Title: ????(Head Injury)
1????(Head Injury)
2Glasgow Coma Scale
3Classifications of Severity
- Mild head injury (GCS 14-15)
- Moderate head injury (GCS9-13)
- Severe head injury (GCS? 8)
4Immediate Management of Head Injury
- General principles
- Not a single disorder.
- Tailored therapeutic plans for the specific
lesion and individual patient from time to time. - No stable hemodynamics, no accurate GCS score.
5Begin at the trauma scene
- Airway with cervical spine control
- Breathing
- Circulation with hemorrhage control
- Stabilizing the cervical and thoracolumbar spine
(Disability) gt C-spine, CXR, pelvis - Identifying and stabilizing Extracranial injuries
- Mini-neurologic Examination.
- ?ABCDEE
6Mini-neurological Examination
- Level of consciousness (E4V5M1???)
- Pupillary function (unilateral? L/R? Doll eye
sign?) - Lateralized extremity weakness
7Risk Factors (5H-CSI)
- Hypotension ? double mortality rate
- Hypoxia ? add hypotension ? 75 mortality
- Intracranial Hypertension (IICP)
- Hyperthermia
- Electrolyte disturbance (H)
- Coagulopathy
- Seizure
- Infection
8Mild Head Injury (GCS 14-15)
- Brain concussion (initial loss of consciousness)
- All head-injured patients should have a CT scan,
except the true asymptomatic patients. - If CT scan is not available ? admission and
observation for 1-2 days. - 2-3 serious intracranial insult.
- Abnormal CT scan 18 ? 5 need op
9Mild Head Injury
- Risk factors of neurological deterioration
- Older age and anticoagulant therapy
- CPR
- Alcohol or drug abuse
- Presence of subdural effusion or hematoma at the
initial CT scan - Epilepsy
- Previous neurosurgical treatment.
- ? ?????????????????,???????.
10Mild Head Injury
- Admission criteria (?????ER????)
- Penetrating head injuries
- Abnormal CT scan or skull fracture
- Loss of consciousness or amnesia
- Moderate to severe headache or vomiting
- Worsening in GCS score
- Pneumocephalus or CSF leakage
- Associated extracranial injuries
- Alcohol or drug abuse, coagulopathy and other
risk factors for deterioration - No reliable assistance at home
11Mild Head Injury
- While being discharged, give a warning sheet
(??????) - Within 1-2 weeks, OPD F/U.
12Moderate Head Injury (GCS 9-13)
- CT scan should be done in all cases of moderate
head injury. (abnormal CT 40) - Admission criteria
- In non-severe head injury, causes of mortality
are inadequate observation and extracranial
injuries. - Higher risk of deterioration
- Older
- An initial abnormal CT scan
- Lower GCS motor score
13Moderate Head Injury
14Severe Head Injury (GCS lt8)
- First priority (before calling NS Drs)
- Securing airway, breathing, and circulation
(ABC). - Emergent intubation !!
- Avoid hypoxia (PaO2lt60mmHg)
- Avoid hypotension (SBPlt90mmHg)
- Avoid electrolyte imbalance Na, K, Glu, Mg
- Other system injury (life threatening) check
chest and abdomen
15Acute treatment for severe head injury
ABCDE
E
5H-CSI
16 To control ICP should be started empirically
even before a CT scan is obtained.
- Comatose patients
- Decline in GCS
- Pupillary asymmetry
- Hemiparesis
- Any signs of presence of a traumatic mass lesion.
- Intubation
- Mild hyperventilation
- IV bolus of mannitol
- Prophylactic phenytoin
- Sedation
CT room
17???????
- ??????,?????????????????
- ????????????,??????????????, ?????,?????????
- ??????????(since 1973),????????????
18???????????
- ?????????????(secondary injury ),?????????????????
(??????????)???????????????????????,???????????,??
?????????????
19???????????
- ??????????(neurological examination monitoring)
- ?????((ICP monitor)
- ????????(Transcranial Doppler, TCD)
- ?????????(jugular bulb oxygen saturation , SjvO2)
- ??????(brain oxygen saturation monitoring)
- ???????(neurophysiology monitoring)??????(EEG)???
