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ATLS - Head Trauma Imodified

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698 views39 pages

ATLS - Head Trauma Imodified

Uploaded by

Sammon Tareen
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd
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Committee on Trauma Presents

Head
Trauma

©ACS
Head Trauma

• 1/3-1/2 of trauma deaths


• Good outcomes possible without CT
scans and neurosurgeons
• Aim to avoid secondary brain injury
• Hypoxia and hypotension double
mortality

121
Objectives

 Describe basic intracranial physiology.


 Recognize the importance of limiting
secondary brain injury.
 Perform a focused neurologic exam.
 Stabilize and arrange for definitive care.

©ACS
Anatomy and physiology effects?

 Rigid, nonexpansile skull filled with


brain, CSF, and blood
 CBF autoregulation
 Autoregulatory compensation
disrupted by brain injury
 Mass effect of intracranial hemorrhage
©ACS
Monro-Kellie Doctrine
Venous Art. Brain CSF
Volume Vol.

Ven. Art.
Brain Mass CSF
Vol. Vol.

75 mL Arterial 75 mL
Brain Mass CSF
Volume

©ACS
Volume – Pressure Curve

60- Herniation
55- ICP
50- (mm Hg)
45-
40-
35- Point of
30- Decompensation
25-
20-
15-
10-
5- Compensation
Volume of Mass
©ACS
Intracranial Pressure (ICP)

 10 mm Hg = Normal
 > 20 mm Hg = Abnormal
 > 40 mm Hg = Severe
 Many pathologic processes affect outcome
 Sustained  ICP leads to  brain function and
outcome

©ACS
Cerebral Perfusion Pressure*

MBP – ICP = CPP


Normal 90 10 80
Cushing’s
Response 100 20 80

Hypotension 50 20 30

* CPP  Cerebral Blood Flow


©ACS
Autoregulation

 If autoregulation is intact, CBF is


maintained with a mean BP of 50 to
160 mm Hg.
 Moderate or severe brain injury:
Autoregulation often impaired
 Brain more vulnerable to episodes of
hypotension  secondary brain injury
©ACS
Classifications of Brain Injury

By Morphology: Brain
 Epidural (extradural)
Focal  Subdural
 Intracerebral

 Concussion
Diffuse  Multiple contusions
 Hypoxic / ischemic injury
©ACS
Diffuse Brain Injury

 Mild concussion  Severe, ischemic


insult

Normal CT Diffuse Injury ©ACS


Contusion / Hematoma

 Coup / contracoup injuries


 Most common: Frontal / temporal lobes
 CT changes usually progressive
 Most conscious patients: No operation

©ACS
Contusion / Hematoma

Large frontal
contusion with
shift

©ACS
Epidural Hematoma

 Associated with skull fracture


 Classic: Middle meningeal artery tear
 Lenticular / biconvex
 Lucid interval
 Can be rapidly fatal
 Early evacuation essential
©ACS
Epidural Hematoma
Temporal
Epidural
Hematoma

Uncal
herniation

©ACS
Subdural Hematoma

 Venous tear / brain laceration


 Covers cerebral surface
 Morbidity / mortality due to
underlying brain injury
 Rapid surgical evacuation
recommended, especially if > 5 mm
shift of midline
©ACS
Subdural Hematoma

©ACS
Priorities

 ABCDE
 Minimize secondary brain injury
 Administer O2
 Maintain blood pressure
(systolic > 90 mm Hg)

©ACS
Focused Neurologic Exam?

 GCS Score
 Pupils
 Lateralizing signs

Consult neurosurgeon early

©ACS
Head Trauma
GCS Eye opening

Open spontaneously 4
Open to command 3
Open to pain 2
None 1

132
Head Trauma
GCS Best Verbal Response

Oriented 5
Confused 4
Inappropriate words 3
Inappropriate sounds 2
None 1

133
Head Trauma
GCS Best Motor Response

Obeys command 6
Localises to pain 5
Withdraws to pain 4
Abnormal flexion 3
Extensor response 2
None 1
134
Head Trauma
Severity of Head Injury

Severe GCS <8


Moderate GCS 9-12
Minor GCS 13-15

135
Indications for CT Scan?

©ACS
Mild Brain Injury

 GCS Score = 14–15  X-rays as indicated


 History  Alcohol / drug
 Exclude systemic screens as indicated
injuries  Liberal use of head
 Neurologic exam CT

Observe or discharge based on findings


©ACS
Moderate Brain Injury

 GCS Score = 9–13  Admit and observe


 Frequent
 Initial evaluation
neurologic exams
same as for mild
 Repeat CT scan
injury
 CT scan for all  Deterioration:
Manage as severe
head injury
©ACS
Severe Brain Injury

 GCS Score = 3–8


 Evaluate and resuscitate
 Intubate for airway protection
 Focused neurologic exam
 Frequent reevaluation
 Identify associated injuries
©ACS
Medical Management

 Intravenous fluids
 Euvolemia
 Isotonic

 Controlled ventilation
 Goal: Paco2 at 35 mm Hg

©ACS
Medical Management

 Mannitol
 Use with signs of tentorial herniation
 Dose: 1.0 g / kg IV bolus
 Consult with neurosurgeon first

©ACS
Medical Management

 Other medications
 Anticonvulsants
 Sedation
 Paralytics

©ACS
Surgical Management

Scalp Injuries
 Possible site of major blood loss
 Direct pressure to control bleeding
 Occasional temporary closure

©ACS
Surgical Management

Intracranial Mass Lesion


 May be life-threatening if expanding
rapidly
 Immediate neurosurgical consult
 Hyperventilation / Mannitol
 Damage control craniotomy: Transfer
to neurosurgeon (rural / austere areas)
©ACS
Summary: What should I do?

 Maintain mean BP > 90 mm Hg


 Maintain Paco2 near / at 35 mm Hg
 Use isotonic solution for euvolemia
 Frequent neurologic exams
 Liberal use of CT scans
 Early neurosurgical consult
©ACS
Summary: What should I not do?

 Allow patient to become hypotensive


 Over-aggressively hyperventilate
 Use hypotonic IV fluids
 Use long-acting paralytics
 Paralyze before performing complete exam
 Depend on clinical exam alone
©ACS

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