head trauma - case

8/11/2019 Head Trauma - Case

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Lamhot Asnir L. Tobing, M.D.

Neurosurgeon

Presentant:

Sardito (2012.061.069)

Deiby P S (2013.061.015)


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Identity

Name : Mr. A Y

Gender : Male

Age : 30 y.o.

Occupation : Construction worker

Religion : Moslem

Address : Gong Bay Date of hospitalization : July 11th2014


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Anamnesis

Chief complaint : loss of consciousness

History of present illness : Patient came with chief complaint of loss of

consciousness approximately for a 30-minute period

after trauma Patient fell from a 5-metre height while he was

working on a building construction around 40minutes before hosptalization.

According to the witnesses, the patients right leg hit

an iron rod before finally fell onto the road (ashpalt)with the left side of the head hitting the road first.

Along the journey to the hospital, the patientreceived no medication at all.


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Meanwhile during in the Emergency Room, the

patient vomited 4 times with the total of +600mL

fluid being discharged containing gastric juice andblood.

Patient also felt pain throughout the body

including severe headache

The patient denied the existence of blood

discharge from the nose and ears


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History of past illness:

History of hypertension denied

History of stroke denied

History of allergy denied

History of Diabetes Melitus denied

History of past trauma denied

History of chronic cough denied

History of regular drug consumption denied


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Habits:

Patient has been smoking cigarette since 15years ago 12 cigars per day

Patient also occasionally counsumed alcoholic

beverages but not on a regular basis and not sure

about the amount consumed Development :

Patient experienced no problem in during

developing stage of life


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Primary Survey

A : good articulation, obstruction (-)

B : RR: 26 tpm

C : BP : 160/100 mmHg; HR : 120 bpm

D : Compos Mentis (GCS 14E3M6V5)

E : Temp : 36,5oC


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Allergy : -

Medication : -

Past Illness : -

Last Meal : unkown

Environment : 5-metre height fell


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Physical examination

General condition : severely ill

Head :

Calvarium : hematoma a/rfrontalis sinistra o

+ 3cm

Face : asymmetrical

Eyes : edema palpebra sinistra

Nose : nasal septal in the middle Mouth : oral mucose wet

Ear : MAE +/+


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Neck :

JVP : not assessable Carotid Artery : +

Thyroid : not palpable

Thorax : Cor : cardiomegaly -; Heart Sound I & II regular;

Murmur -; Gallop -

Pulmo : symmetrical; VBS +/+; Wheezing -/-;

Rales -/-


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Abdomen :

Liver : hepatomegaly

Spleen : splenomegaly

Bladder : not palpable

Extremities :

Warm, CRT


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Neurological examination

Meningeal stimulation

Not assessable

Signs of intracranial pressure increase

Headache +

Blurry vision

Bradycardia

Papiledema

Cranial nerve examination is between

normal limits


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Motoric :

Upper arms : 5555/xxxx

Lower arms : 55/55

Hands : 55/55

Fingers : 5555/5555

Upper legs : xxxx/5555 Lower legs : xx/55

Feet : 55/55

Toes : 55/55


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Physiological reflexes :

Biceps : +/+

Triceps : +/+

Patella : x/+

Achilles : -/-

Pathological reflexes : all are negative Clonus : patella -; feet

Tonus : normotonus, spasticity -; rigidity-

Coordination and cerebelar function : not assessable


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Sensibilities are between normal limits

Autonomic system

Miction : + (catheter)

Defecation : -

Sweating : + above shoulder

Noble function :

Motoric aphasia : -

Sensoric aphasia : -

No signs of regression Peripheral nerve are not palpable


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Lab test - July 12, 2014Parameter Value

