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Hugo Poncia

Hugo Poncia. Head Trauma. Epidemiology Physiology History Examination Investigations Treatments Cases. Introduction . 165,000/year in UK Mean age 20-30 50% all trauma deaths are caused by Head injury Commonest cause of life-long disability 15,000 are moderate or severe

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Hugo Poncia

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  1. Hugo Poncia

  2. Head Trauma • Epidemiology • Physiology • History • Examination • Investigations • Treatments • Cases

  3. Introduction • 165,000/year in UK • Mean age 20-30 • 50% all trauma deaths are caused by Head injury • Commonest cause of life-long disability • 15,000 are moderate or severe • 7.5% death, 20% disability

  4. Brain Injury • PRIMARY injury: Shearing, Diffuse axonal injury, Contusion, Haemorrhage, Laceration. • SECONDARY injury: Cerebral oedema, Hypoxia, Hypercapnia, intracranial Haemorrhage, Increased ICP, Hypotension, reduced CBF, infection, Epilepsy.

  5. Potentially avoidable deaths are often the result of delayed, inappropriate or inadequate treatment of secondary brain damage.

  6. Venous Arterial Brain Mass CSF volume volume Physiology • Monro-Kellie doctrine • CPP= MAP- ICP • Normal ICP 8-15 mmHG • Small changes in volume can result in big increases in ICP

  7. Physiology • Autoregulation limits 60-160 mmHG • CPP >70 is ideal • Normal CBF 50ml/100g brain/min • If > 130mmHg Oedema • 50% of severe head injuries (GCS<9), ICP will rise > 20

  8. Intracranial Haematoma • Extradural • Intradural • Subdural • Intracerebral • Subarrachnoid • Mixed

  9. Extradural Epidemiology: All ages but more common if <40yrs and males The most common site in children Symptoms and signs: Lucid period. Pupils dilate late. 75% have skull # Prognosis: 10% mortality usually due to diffuse axonal injury

  10. Acute Subdural Epidemiology Mostly over 40yrs with significant trauma Small brains, coagulopathies, 3 days from injury Types Diffuse, multiple collections (more common) One big bleed Usually associated with axonal injury Prognosis- 30% mortality

  11. Subacute and Chronic Subdural Frequently no history of trauma Present as raised ICP, sometimes weeks after cause Associated with underlying brain trauma. Frequently (approx 20%) recollect (osmotic/rebleed)

  12. Traumatic Subarrachnoid Not raised ICP, presents like ordinary SAH Which came first the accident or the headache? If in doubt - needs arteriography to exclude aneurysm Nimodipine and hydration are effective Prognosis better than aneuysmal SAH

  13. Intracerebral Haematoma Cerebral contusions and haematomas are different Treatment may involve surgery if Signs of raised ICP CT suggests that raised ICP will develop! Posterior fossa bleeds Otherwise treat as diffuse injury

  14. History • Mechanism • Baseline GCS • AMPLE • Alcohol, Diabetes, Anticoagulants • Symptoms: Nausea, Vomiting, Headache, Visual Symptoms, Fits, Amnesia.

  15. Criteria for admission • Skull fracture • Persistent GCS < 15 • Persistent vomiting • Epileptic fit • Abnormal neurological signs • Mastoid bruising • Orbital bruising • Lack of supervision at home • IF IN DOUBT ADMIT!

  16. Beware the drunk head injury!

  17. Examination • AVPU or GCS • Pupillary response • Examine for Basal skull # • Depressed skull #- explore scalp wounds • Lateralising weakness, tendon reflexes, plantars, sacral sensation

  18. Examination- Basal Skull # • Raccoon Eyes • Scleral haemorrhage without posterior limit • Haemotympanum, rhinorrhoea & otorrhoea • Battles sign- bruising over mastoid • (intracranial air, opaque sphenoid sinus)

  19. Neuro obs Record neuro-observations half hourly GCS Pupillary size (mm) and reactivity Respiratory rate Pulse rate Blood pressure Limb power