??(evoked potential, EP) - ??????(neurometabolic monitoring)
- ??????(PaO2)??????(PaCO2)?????(pH)???
20??????????
- ????(GCS)?????????????????????????????
- ????????,?????????(SaO2)????(ECG)??????(CVP)??????
?????(End tidal CO2)?????????????????? - ??????????????????????????,???????????????????????
???????????? - ??????????????,??????(hypotension)???(hypoxia)?
21??????????
- ???????????????????????????
- ?????????,???????????????????????,??????
- ?????????,???????????
22???????
- Monro-Kellie?? ?????????, ??????????????????????,
?????1500-1900??? - ?????????????????????????(intracranial pressure,
ICP)
23Monro-Kellie??
Total 1700ml
???? Blood 150ml
??? CSF 150ml
??? Parenchyma 1400ml
??? Intraventricular space 50ml
?????? Subarachnoid space 100ml
24??????????
- ??????
- ???????,?????????
- ???????????
- ???
- ?????????,??????
- ????
- ???????????
25????????
- ????????(cerebral perfusion pressure,CPP)????
- CBFCPP/CVR
- ????????????(mean arterial pressure,MAP)?????
- CPPMAP-ICP
- ?????????,????????
26???????
- ????????????
- ????????10-15mmHg
- ???????3-7mmHg
- ??????1.5-6mmHg
- ????????? 60-80mmHg
27????
- ??????,???????????????????????(intracranial
hypertension)? -
28??????????
- ???????????,?????????
- ???
- ??????
- ?????(papilledema) ?
- ????--?????????
- ???(herniation)?
29??????????
- Cushing triad ??????
- ???????????????
- ?????,?????????????????
30????????
- Severe head injury with an abnormal admission CT
scan. - Severe head injury with a normal CT scan if two
or more of the following features are noted at
admission - Age over 40 years,
- unilateral or bilateral motor posturing
- Systolic blood pressure lt 90mmHg.
- Not routinely indicated in patients with mild or
moderate head injury.
31ICP monitor techniques
- The gold standard technique for ICP monitoring is
by means of an intra-ventricular catheter.
(ventriculostomy, EVD external ventricular
drainage ?????) - Alternative techniques
- Parenchymal, subdural, or epidural catheter.
- Complication parenchymal injury, infection,
hemorrhage, malfunction, or malposition. - Up to one week and providing prophylactic
antibiotics.
32??????????
- ?????????
- ??(fluid restriction)
- ???????(??mannito1?glycerol)
- ????(hyper-ventilation)
- ????(hypothermia)?????????
- ????????
- ?????????????(squeezing the oxygenated blood
through a swollen brain)? - CPP MAP - ICP
Focus on CPP!!
33????????????
- ??????????,???????????
- ????30?(???????56mmHg)
- ??????(????????56 mmHg)
- ????????
- ?????(PEEP)
- ????(Valsalva maneuvers)
- ???????(???????????)?????????
- ???????
- ?????
- ?????
- ????????(??45mmHg)?????
- ??
34?????????
- ????????70mmHg?
- ???????????? (normovolemia)
- ?????????6-15cmH2O
- ?????12-15mmHg?
- ???????????(isotonic crystalloid)????(colloid)???
????????
35??????????????
CBFCPP/CVR CPPMAP-ICP
????
- ??????
- ????? ????
- ???????
???????, ????, ?????
CSF??, ?????
???30?,?????? ??????,??????
36??????,??????????????
CBFCPP/CVR CPPMAP-ICP
????, ??
- ??????
- ????? ????
- ???????
???????, ??????, ?????
??? ???
??????,???? ??????,?????
37?????
?????100??????????(euvolemia)???????? ?6-15cmH2O
????????12-15mmHg??????? 70mmHg,?????????35mmHg
?????????????
??????,??????
?????(mannitol) 0.25-1gm/kg
???????,PaCO2 30-35mmHg ?????????(SjvO2)???
???????????
38?????