HEMATOLOGY

IV Routine

Hemoglobin 14.9

Hematocrit 41

WBC 20.9

Thrombocyte 308

Erythrocyte sedimentation rate 10

DIFFERENTIAL COUNT

Basophils 0

Eosinophils 0

Band neutrophils 0

Segmented neutrophils 83

Lymphocytes 12

Monocytes 5

Bleeding Time 3

Clotting Time 5


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Lab testJuly 12, 2014

BLOOD CHEMISTRY Value

SGOT/AST 36

SGPT/ALT 54

Renal Function

Ureum 20

Creatinine 0.8

CARBOHYDRATE

Random blood glucose 173


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Lab test - July 13, 2014Parameter Value

BLOOD CHEMISTRY

ELECTROLYTE

Sodium 159

Pottasium 4.47

Calcium 1.21

Chloride 128

ARTERIAL BLOOD GAS

Temperature 37.4

Hemoglobin 12.7

Result

pH 7.35

pCO2 47pO2 211

HCO3act 25

Base excess 1

ctCO2 60

O2Sat 100

O2CT 18


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Lab testJuly 16th, 2014


CARBOHYDRATE

Random blood glucose 136


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Parameter Value

BLOOD CHEMISTRY

ELECTROLYTE

Sodium 175

Pottasium 2.71

Calcium 1.4

Chloride 141


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SGOT/AST 101

SGPT/ALT 164

Renal Function

Ureum 52Creatinine 1.4


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Parameter Value

URINE

COMPLETE

Glucose (-)

Protein One (+)Bilirubin (-)

Urobilinogen One (+)

Ph 6

Density 1015

Smear blood Three (+++)Keton (-)

Nitrit (-)

Leucocyte (-)

Sediment

Leucocyte 0-1Erythrocyte 7-10

Epithel (+)

Silinder (-)

Crystal (-)

Bacteri (-)


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InterpretationJuly 11th, 2014

Cereberal edema with subarrachnoidhemmorrhage and mild cereberalcontussion at frontal sinistra

Multiple fracture at os. Frontalis withminumum depressed fragment, cranialbase fracture, left temporal

Left retro orbital no fracture fragment seen

Bilateral maxillary, ethmoidal, frontal, andsphenoid hematosinus

Left hematomastoid


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Facial CT Scan 3DJuly 15th, 2014

Multiple fracture at os frontal with minimumdepressed fragment, fracture line thatelongates from left frontal to left orbital rimdirection until left maxillary sinus anterior walland left lamina cribiformis, no fracturefragment seen in left retro orbita.

Bilateral maxillary, ethmoidal, frontal, andsphenoid hematosinus

Basis cranii fracture

Subarachnoid hemorrhage Left hematomastoid

No fracture seen in cervical CV 1-6


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EKG


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Resume

A patient, male, 30 y.o., came with chief complaint ofloss of consciousness for 30 minutes after he fellfrom a 5-meter height building construction. Patientexperienced severe headache and during in the ER,the patient vomited 4 times with total + 600mL

gastric juice with blood discharged. The patient denied any history of past illness,

smokes cigarette regularly and drinks alcoholoccasionally.

From the physical examination there is hematomaa/r frontalis sinistra, headache as a sign ofintracranial pressure increase. From lab test, thepatient has leucocytosis, increased liver enzyme,hyperglycemia, hypernatremia, hyperchloremia, andanemia.


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From the CT-scan were found Subarachnoid

haemorrhage with cerebral edema. Bilateral

maxillary, ethmoid, frontal, and sphenoid

sinuses fractures with haematosinus.


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Diagnosis

Clinical : Headache

Topis : Subarachnoid

Etiology : Trauma

Pathology : Haemorrhage


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Os patella dextra fracture

Bilateral maxillary, ethmoid, frontal,

sphenoid sinus fracture


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Assessment

A patient, male, 30 y.o., capitis trauma,

anhydrosis, multiple vulnus laceratum

and os patella dextra fracture


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Treatment

Collar neck

IVFD RL 1000cc/24hours

Omeprazole 2x40mg IV

Ceftriaxone 2x2 g IV

Vit C 1x400mg IV

Mannitol 250cc4x125cc

Tramadol 2x50mg/drip

Metilprednisolon 2x125mg


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Follow up12/07/14 13/07/14 14/07/14 15/07/14 16/07/14 17/07/14

