAL AND DOMESTIC ACCIDENTS One of the most frequent cause of death and disability in young adults. LOC:Loss of consciousness PTA:Post traumatic amnesia. Clinical manifestations.

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Head Trauma

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  1. HeadTrauma Artun KIRKER

  2. MVA • FALLING OF HEIGHTS • VIOLENCE • SPORTS • PENETRATING WOUNDS • INDUSTRIAL AND DOMESTIC ACCIDENTS • One of themostfrequentcause of deathanddisability in youngadults

  3. LOC:Loss of consciousnessPTA:Posttraumaticamnesia

  4. Clinicalmanifestations • Bilateralpreorbitalecchymosis(Racooneyes) • Ecchymosis of themastoidprocess(Battle sign) • CSF rhinorrheaorotorrhea (Ear) • Cranialnervepalsy • Bleeding • Amnesia • Loss of consciousness • Cushingreflex—HT,Bradycardia,irregularrespirations

  5. EpiduralHematoma • Between dura andskull • %1 of headtraumaaddmissions • %80 temporalarea • Middlemeningealartery is themostcommonsource • Dural sinusesandbridgingveinsmay be thesource • Moslyaffectsyoungadults

  6. Clinical Mani. • Brief LOC • Lucidinterval(TALK AND DIE) • İpsilateraldilatepupil • Contralateralhemiparesis

  7. Treatment • Conservative: if GCS>8,no midlineshiftand <30 ml blood • Surgery: Anisocoriaand GCS <8 • Best prognosticfactor is consciousness

  8. SubduralHematoma • Collection of bloodbetween dura andaracnoid • Mva,falls (Severe trauma) mostlyforyoungs • Anticoagulants can be thecause in elderly • Acute <72h--hyperdense on CT Subacute 3-7 daysaftertrauma Chronic >3 weeks--hypodense  on CT • Mostly in temporalandfrontalareas • High mortality&morbility

  9. Clinicalpresent • Comaaftertrauma • Hemiparesis • increased ICP • Alteredlevel of consciousness • Acute form maypresentwith <9 GCS

  10. SubarachnoidHemorrhage

  11. Subarachnoidhemorrhage is extravasation of bloodintothesubarachnoidspacebetweenthepialandarachnoidmembranes

  12. Symptoms • Headache (48%) • Dizziness (10%) • Orbitalpain (7%) • Diplopia (4%) • Visual loss (4%)

  13. Signs • Mildtomoderate BP elevation • Temperatureelevation • Tachycardia • Papilledema • Retinalhemorrhage • Global orfocalneurologicabnormalities

  14. Clinicalpresentation • Suddenonset of severe headache (worstheadache) • Accompanyingnauseaorvomiting • Symptoms of meningealirritation (%80 maytakeseveralhours) • Photophobiaandvisualchanges • Focalneurologicdeficits (CN III, CN VI--ICP) • Seizuresduringtheacutephase (Sudden ICP increase)

  15. Stronglyassociatedwith SAH • Aged 40 yearsorolder • Witnessedloss of consciousness • Complaint of neckpainorstiffness • Onset of manifestationswithexertion • Arrivalbyambulance • Vomiting • Diastolicbloodpressure ≥100 mm Hg orsystolicbloodpressure ≥160 mm Hg

  16. ClinicalGradingScales • Glasgow ComaScore--Clinical • TheFisherscale—CT Based • TheHuntandHessgradingsystem

  17. TheFisherscale (CT scanappearance) is as follows: • Group 1 - No blooddetected • Group 2 - Diffusedeposition of subarachnoidblood, noclots, andnolayers of bloodgreaterthan 1 mm • Group 3 - Localizedclotsand/orverticallayers of blood 1 mm orgreater in thickness • Group 4 - Diffuseornosubarachnoidblood, but intracerebralorintraventricularclotsarepresent

  18. Complications • Hydrocephalus (%20) • Rebleeding (HT,Anxiety) • Vasospasm (Delayedischemiafromarterialsmoothmusclecontraction of thelargecapacitancevessels at thebase of thebrain is theleadingcause of deathanddisabilityfollowinganeurysmal SAH) • Seizures • Cardiacdysfunction & pulmonaryedema