  20. GCS • Minor GCS 13-15…….. 280 per 100.000 • Moderate GCS 9-12 ……...18 per 100,000 • Severe GCS <8…... ……...8 per 100,000 • Deteriorating GCS is hallmark of secondary brain injury…….. RE-ASSESS

  21. GCS- Eyes • Best response • Supra-orbital stimulus • E 4 Spontaneous • E 3 Speech • E 2 Pain • E 1 None

  22. GCS- Motor • M 6 Commands • M 5 Localises • M 4 Withdraws • M 3 Abnormal Flexion • M 2 Extends • M 1 None

  23. GCS - Verbal • V 5 Orientated • V 4 Confused • V 3 Inappropriate words • V 2 Incomprehensible sounds • V 1 None

  24. Risks of Intracranial Haematoma • GCS 15 no # 1:5983 • Confused no skull # 1:121 • Fully orientated with skull # 1:32 • Confused with skull # 1:4

  25. A fully conscious patient (GCS 15) with a skull fracture has a 1 in 30 chance of harbouring an intracranial haematoma .

  26. A patient who is not fully conscious with a skull fracture has a 1 in 4 chance of harbouring an intracranial haematoma

  27. Investigation • Blood glucose • ABG • Clotting • G&S / X-match • CT • DPL?

  28. Indications for SXR? • Loss of consciousness • Post traumatic amnesia • Scalp damage • GCS < 15 • Abnormal neurological signs • Vomiting

  29. Criteria for CT Scan? • GCS < 15 + skull # • Abnormal neurology + skull # • Fit + skull # • Developing neurological signs without coma • Fall in GCS with normal BP and pO2 • GCS < 15 for > 8 hours • Persistent vomiting

  30. Treating shock and hypoxia takes precedence over moving or CT scanning the patient.

  31. Treatment • ABC • INTUBATION?…What are the indications? • GCS<8 • Loss of laryngeal reflexes • Inadequate ventilation (pO2<9Kpa on air or 13Kpa on O2, pCO2>6Kpa) • Respiratory arrhythmia • Reduce ICP by hypocarbia pCO2<3.5Kpa

  32. Avoid BVM with basal skull # • Rapid sequence induction..c-spine injury? • Paralysis • Sedation..propofol? • Orogastric tube • Talk to neurosurgeon early

  33. C • Cautious fluid replacement • Avoid hypo-osmolar fluids • Treat hypovoalemia/shock aggressively • Avoid Internal jugular lines • Urinary catheter/ Arterial line • Abdominal/Pelvic injury? • Bolt?

  34. Treatments • Resuscitation.. THINK ABC • Consider early ventilation • Treat space occupying lesions with surgery • Treat Fits • Diazepam • Phenytoin (5-10mg/kg at 50mg/min) • Thiopentone infusion • Mannitol? 0.5-1g/kg over 15-20 mins • Good secondary survey

  35. Mannitol • Buys time • Osmotic gradient between plasma /brain • 1g/Kg (5ml/Kg) 0.5g/100mls of 20% over 15mins • 50ml aliquots of 20% over 10 mins • Equilibration, fully osmolised at 310 mOSM, don’t give if >320 • May cause ATN, Hypertension & high intracellular osmotic pressure, phlebitis

  36. From the following list which patients need to be admitted?: • A 25 year old with a parietal skull fracture. • A 43 year old who keeps on asking what happened. • A fully alert 37 year old with an aortic valve replacement and normal skull X-ray. • A 19 year old student who lives in a bed sitter.

  37. Which of the following would you X-ray? • A 3 month old baby who has "rolled off a couch". • An 18 month old who has run into a door sustaining a large right sided forehead swelling. • An 18 year old struck over the head with a billiard cue. • A 25 year old in a 3 metre fall from scaffolding. • A 43 year old intoxicated man who had fallen backwards from a bar stool onto a concrete floor. • A 72 year old who struck her head on an open cupboard door.

  38. That’s all folks

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