Objectives: A- Review specific of anatomy and physiology as related to head injuries. B- Identify the principles of general management of the unconscious traumatized patient and the delayed complications. C- Outline the method of evaluating head injuries using a mininurological examination.
D- Explain the management techniques to be used in specific types of head injuries. E- Demonstrate the ability to assess various types of head, maxillofacial and neck injuries using a head-trauma model. F- Explain clinical signs and outline priorities for initial management of injuries identified in the assessment.
Head Trauma • Neurosurgical consult essential • Early transfer reduces morbidity and mortality • Cardiorespiratory • Level of consciousness • Pupillary reaction • Vital signs • Associated injuries • Skull film results
Cranial Nerve Assessment • Pupils occulomotor nerve ( IIIrd ) • Others- lower assessment priority • Alteration of Consciousness is The Hallmark of Brain Injury
Unconsciousness Injury • Bilateral cerebral cortices • Brain stem RAS • Increased ICP • Decreased CBF • Increased ICP Results in: • Decreased perfusion • Altered level of consciousness
History • Determine cause and effect • Pre- and post injury status • Document communicate • Reassess Vital signs • Identifies status neurologically and systemically. • Respiratory Assessment • Assess and correct deficiencies • Increased ICP - slower RR • Increased ICP – noisy tachypnea • Asses for other etiology
Blood Pressure • Increased ICP Increased BP & widened pulse pressure • Assess for other etiology • Treat shock vigorously Pulse • Increased ICP bradycardia • Tachycardia grave sign • Assess for etiology
Temperature • Temperature • Weather extremes • Control hyperthermia Eye Opening Response • Spontaneous – already open with blinking (normal) : four (4) points • To speech – not necessarily to request eye opening : three (3) points • To pain – stimulus should not be to face : two (2) points • None – make note if eyes are swollen shut : one (1) point
Verbal Response • Oriented - knows name, age, etc. : five (5) points • Confused conversation - still answers questions: four (4) points • Inappropriate words - speech is either exclamatory or random : three (3) points • Incomprehensible sounds - do not confuse with partial respiratory obstruction : two (2) points • None – make note if intubation prevents speech: one (1) point
Best Motor Response • Obeys - moves limb to command and pain is not required: six (6) points • Localizes - changing the location of the pain stimulus causes the limb to follow: five (5) points • Withdraws - pulls away from painful stimulus: four (4) points • Abnormal flexion - three (3) points • Extensor response - two (2) points • No movement - one (1) point
C-spine Assessment • High index for suspicion • Reflex assessment • Sensory assessment • X-rays
Hints to Cervical Cord Injury • Flaccid areflexia, especially with flaccid rectal sphincter • Diaphragmatic breathing • Ability to flex forearms but not extend them • Facial grimaces in response to pain above the clavicle but not below • Hypotension without other evidence of shock (ie, hypotensive with warm extremities) • Priapism is an uncommon but characteristic sign
Brain stem responses :Neurosurgeon to perform occulocephalic & occulovestibular cranial nerve test. • Skull X-rays • Do not delay primary assessment & management to obtain skull X-rays.
Management Reassessment, O2 and Airway Concussion • No significant brain injury or localizing signs • History : amnesiac of event • Admit : individualize Contusion • Significant alterations in consciousness and localizing signs • Countercoup injury • Admit and observe 48 hours
Intracranial Hemorrhage • Meningeal or brain • CT - precise or diagnose • Clinical findings similar • Acute epidural • Middle meningeal artery tear • Rapidly fatal • Hallmark : ipsilateral, dilated fixed pupil • Immediate surgery • Prognosis : good
Acute Subdural • Venous hemorrhage • life- threatening gradual onset • severe underlying brain injury • Prognosis : poor Subarachnoid • Bloody CSF, meningeal irritation • Headache, photophobia • Nuchal rigidity, R/O C-spine injury • High index of suspicion • Admit
Closed Brain Hemorrhages • Occur at any location • CT- precise diagnosis • Neurological deficits- region and size of hemorrhage Increased ICP Complications • Cerebral edema • Vasospasm • Loss of autoregulation( Neurosurgical consult )
Fluid Restriction Prevent Overhydration Diuretics • Neurological consult • Mannitol 50 gms IV • Furosemide 40-80 mg IV • Urinary catheter Deliberate Hypocapnia • Maintain PCO2 at 26-28 torr • Intubation • Latrogenic paralysis • Monitor ABGs ( Neurosurgical consult )
Convulsions • Intracranial hemorrhage Treatment • Diazepam 10mg IV • Diphenylhydantoin 1 gm IV • Phenobarbital or anaesthesia • Restlessness • Identify etiology • Correct cause Hyperthermia • Potential disastrous • Reversible neurologic findings • Vigorous intervention Scalp Wounds • Blood loss • Inspection • Repair
Surgical Management • Obtain necessary tests early • Emergent surgeries for hematomas • Transfer to neurosurgeon • Avoid delays
Summary A- Obtain and maintain an open airway B- Ventilate to avoid hypercarbia C- Treat shock, if present and look for cause D- Except for shock, restrict fluid intake to maintenance levels E- Establish baseline parameters F- Search for associated injuries G- Obtain X-rays as needed, but only after the patient is stable H- Consult a neurosurgeon and consider early transfer
I- Should the patient's condition show a change for the worse, consider other diagnoses and forms of treatment. • Consult with a neurosurgeon and consider transfer. • J- Reassess continually to identify changes necessitates neurosurgical intervention.