Vomits

300cc,

dizzy, pain

fullout the

body

Left shoulder

pain, dizzy,

post

operation

wound pain

110/70;116;

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150/100;140

;22;37

157/104;138;

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160/99;108

;24;38

147/93;106

;25;38.2

125/83;161;

43;39.7

GCS 14

E3V5M6

GCS 15

E4V5M6

GCS 14

E3V5M6

GCS 14

E3V5M6

GCS 14

E3V5M6

GCS 14

E3V5M6

NGT 300cc

dark brown

NGT 425cc

cloudy

Motoric

weakness in

all

extremities


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Introduction

Primary goalprevention of secondary

brain injury

Adequate O2 and BPgood perfusion

= limiting brain damage

ABCDE + identify mass lesionCT

Scan

CT Scan Should Not Delay Referal!


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SCALP

Skin

Connective Tissue

Aponeurosis (galea aponeurotika)

Loose areolar Tissue

Subgaleal haematomblood loss in infants

and child

Pericranium


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Bleeding of the Scalp


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The Cranium


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The Meninges


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The Brain Frontalexecutive,

emotions, motor, speech

Parietal - sensory functionand spatial orientation

Temporal - memory

functions

Occipital - vision

Brainstem

Midbrain - RAS

Pons - RAS MedullaCardiorespiratory

Cerebellumcoordination

and balance


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Tentorium

Supratentorial Fossa cranii anterio and media

Infratentorial Fossa cranii posterior

Midbrain Tentorial hiatus

Connects brain hemispherepons and medulla

N.IIIalong tentorium edge Medial Temporal lobe (Uncus) herniation

dilated pupil

T t i


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Tentorium


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Monro-Kellie Doctrine


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Epidemiology

In USA, 1,5 million cases/year

50.000 +, 80.000-90.000 longterm

neurologic impairment

Head trauma is the main cause of deathin traumatic patients

Main cause of head trauma : fall and

traffic accident (80%)


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Types of Injury

Injuries on head trauma is classified into 2 :

Primary injuryanatomy and physiology

disorder caused directly by trauma

Secondary injuryextention of primaryinjuryswelling, hypoperfusion, hypoxemia,

ICP increase)

Acute phase management : to prevent

secondary injury


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Recucitation priority

Hypotension caused twice the death

compared to hypoxemiaGoal: sistole

90


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Classification of Head Injury

Based on mechanism of injury: blunt(automobilecollisions, fall, blunt weapon) or penetrating

(gunshot, stab)


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Basal Skull Fracture

Sign:

Racoon eyes (periorbital ecchymosis)

Battle sign (retroauricular ecchymosis)

Rhinorrhea & otorrhea (CSF leakage)

N. VII and N. VIII dysfunctionN. VII

recovery prognosis better than N. VIII

Management of Minor Brain


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Management of Minor Brain

Injury (GCS 13)


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Management of Moderate Brain


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gInjury

(GCS 9-12)

Management of Severe Brain


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gInjury

(GCS 8)


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Summary of Management

Minor: Neuro PE & CT (if needed)

Moderate: Minor+ CT, Close

Observation,baseline blood work, CT

follow up Severe: Moderate+ Therapeutic agent


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Therapeutic Agent

IV fluid isotonic Prevent Hypovolemia

Hyperventilation

As indicated, normocapnia preferredAnticonvulsant (fenitoin) Inhibit brain recovery

Prolong seizure = secondary brain injury

Manitol (ICP in acute phase)

Barbiturat (ICP in chronic phase)


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Surgical Management

Indications: Scalp wounds - Wound Toilet, Hecting

Depressed Skull Fractureoperative

elevation Intracranial Mass Lesioncraniotomy

Penetrating Brain Injuryneurosurgicalremoval

Partially exteriorized object SHOULD NOTBE REMOVE!!vascular injury, intracranialhemorrhage


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head trauma - case

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