???????????(hypothermia)??????? ???????(PaCO2lt30mm
Hg) ?????(decompression craniectomy)
39???(sedation)???????? (neuromuscularblockade)
- ???????????????,???????????
- ???????midazolam, propofo1 ????????atracurium,
pancuronium, vecuronium? - ??????20mmHg??24??,???????????
40??????(CSF drainage)
- ?????????(ventriculostomy),????????????????
- ????3-5 ml,???????????
- ?????8????75 ml.??????
41?????(osmotic diuretics)
- ??????? mannitol ? glycerol
- ?????????????????,??????????????,???????????????
- ??????????????,????????,??????????,???????????????
???? - ????15????????
- ???????????????(bolus, rapid infusion)?
42?????(osmotic diuretics)
- ???????0.25-1 g/4-6hrs,????????????
- ????????,???????320 mOsm/L,????????
43?????(osmotic diuretics)
- ????????????(hypotension)?????(hypovolemia)???????
????????????????(CPP protocol)???????????? - ??? lasix ??? mannitol ?????????????20-40mg/3-4hr
s (0.3 to 0.5 mg/kg),?????????????????????????????
?
44Steroids
- Although steroids clearly are useful in reducing
the perifocal edema associated with brain tumors,
their value in head injury has not been
demonstrated.
45Anticonvulsants
- Post-traumatic epilepsy 15-30 of severe H.I.
5 of mild H.I. - 90 occur within the first 24 hours
- Indication
- GCS ?10 on admission
- Acute EDH, SDH, ICH (supratentorial)
- Open depressed skull fracture with parenchymal
injury - Cortical contusion on CT scan
- Seizure within the first 24 hrs after injury
- Penetrating brain injury
- History of significant alcohol abuse.
46D/C of anticonvulsants
- Taper after 1 week of therapy except in the
following - Penetrating brain injury
- Development of late seizure
- Prior seizure therapy
- Patients undergoing craniotomy
- The above four situations maintain for 6-12
months.
47Indication for Surgery
- Critical factors
- Patients neurological status
- Imaging findings
- Presence and severity of extracranial lesions.
- Time is life.
48Significant Mass Effect
- Displacement of midline structures? 5mm.
- Effacement of basal cisterns on CT scan.
49EDH (epidural hematoma)
- Located in the temporal region tear of the
middle meningeal vessel, sinus injury - In 50 of patients there is no radiographic
evidence of a fracture. - Small, stable, asymptomatic ? conservative
- All acute traumatic extraaxial hematoma 1cm or
greater in thickness ? op - Outcome children better than adult.
50SDH (subdural hematoma)
- 30 of severe head injury
- Bleeding of lacerated brain and cortical vessels
avulsed bridging vein - No significant mass effect without brain swelling
? conservative - Larger craniotomy
- Worsen prognosis than EDH
- Golden time 4 hours
51Contusional and intracerebral hematomas (ICH)
- Located in anterior frontal and temporal lobes.
- Awake and alert? conservative
- gt2cm(surface), mass effect, uncontrolled ICP ? op
- Early surgical intervention for temporal and
posterior fossa lesions. - Adult with GCS of 3, non-reactive dilated pupil
without spontaneous respiration ?
conservative - Over 75 Y/O, GCS of 5 or less
? conservative
52Skull fracture
- Non-op closed, linear, non-depressed skull
fracture ? heal spontaneously. - OP
- open fractures or fractures depressed more than
the thickness of the skull required surgical
elevation or repair. - Cosmetic consideration.
- Near a major dural sinus ? non-op, even occluded
sinus.
53Skull fracture
- There is no evidence to support the theory that
correction of a depressed skull fracture reduces
the risk of subsequent seizures.
54Growing skull fracture
- Inspecting the site of injury for a palpable,
non-tender swelling. - A linear fracture separated more than 3 mm on CT
scan suggest an associated dural tear. - OP or F/U
- They rarely occur in children over 18 months of
age and rarely show after 6 month from injury.
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56Skull Fracture
Raccoons eye sign
Battles sign
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58The End!!