  19. D.D • Aseptic Meningitis • Cluster Headache • Encephalitis • First Adult Seizure • HypertensiveEmergencies • Intracranial Hemorrhage • IschemicStroke • Meningitis • Migraine Headache • TransientIschemic Attack

  20. DX • Noncontrast CT • LP      (CT(-) andifsuspiciouscase):Mostsensitive but can be falsepositive—Traumatic tap • CTA,MRA,Catheterangio (toidentysource)

  21. Work-up • EKG • CXR-Forevaluation of possiblepulmonarycomplications • Serum chemistry panel - Toestablish a baselinefordetection of futurecomplications • Complete bloodcount - Forevaluation of possibleinfectionorhematologicabnormality • Prothrombin time (PT) andactivatedpartialthromboplastin time (aPTT) - Forevaluation of possiblecoagulopathy • Blood typing/screening - Toprepareforpossibleintraoperativetransfusions • Cardiacenzymes - Forevaluation of possiblemyocardialischemia • Arterialbloodgas (ABG) - Necessary in patientswithpulmonarycompromise

  22. Keep in mind • May be traumaticorspontaneous (Truma is morecommon) • Spontaneous SAH mostlycausedbyaneurysmalrupture • %30 occurs in sleep

  23. Treatment-Emergency • ABC!--Intubation of patientswithcoma,depressedlevel of consciousnessorhigh ICP • Monitoring--Cardiacmonitoring • Pulseoximetry • Automatedand/orarterialbloodpressuremonitoring (arterial BP monitoring is indicated in high-grade SAH orwhenbloodpressure is labile) • End-tidalcarbondioxide, ifapplicable • Urineoutputviaplacement of a Foleycatheter

  24. Thegoals of treatment in patientswithsubarachnoidhemorrhage (SAH) are as follows: • Blood pressurecontrol • Prevention of seizures • Management of intracranialpressure • Prevention of vasospasm • Control of pain • Maintenance of cerebralperfusion

  25. Main goal is strictbloodpressurecontrol, withfluidrestrictionandantihypertensivetherapy • >130mm Hg MAP—  I.V Beta blockers (Antihypertensive of choice) • High ICP orherniaton—intubation, hyperventilation, osmoticagents (mannitol) fordecrease ICP dramatically • Patientsmust be admittedtotheintensivecareunit • To minimize stimulithatmayleadto an elevation of ICP, havethepatientplaced in a darkened, quiet, privateroomandgivenmildsedationifagitated

  26. Prevention of rebleeding (themostdreadedearlycomplication) is clippingtherupturedberryaneurysmorendovasculartreatment (ie, coiling) 

  27. Topreventvasospasmmaintenance of normovolemia, normothermia, and normal oxygenationareparamount • Oral nimodipine is themoststudiedcalciumchannelblockerforprevention of vasospasmafter SAH • Transluminalballoonangioplasty is recommendedfortreatment of vasospasmafterfailure of conventionaltherapy

  28. Cerebralcontusions • Bruise of theneuralparenchyma • Causedbyinjurytosmallbloodvesselsmostly in thecrown of thegyrus • 4 types: Coup: Site of impact                    Counter coup: Opposite site of impact Gliding: parasagittalhaemorrhagiclesion (Rostraltocaudalmovement) Intermediary: in thedeepstructure of brain

  29. Intracerebralhemorrhage • Causedbydecelerationinjury • Frontal—temporalregion %90 • May be delayedandwith SDH and SAH • Delayedtraumaticintracerebralhemorrhage:Presence of ICH in previously normal area of brain in initial CT—MORTALITY RATE GETS HIGHER 

  30. Treatment • Considernonsurgicalmanagementforpatientswith minimal neurologicaldeficitsorwithintracerebralhemorrhagevolumeslessthan 10 mL. • Admit ICU andmonitoringandserial CT scans

  31. DiffuseAxonalInjury • Accelerating-deceleratinginjury • Confluenthaemorrhages • Frontal-temporal %80-90 • Axonsareinjuredbyshearingandimpaired transport • Is thecause of theloss of consciousness in headtraumapatients • CT is usually not enough • MRI T2W mayshowhyperintenselesions

  32. Concussion • Clinicalterm—Post traumaticalteration of consciousness • Minimal ornochanges on CT/MR • Mild form of diffuseaxonalinjury

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