head injury westville 2.pptx

Head Injury Dr. Basil Enicker Department of Neurosurgery University of KwaZulu-Natal  Definitions Traumatic brain injury “An insult to the brain, not of degenerative or congenital nature caused by an external physical force that may produce a diminished or altered stat...

Head Injury Dr. Basil Enicker Department of Neurosurgery University of KwaZulu-Natal  Definitions Traumatic brain injury “An insult to the brain, not of degenerative or congenital nature caused by an external physical force that may produce a diminished or altered state of consciousness, which results in an impairment of cognitive abilities or physical functioning. It can also result in the disturbance of behavioral or emotional functioning.” Anatomy: Scalp Skull Brain Epidemiology  Pathophysiology Primary vs Secondary Brain Injury TBI Causes Transportation 44% Falls 26% Other 13% Firearms 8% Non Firearm Assaults 9%  Annual mortality of children from RTC 3.89 per 100 000 *Road traffic accident deaths in South Africa, 2001-2006: Evidence from death notification. Available at: http ://www.statssa.gov.za/publications/report-03-09-07/report-03 -09-07  Concepts Monro-Kelly Doctrine  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 Autoregulation 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 Herniation syndromes Classification of Head Injury Glasgow Coma Scale  Clinical scenario 20 year old male in MVA – Intubated Score 1T – Eyes open to pain Score 2 – Briskly localizes Score 5 Total GCS 8T Approach To Head Injury Transfer  History Mechanism of injury Loss of consciousness Vomiting Seizures Intoxicants Post traumatic amnesia  Clinical examination Dilated non reactive pupils Hemiplegia/ hemiparesis Aphasia/dysphasia Facial weakness Cranial nerve palsy Papilloedema  Signs of skull base fracture Raccoon eyes Battle sign  Investigations Skull X-ray useful only to detect skull fracture but in the trauma setting wastes time Cervical spine injury Cervical spine x-ray CT scan  Indications for CT - GCS ≤ 14 - Focal neurological deficits - Deteriorating GCS - Penetrating head injuries e.g. gunshots and stabs - Post traumatic seizures - Loss of consciousness and amnesia - Multiple trauma - Skull fracture - Patients who are intoxicated - Patients on anti - coagulant therapy - Mechanism of injury e.g. motor bike injuries  Indications for observation at home - Normal CT - GCS 15 - No focal deficits - Easy access to E/R - Responsible adult to observe at home - No complicating circumstances e.g. abuse  Indications for re-admission - Drowsiness - CSF leak - Seizures - New focal deficit - Fever Pathology: Primary Injury Acute Extradural Haematoma Acute Subdural Haematoma Contusion/Intracerebral Haematoma Diffuse Cerebral Injury Skull Fracture Gunshot Injuries Penetrating stab injuries Concussion in sports Non accidental injury Secondary Brain Injury  Prevention of Secondary Brain Injury - Po2 > 60 mmHg / Sats 100 % - Systolic BP > 90 mmHg - Glucose control - Appropiate IVI fluids - Control ICP - Treat underlying pathology  Conservative management - GCS 13-15 - No focal deficits - Neurological observations: ICU/ high care (Hourly) a. GCS b. BP c. Pulse d. Pupils Cushing reflex Surgical Management  ICU management General measures - Head elevated 30 degrees - Neck neutral position - Urinary catheter - Analgesia - Gastro-protective agents - Anti-seizure prophylaxis : 7 days – phenytoin/ epilim - DVT prophylaxis - Nutrition - Fluids Fluids  Medical management - Ventilation: PCo2 30-35 mmHg - Sedation - Mannitol - Hypertonic saline  General monitoring - ECG - Saturations: 100 % - Systolic BP : > 90 mmHg (MAP 80 mmHg) - Pulse - Temperature: maintain euthermia or mild hypothermia CVP: 8-14 mm Hg Glucose: normoglycaemic  ICP monitoring - Indications GCS ≤ 8 Polytrauma Prolonged ventilation Hypotension 40 Posturing - ICP > 20 mmHg abnormal  Brain Tissue Oxygen Tension Monitoring ( PbtO2) Normal values : 20 - 35 mmHg  Cerebral Perfusion Pressure - CPP = MAP – ICP - Targeted value : 60 mmHg - Values < 50 mmHg = cerebral ischaemia & hypo perfusion - Values > 70 mmHg = cardiorespiratory failure, ARDS ICP management steps  Prognostic factors - Age Younger pts have greatest potential for survival and recovery 61-75% mortality if over 65 90% mortality in elderly with ICP >20 and coma for more than 3 days 100% mortality if GCS < 5, uni- or bilateral dilated pupils, and age over 75 - Mechanism of injury e.g. motorbike crashes - GCS < 8 - ICP > 45 - Hypotension: > 50% increase in mortality with single episode of hypotension - Hypoxia: PO2 < 60 mmHg Sats < 90%  Glasgow Outcome Scale 1 = Dead 2= Vegetative state 3= Severe disability 4= Moderate disability 5= Mild disability  Late complications - Post traumatic seizures - Hydrocephalus - Infections - Post concussive syndrome  Post concussive syndrome - Somatic Headaches Dizziness Anosmia Hearing difficulties Balance difficulties  Post concussive syndrome - Cognitive Difficulty concentrating Dementia Impaired judgement  Post concussive syndrome - Psychosocial Emotional problems Personality changes Loss of libido Tiredness Difficulty sleeping  Multidisciplinary Team - Physiotherapists - Occupational therapists - Psychologists - Social workers - Nurses - Doctors  Key Points - 2 mechanisms of brain injury Impact injury Secondary injury - GCS < 8 = coma / severe head injury - CT imaging study of choice in the acute assessment of head injury - Operative and non-operative strategies are generally aimed at reducing mass effect and, therefore, reducing ICP - ICP < 20 mmHg CPP =60 mmHg - Nothing beats a neuro exam - Multidisciplinary team Thank you