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Head Trauma

Head Trauma

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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