Download
head trauma n.
Skip this Video
Loading SlideShow in 5 Seconds..
Head Trauma PowerPoint Presentation
Download Presentation
Head Trauma

Head Trauma

265 Views Download Presentation
Download Presentation

Head Trauma

- - - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript

  1. Head Trauma Chapter 6

  2. Objectives • Review the key anatomic features of the head (face) and neck • Describe injury patterns • Describe the evaluation of the patient with suspected head (face)/neck injury • Review epidemiology and pathology associated with traumatic brain injury (TBI) • Understand the initial evaluation and management of a patient with a TBI

  3. ANATOMY • Soft Tissues • Includes parotid glands • Bones • Facial and cervical spine • Neck blood vessels • Carotid and vertebral arteries • Jugular and other veins • Trachea • Esophagus • Globes and surrounding ducts

  4. ABCDE’s REMAIN BASIC! • Soft tissue or bony injuries may immediately threaten the airway • Uncontrolled bleeding can change “stable” to “unstable” very quickly • Standard maneuvers may be less successful in setting of fractures, etc. • Associated brain or spine injuries may cause airway loss as well • All blunt face/neck trauma must be considered at risk for C-spine injury • Neurologic injuries may worsen with time as well

  5. TRACHEAL INJURIES • Securing the airway remains critical • Tracheal injuries may cause significant air leak • Pneumomediastinum • Pneumothorax, even tension pneumothorax • Surgical repair is required • If unavailable, manage with secure airway and chest tubes if necessary • Minimize airway pressure on ventilator

  6. BLUNT TRACHEAL INJURY Pneumothorax and Pneumomediastinum Tracheal Injury

  7. EPISTAXIS • May result in significant bleeding • Separated into anterior and posterior sources • Intubation for airway control prior to packing may be needed

  8. EPISTAXIS Posterior Packing

  9. EPISTAXIS Anterior Packing Epistat Balloon

  10. ZONES OF THE NECK

  11. ZONE 1 INJURY • Difficult to access from neck incision, may need sternotomy/thoracotomy • Initial management with angio/CT angio, bronchoscopy, esophagoscopy • Basically need to evaluate all vascular and aerodigestive structures potentially in harm’s way • As with most trauma, “stable or unstable” guides the initial management • Active bleeding, expanding hematomas, or hemodynamic instability need to be addressed first in the OR and then with staged work up if indicated

  12. ZONE 2 INJURY • Only zone that is easily accessed from a neck incision • Still requires investigation of vascular and aerodigestive structures • In a STABLE patient, can be investigated with CT and endoscopy potentially • Again, unstable patients or those with active bleeding issues need to be addressed in the operating room!

  13. ZONE 3 INJURY • Similar to Zone I, potentially difficult to access surgically and so angiography or CT needed, with possible endoscopy • These tend to be vascular injuries at the skull base that are very difficult to control surgically • Again, instability should prompt rapid damage control in OR, followed by additional work up if needed

  14. VASCULAR INJURY COMPLICATIONS • Hemorrhage is the first concern • Stroke is the second concern (up to 25% of ICA injuries) • Revascularization may be required ICA/ECA Injury with Reconstruction

  15. BLUNT CEREBROVASCULAR INJURY • More frequent that was believed in the past • Roughly 1-1.5% of blunt admissions • Workup with CT Angio or conventional angiography • Treatment based on grade • Low grade lesions no intervention or ASA • Higher grade lesions need anticoagulation or possibly stenting, with recent interest in aggressive antiplatelet agents • Complications related to increased stroke risk

  16. FACIAL FRACTURES • Frequent injuries, but rarely have to be addressed immediately from a surgical standpoint • The primary question should be one of airway protection • The anatomic disruption or bleeding may cause loss of airway • The situation may deteriorate as swelling progresses in the upper airway • Remember that the globes may be injured by fractures and a good exam, including visual acuity, is mandatory

  17. UPPER FACE FRACTURES • Clinical exam is very useful – pain, bruising, crepitance, movement • Malocclusion often occurs with mandible fractures • Check a cranial nerve exam!

