head & brain trauma

8/6/2019 Head & Brain Trauma

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AnatomyAnatomy

CraniumCranium

Double layer of solid bone which

surrounds a spongy middle layer

Frontal, occipital, temporal, parietal,mastoid

MiddlemeningealarteryMiddlemeningealartery

lies under temporal bone

common source of epiduralhematoma

ForamenmagnumForamenmagnum


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DivisionsDivisions

Cerebrum

Cerebellum

Brain Stem


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CerebrumCerebrum

CortexCortex

Voluntary skeletal movement

level of awareness

FrontallobeFrontallobe

Personality

ParietallobeParietallobe

somatic sensory input

memory

emotions


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TemporallobeTemporallobe

speech center long term memory

taste

smell

OccipitallobeOccipitallobe origin of optic nerve


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CerebrumCerebrum

Hypothalamus

center for vomiting, regulation of

body temp and water

sleep-cycle control

appetite

Thalamus

emotions and alerting or arousal

mechanisms


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CerebellumCerebellum

coordination of voluntary muscle

movement

equilibrium and posture


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Brain Stem

connects hemispheres, cerebellum and

SC

responsible for vegetative functions &

VS

midbrain

relay point for visual and auditory

impulses


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Pons

conduction pathway between brain

and other regions of body

medullaoblongata

cardiac, respiratory, and vasomotor

control centers

control of vomiting and coughing


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Brain Stem Cranial Nerves

Reticular Activating System

level of arousal (level of

consciousness)

Primary control along with

cerebral cortex

Meninges

dura materdura mater: tough outer layer,

separates cerebellum from cerebral

structures, landmark for lesions

arachnoidarachnoid: web-like, venous vesselsthat reabsorb CSF

pia materpia mater: directly attached to brain

tissue


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Brain Stem

Cerebral Spinal Fluid (CSF)

clear, colorless

circulates through brain and spinal

cord

cushions and protects

ventricles

center of brain

secrete CSF by filtering blood

forms blood-brain barrier


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Mechanisms of InjuryMechanisms of Injury

MotorVehicleCrashes most common cause of head trauma

most common cause of subdural

hematoma

Sports Injuries Falls

common in elderly and in presence of

alcohol

associated with subdural hematomas PenetratingTrauma

missiles more common than sharp

projectiles


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Brain InjuryBrain Injury

a traumatic insult to the brain capable ofproducing physical, intellectual, emotional,

social and vocational changes

Threebroadcategories

Focal injuryFocal injury cerebral contusion

intracranial hemorrhage

epidural hemorrhage

Subarachnoid hemorrhageSubarachnoid hemorrhage Diffuse Axonal InjuryDiffuse Axonal Injury

concussion (mild and classic form)


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Causes of Brain InjuryCauses of Brain Injury

Direct (Primary)Causes

Impact

Mechanical disruption of cells

Vascular permeability or disruption

Indirect (SecondaryorTertiary)Causes

SecondarySecondary

edema, hemorrhage, infection,

inadequate perfusion, tissue

hypoxia, pressure

TertiaryTertiary

apnea, hypotension, pulmonary

resistance, ECG changes


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Head InjuriesHead Injuries

Scalp Laceration/Avulsion

Most common injury Vascularity = diffuse bleeding

Generally does not cause hypovolemia

in adults

Can produce hypovolemia in children


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Depressed

Basilar

Linear

Stellate

SkullFractures


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Depressed SkullFracture

Segment pushed inward

Pressure on brain causes brain injury Neurologic signs and symptoms

evident


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BasilarSkullFracture

Difficult to detect on x-ray

Signs & Symptoms depend on amount

of damage

Diagnosismadeclinicallyby finding:Diagnosismadeclinicallyby finding:

CSFOtorrhea

CSF Rhinorrhea

Periorbitalecchymosis Battlessign


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CerebrospinalFluid

Bloodclottingdelayed

Halosign

Doesnotcrustondrying

PositivetoDextrostick


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BasilarSkullFractureBasilarSkullFracture

Do NOTNOT pack ears

Let drain

Do NOTNOT suction fluid

Do NOTNOT instrument nose


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Open SkullFractureOpen SkullFracture

Cranial contents exposed

Manage like evisceration

Protect exposed tissue with moist,

clean dressing (if possible)

Neurologic signs & Symptoms evident


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IntracranialHematomas

Epidural

Subdural

Intracerebral


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EpiduralHematoma

Blood between skull and dura Usually arterial tear

middle meningeal artery

Causes increase in intracranial

pressure


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EpiduralHematomaEpiduralHematoma

Unconsciousness followed by lucid

interval

Rapid deterioration

Decreased LOC, headache, nausea,vomiting

Hemiparesis, hemiplegia

Unequal pupils (dilated on side of clot)

Increase BP, decreased pulse

(Cushings reflex)


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SubduralHematomaSubduralHematoma

Slower onset

Increased ICP

Headache, decreased LOC, unequal

pupils

Increased BP, decreased pulse

Hemiparesis, hemiplegia


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IntracerebralHematomaIntracerebralHematoma Usually due to laceration of brain

