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Head injury

Head injury. Dr. B.Padmashini Department of Accident, Emergency & Critical Care Medicine. Vinayaka Mission Kirupananda Variyar Medical College & Hospital. Salem,Tamil Nadu. Head Injury.

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Head injury

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  1. Head injury Dr. B.Padmashini Department of Accident, Emergency & Critical Care Medicine. Vinayaka Mission Kirupananda Variyar Medical College & Hospital. Salem,Tamil Nadu

  2. Head Injury • Number One Killer in Trauma • 25% of all trauma deaths • 50% of all deaths from MVC • 200,000 people in the world live with the disability caused by these injuries

  3. Road Traffic Crashes

  4. Sports injuries

  5. Assaults (Sickle injuries)

  6. Basic Anatomy • Scalp • Skull • Meninges • Dura Mater • Arachnoid • Pia Mater • Brain Tissue • CSF and Blood

  7. Skull

  8. Dura- mater

  9. Venous sinuses

  10. Arachnoid mater

  11. Pia- mater

  12. CSF

  13. Grey matter

  14. White matter

  15. Ventricles

  16. Intracranial Volume • 80% Brain Matter • 10% Blood • 10% CSF

  17. The MONROE KELLIE doctrine Dictates that “the total volume of the intracranial contents MUSTremain constant”

  18. Normal state- ICP normal

  19. Compensated state- ICP normal

  20. Uncompensated state- ICP Elevated 75 ml 75 ml

  21. Volume-Pressure Curve

  22. Intracranial Pressure • The pressure of the brain contents within the skull is intracranialpressure (ICP) • The pressure of the blood flowing through the brain is referred to as the cerebralperfusionpressure (CPP) The pressure of the blood in the body is the meanarterialpressure(MAP) CEREBRAL BLOOD FLOW Normal CBF – 50ml/100gm of brain/min “AUTOREGULATION”

  23. ROLE OF INTRACRANIAL PRESSURE • 10 mmHg - Normal • > 20mmHg - Abnormal • > 40mmHg - Severe •  ICP  deteriorates brain function  poor outcome

  24. Intracranial Pressure • CerebralPerfusionPressure (CPP) can be determined by the following formula: CPP = MAP - ICP • NormalCPPrangeis60 - 150forautoregulation to work well!

  25. SYMPTOMS & SIGNS OF INCREASED ICP • Diminishing level of consciousness • Headache, vomiting, seizures • Cushing’s Triad –  bradycardia hypertension  abnormal respiration • Pupillary changes • Papilledema

  26. PATHOPHYSIOLOGY • Primary Injury • Mechanical irreversible damage - brain lacerations, hemorrhages, contusions, and tissue avulsions, • Microscopy - primary injury causes permanent mechanical cellular disruption and microvascular injury.

  27. Secondary Injury • Neurologic outcome after head trauma - degree of secondary brain injury. • Common Secondary systemic insults – Hypotension – SBP < 90 Hypoxia - Po2 less than 60 Anemia – reduces O2 Carrying capacity of the blood, to the injured brain tissue, • Other causes - hypercarbia, hyperthermia, coagulopathy, and seizures.

  28. CLASSIFICATION

  29. MECHANISM • BLUNT INJURY High Velocity Low Velocity • PENETRATING INJURY Gunshot Sharp instruments

  30. Severity -GLASGOW COMA SCALE Mild - GCS 13 - 15 Moderate - GCS 9 - 12 Severe - GCS 3 - 8

  31. MORPHOLOGY • SCALPINJURY Cephal Hematoma Subgaleal Hematoma

  32. SKULLFRACTURES • Vault : linear/stellate depressed/non depressed open/closed

  33. Basilar : with/with out CSF leak with/with out seventh-nerve palsy Battle sign Raccoon eyes CSF rhinorrhea

  34. INTRACRANIALLESIONS • Focal : epidural hematoma subdural hematoma intracerebral hematoma

  35. Epidural haematoma • Collection of blood & clot b/n dura matter and bones of the skull • Source Middle Meningeal Artery Dural Venous Sinuses • C/F Brief loss of consciousness, headache,drowsiness,dizzy,nausea,vomitting • Rapid clinical deterioration • Talk & die

  36. EDH

  37. SDH • Subdural hematomas • Most frequently from tearing of a bridging vein between the cerebral cortex and a draining venous sinus. • - acute - <24hrs - subacute – 24hrs-2wks - chronic - >2wks Shape-Crescent

  38. Intra Cerebral Heamatoma • Formed within brain tissue & caused by shearing or tensile forces that mechanically stretch and tear deep small caliber arterioles • Most common in temporal and frontal regions • C/F depend on site involved

  39. INTRACRANIAL LESIONS Diffuse : concussion multiple contusion hypoxic/ischemic injury

  40. Concussion • Temporary & brief interruption of neurological function after minor head injury • Due to shearing / stretching of white matter fibres at the time of impact or temporary neuronal dysfunction • C/o headache, confusion, amnesia • CT/MRI cannot detect

  41. DAI • Shearing forces disrupt the axonal fibres in the white matter • Shaken baby syndrome • Blunt trauma • Rapid rise in ICT. • Prolonged or permanent.

  42. APPROACH TO A PATIENT WITH HEAD INJURY • History • Initial Assessment Primary Survey Secondary Survey

  43. PRIMARY SURVEY Airway maintenance with cervical spine protection

  44. Intubation with Cervical inline stabilization • Breathingandventilation : Intubation precautions Pre-medicate with Lidocaine, 1mg/kg IV 2 minutes prior to attempt • Laryngoscopy produces an ICP Spike

  45. Circulation • Maintain MAP >90mmhg- adequate • Hematocrit >30% • Cushing reflex

  46. Isolated intracranial injuries do not cause hypotension • LOOK FOR THE CAUSE OF HYPOTENSION

  47. Disability • Pupil size • GCS Pupillary Changes Irregular shaped Equality? Constricted? Dilated? Vision Problems?

  48. SECONDARY SURVEY • AMPLE history • Examination of Head to toe • Glasgow Coma Scale • Detailed Neurological Examination

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