  18. LE FORT FRACTURES

  19. MANDIBLE FRACTURES • Malocclusion a common hint on exam • 50% will break multiple places • Can be managed with soft diet/liquids and pain control in short term • Operative repair ultimately required Panorex

  20. FACIAL FRACTURES • Open fractures may require broad spectrum antibiotic coverage • This isn’t agreed upon, but if a sinus is violated then initial coverage is reasonable • Remember that if enough trauma occurred to fracture bones, the nearby structures are also at risk • At least 20% of facial fractures will have a TBI • About 2% will have a C-spine fracture

  21. OCULAR INJURIES • Evaluation requires a careful exam, including visual acuity • Open globes are as emergent as threatened limbs, and need antibiotic coverage like open fractures • Remember that open globes need an altitude restriction for MEDEVAC

  22. OCULAR INJURIES • Layering of blood in the inferior anterior chamber • Usually managed with rest, elevation of HOB, and correction of clotting factors • 5% will require surgical evacuation Hyphema

  23. OCULAR INJURIES • Minor injury • Resolves spontaneously, though may take weeks • Avoid anticoagulant or antiplatelet drugs • Lubricant eye drops as needed Subconjunctival hemorrhage

  24. SUMMARY thus far • Airway control remains the primary concern • Control of hemorrhage may require packing, angiography, or operation • Facial fracture repair may be delayed if necessary once wounds are closed • Tracheal and esophageal injuries require more urgent repair • Globe injuries should be considered with facial fractures, and known injuries treated with the same urgency as threatened limbs

  25. GLASGOW COMA SCALE (GCS) EYE OPENING (E) Spontaneous 4 To Speech 3 To Pain 2 None 1 BEST MOTOR Obeys Commands 6 RESPONSE (M) Localizes Pain 5 Normal Flexion (Withdraws) 4 Abnormal Flexion (Decorticate) 3 Extension (Decerebrate) 2 None 1 VERBAL RESPONSE (V) Oriented 5 Confused Conversation 4 Inappropriate Words 3 Incomprehensible Sounds 2 None 1

  26. HEAD INJURY • Mild: GCS 14 – 15 • Moderate: GCS 9 – 13 • Severe: GCS 3 - 8

  27. STATISTICS • #1 Cause of Traumatic Death • 500,000 CHI per year • Upon ER Arrival: • Dead: 14% • Mild Injury: 80% • Moderate – Severe Injury: 10% each • Overall Mortality • Mild: 0% • Moderate: 7 – 10% • Severe: 30%

  28. DISABILITY • CHI: Disability within each group • Mild: 10% • Moderate: 50 – 67% • Severe: > 95% • Penetrating GSW to Head • Vegetative or Severely Disabled: 10% • Moderate Disability: 20% • Good Outcome: 20% • The Others: Dead

  29. PATHOLOGY • Anatomy • Types of Injury

  30. ANATOMY • Pia Mater • Arachnoid Layer • Dura Mater

  31. SUBDURAL HEMATOMA • Most common traumatic lesion • In 20-40% of severely head-injured • Located in space between dura and arachnoid layers • Venous bleed • Concave Shape

  32. EPIDURAL HEMATOMA • Located in space between dura and inner table • Arterial bleed • Classic presentation • Convex shape

  33. CEREBRAL CONTUSION • Most common in subfrontal and temporal regions • Bruised tissue with violation of BBB

  34. DIFFUSE AXONAL INJURY (DAI) • Axonal structural failure due to mechanical forces along axons • Culmination in physical separation of axon into proximal and distal segments • Number of axonal disruptions = Amount of deficit

  35. MANAGEMENT • Initial Evaluation • Emergent Surgical Management • Initial Management

  36. EVALUATION • First Priority: Airway, Breathing, Circulation • Disability • Pupillary Exam • Calculate GCS • Resuscitation • Standard Techniques • DO NOT postpone treating hypotension • Preferred Crystalloid: Hypertonic Saline or Isotonic Saline • Blood