Bleeding into cerebral substance Associated with other injuries

DAI

Neuro deficits depend on region

involved and size repetitive w/frontal lobe

Increased ICP


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InjurytoCerebralParenchymaInjurytoCerebralParenchyma

Laceration

Concussion

Contusion


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Laceration

Penetrating wounds

GSW

Stab

DepressedFracture Severe blunt trauma

Sudden acceleration/deceleration


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ConcussionConcussion

Transient loss of consciousness

Retrograde amnesia, confusion Resolves spontaneously without deficit

Usually due to blunt head trauma

PostPost--concussionsyndromeconcussionsyndrome Headaches

Depression

Pers

onality

changes


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Head Trauma AssessmentHead Trauma Assessment

TheBrain IsEnclosed InABox

EarlyDetection/Controlof IncreasedICP

Critical

CerebralPerfusionPressure =

MeanArterialPressure- IntracranialPressure

CPP = MAP- ICP


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Describe LOC changes based onDescribe LOC changes based on

response to environmentresponse to environment

AVPU ScaleAVPU Scale

AA = Alert

VV = Responds to Verbal stimuli

PP = Responds to Painful stimuli

UU = Unresponsive


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Glasgow ScaleGlasgow Scale

Eye Opening

Motor Response

Verbal Response


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Glasgow ScaleGlasgow Scale----EyeOpeningEyeOpening

4 = Spontaneous

3 = To voice 2 = To pain

1 = Absent


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Glasgow ScaleGlasgow ScaleVerbalVerbal

5 = Oriented

4 = Confused 3 = Inappropriate words

2 = Moaning, Incomprehensible

1 = No response


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Glasgow ScaleGlasgow ScaleMotorMotor

6 = Obeys commands

5 = Localizes pain 4 = Withdraws from pain

3 = Decorticate (Flexion)

2 = Decerebrate (Extension)

1 = Flaccid


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EyesEyes

Window to CNS

Pupil size, equality, and response to

light Unequal Pupils + Decreased LOC =

Compression of oculomotor nerveCompression of oculomotor nerve

Probable mass lesionProbable mass lesion

Unequal Pupils + Alert patient = Direct blow to eye, or OculomotorDirect blow to eye, or Oculomotor

nerve injury, or Normal inequalitynerve injury, or Normal inequality


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Respiratory PatternsRespiratory Patterns

Cheyne StokesCheyne Stokes

Diffuseinjurytocerebralhemispheres

Central neurological hyperventilationCentral neurological hyperventilation Injurytomid-brain

ApneusticApneustic

Injurytopons Biot (Cluster)Biot (Cluster)

Injurytouppermedulla AtaxicAtaxic

Injurytolowermedulla


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MotorResponse

Is patient able to move all extremities?

How do they move? Decorticate

Decerebrate

HemiparesisorHemiplegia

ParaplegiaorQuadraplegia


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MotorResponse

Lateralized/Focal Signs =Lateralized or Focal Deficits

Altered motor function may be due to

fracture/dislocation


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Vital SignsVital Signs Cushings Triad

Suggests Increased IntracranialPressure

IncreasedBP DecreasedPulse Irregularrespiratorypattern

Isolated head injury will NOTNOT causehypotension in adult

Look for another life threatening injury Chest

Abdomen

Pelvis

Multiplel

ongb

one fra

ctures


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Head Trauma ManagementHead Trauma Management

AirwayAirway

OpenOpen

Assume C-spine Trauma

Jaw Thrust with C-spine Control Clear - Suction As Needed

MaintainMaintain

Intubation if No Gag Reflex, or

RSI

Avoid nasal intubation


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Breathing

Oxygenate - 100% O2

Ventilate No ROUTINE Hyperventilation

Hyperventilateat 20 to 24 breathsperminute IF:

Glasgow less than 8

Rapid neurologic deterioration

Evidence of herniation


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CirculationCirculation

Maintain adequate BP and Perfusion

IV of LR/NS TKO if BP normal or

elevated If BP decreasedIf BP decreased

LR/NS bolustitratedtoBP ~90 mmHg

ConsiderPASG/MASTifBPbelow 80

Monitor EKG -- Do NOTNOT treat

bradycardia


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Drug Therapy ConsiderationsDrug Therapy Considerations

OnlyafterOnlyafter:

Management of ABCsManagement of ABCs Controlled hyperventilationControlled hyperventilation

DexamethasoneDexamethasone

Steroid

Decreasescerebraledema Effectsdelayed

Littleusagetoday


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Mannitol (Osmitrol)Mannitol (Osmitrol)

Osmoticdiuretic Decreasescerebraledema Maycausehypovolemia May worsenintracranialhemorrhage

Oftenreserved forherniation


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Diazepam (Valium)Diazepam (Valium)

Anticonvulsant

Giveifpatientexperiencesseizures

Maymask changesin LOC

Maydepressrespirations May worsenhypotension


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GlucoseGlucose

Assessbloodglucose

Administeronlyifhypoglycemic


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THANKSYOUTHANKSYOU

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