  37. EVALUATION • Secondary Survey • Assess for other injuries • Complete neurological assessment • Radiologic Evaluation • Hemodynamically stable • CT Scan of Head: Gold Standard

  38. EMERGENT SURGICAL INTERVENTION • Significant mass effect • Displacement of > 5mm off midline • Penetrating injuries may need simple debridement

  39. INITIAL MANAGEMENT • Significant reductions in mortality & morbidity by using intensive management protocols: • Early intubation • Rapid transportation to appropriate trauma care facility • Prompt resuscitation • Early CT scanning • Immediate evacuation of intracranial mass lesions • TCDB Mortality: 50% vs 36% (using these protocols)

  40. INITIAL MANAGEMENT • Sedation • No studies have proven sedation to influence TBI outcome • Neuromuscular Blockade – Results in: • Longer ICU Course • Increased pneumonia rate • Trend towards increased sepsis • No improvement in outcome

  41. INITIAL MANAGEMENT • Blood Pressure • Single episode of hypotension (SBP < 90 mm Hg) • Increased morbidity • Doubled mortality • Hypotension is an INDEPENDENT predictor of outcome

  42. INITIAL MANAGEMENT • Cerebral Perfusion Pressure • CPP = MAP – ICP • Very low following TBI; may be near ischemic threshold • Critical threshold is 60 mm Hg • Significant decline in outcome for those with persistent CPP < 60 mm Hg • CPP < 50 mm Hg associated with: • Critical reductions in PbO2 • Increased morbidity and mortality

  43. INITIAL MANAGEMENT • Oxygenation • Hypoxemia: PaO2 < 60 mm Hg • Results in: • Increased mortality: 14% vs 50% • Worse outcome • Mannitol • Studies support use of mannitol for ICP management

  44. INITIAL MANAGEMENT • Hyperventilation • Introduction • Cerebral blood flow in first day after injury is half that of normal individuals • Severe hyperventilation results in cerebral ischemia • Hyperventilation is known to decrease ICP and lower CBF • Aggressive Hyperventilation (PaCO2 < 30 mm Hg) • Reduces CBF, reduces ICP, possible loss of autoregulation • Outcomes at 3 and 6 months are better without prophylactic hyperventilation

  45. INITIAL MANAGEMENT • Hyperventilation (continued) • Guidance • STANDARD: In absence of increased ICP, chronic prolonged hyperventilation (pCO2 < 35 mm Hg) therapy should be avoided after severe TBI • Guideline: Use of prophylactic hyperventilation during first 24 hours after severe TBI should be avoided because it can compromise CBF during a time when CBF is already low

  46. ICP MONITORING • At Risk Patients • ICP Data and Patient Management • Guidelines

  47. AT RISK PATIENTS • Mild and Moderate Head Injury • Low risk for ICH • Less than 3% (Mild) and 10 – 20% (Moderate) will deteriorate into coma • Routing ICP monitoring is not recommended • Severe Head Injury • ICH Incidence • Abnormal CT: 53 – 63% • Normal CT: 10 – 15% • Normal CT + 2 of 3 adverse features: Similar to abnormal CT • Normal CT Strategy • Up to 1/3 may develop new pathology within a few days from injury • Follow-up scanning for those without ICP monitoring

  48. ICP DATA & MANAGEMENT • All Therapies are Double-Edged Swords • Hyperventilation • Reduces ICP • Causes cerebral vasoconstriction and ischemia • Mannitol • Reduces ICP • Cumulative doses can exacerbate brain edema • Sedation, analgesia, and paralysis • Reduce ICP • Impossible to interpret clinical exam

  49. GUIDELINES • Severe TBI (after resuscitation) and Abnormal CT • Severe TBI (after resuscitation) and Normal CT + 2 of 3: • Age over 40 years • Unilateral or bilateral posturing • SBP < 90 mm Hg • Not routinely in Mild or Moderate TBI • ICP management initiated at upper threshold of 20 – 25 mm Hg