Head Injury
Dr. Saad Farhan Al-MasoudiRadiological evaluation of head trauma
CT scan : almost without exception , an unenhanced (i.e.- non – contrast ) CT scan of brain suffices for patients seen in emergency department presenting after trauma or with new neurological deficit . The main emergent conditions to rule out : 1. blood ( hemorrhages or hematomas) a. EDH ( extradural hematoma ( b. SDH ( subdural hematoma ( c. subarachnoid hemorrhage d. intracerebral hemorrhage e. intraventricular hemorrhage2. hydrocephalus . 3. cerebral swelling 4. evidence of cerebral anoxia , loss of gray –white interface 5. skull fracture : linear , depressed , diastatic …. 6. ischemic infarction 7. pneumocephalus → air inside skull ( in skull fracture ( 8. shift of midline structures
Indication for initial CT scan
A. moderate to severe head injury which criteria: GCS ≤ 14unresponsiveness focal deficit amnesia for injury altered mental status deterioration in neurological status sign of basal or vault fractures B. assessment prior to general anaesthesia for other procdures .skull x ray
skull x . ray affect management of only 0.4-2% patients in most reports . Skull x. ray may be helpful in following :-in patients with moderate risk for intracranial injuries by detecting unsuspected depressed skull fracture .if CT scan can not obtain to identify pineal gland shifting , pneumocephalus , air – fluid levels in the air sinuses , skull fractures .in patients with penetrating missile injuries .III . MRI :- usually not appropriate for acute head injuries while MRT is more sensative than CT, there were no surgical lesions demonstrated on MRI that were not evident on CT . IV . arteriogram in trauma :- cerebral arteriogram useful with non missile penetrating trauma , also useful in experienced hands if CT is unavailable for diagnosing EDH .
Resuscitation of multiply injured patient
Classified to primary survey and secondary survey with Resuscitation .*Primary survery :- anoxia and cardiac arrest result in cessation of oxidative phosphorylation within 15 – 20 seconds making the brain and other tissues depend upon anaerobic metabolism and depletion of ATP stores thus , the best response is to provide an airway if an adequate one does not exist , so I survey include :-1. air way establishment oro pharyngeal tube naso pharyngeal tube crico thyroidotomy . 2. ventilation . after an airway is established , breathing or ventilation must be assured by auscultation of both lung fields .3. circulation : assessment and management . crystalloid solutions , blood , plasma , colloid fluid , and hyper tonic saline .secondary survey
which involve a more detailed examination of individual body regions and which include : Head and neck Head : wounds , fracture in face and skull , csf leak Neck : Neck wound , Hematoma Chest : tension or open pneumothorax , hemothorax , cardiac tamponade and cardiac contusion . Abdomen : abdominal injury either by penetrating or blunt trauma . extremities : bleeding should be stopped and replaced , decrease in limbs perfused should also be identify and treated.
* Intesive management of traumatic brain injuries
It classified to 3 parts A. management at accident site or during transport to hospital . aim : To prevent hypoxia and hypotension RX: 1. hypoxia corrected by : clear air way .air way tube and ambo bag endotracheal tube or crico – thyroidotomyassisted ventilation with positive pressure ventilation ( ppv ) 2. circulation corrected by : - fluid replacement exp. ( Nacl , ringer( - military antishock trousers ( MAST) for rising BPmanagement at emergency room . B
Aim : To prevent secondary brain injury and diagnose the pathology . The management of head injury emergency unit include : 1.evaluation of patient with head injA. general B. Neurological 2. CT scan for unconscious patient to exclude intra cranial pathology as soon as 4 hrs . 3. lab test include blood gas , CBP, coagulation profile ect… 4.if available investigate and diagnose for cerebral blood flow ( CBF ) by Trans cranial Doppler (TCD ) ultra sonography .5. treatment of patient with H.I. in emerging unit divided to . A.medial treatment including assessment and resuscitation of traumatize patient by primary and secondary survey. B.Surgical treatment for intracranial surgical pathology like depressed fracture, hemaoma whether extrdural , subdural , intraventricularmanagement at intensive care unit
which include ventilation assessment and assistant by controlled ventilation (PEEP 15 mmHg ) or hyperventilation .monitoring of Blood pressure . Monitoring and treatment of fluid , volume , and electrolytes status . seizures monitoring and treatment .pulmonary therapy to decrease infection and oedema in ARDS or fat embolism .Monitoring and treatment of ↑ ICP . ↑ CCP ( cerebral perfusion pressure ) to level of 6o – 70 mmhg .nutrition and metabolic support ( NG feeling ) .Outcome prediction in severe head injury
neurological status GCS Brain stem function Pupillary responsiveness . age of patients younger children , infant and elderly patient had a poor prognosis Neurological status and age of patient one the most important prediction factors . vital sign :- hypoxia , hypotension .CT scan finding like brain shift or cisternal obliteration → poor prognosis .increase ICP for those more than 30 mmHg after medical and surgical treatment → poor prognosis . evoked potentials like somatosensory evoked potential and brain stem auditory evoked potential if they are abnormal → poor prognosisIndications for admission to hospital in patient with head trauma
History. 1. history of impaired consciousness or fits 2. progressive headache .3. vomiting 4. post traumatic amnesia > 30 min 5. Dizziness or blurring of vision . 6. unreliable or inadequate history . 7.unaccompanied patient or patient with diffuclt access to hospital Examination :- 8. any neurological abnormality or impaired consciousness . 9. evidence of basal or depressed fracture . 10. suspected skull penetration .Diffuclt to assess: 11.all children under 6 years 12patient under the effect of alcohole or drugs. Radiological evaluation: 13. all skull fracture . 14. abnormality on CT scan Medical indication : 15. diabetic , hypertensive or with history of other chronic diseases . 16. patient under treatment with anticoagulant , insulin or other potential drugs .
Skull fractures
1. linear # : DX:- skull x-ray , CT scan RX :- conservative unless there is underlying hematoma like EDH. 2. Depressed # :- DX: skull x-ray , CT scan . to treat this type of fracture we have to classify it to open fracture ( compound ) and closed fracture ( simple ) ie no wound over it . Indication for surgical correction or elevation of fracture . compound fracture ( open ) associated with neurological deficit . associated with epilepsy associated with CSF leak ie dural laceration . closed fracture but cause significant cosmetic deformity like close fracture in frontal bone . closed fracture but extend to air sinuses . closed fracture associated with under lying hematoma like EDH , SDH . RX: 1..antibiotic treatment . 2. antiepileptic drugs if # associate with fits 3. surgical treatment by elevation of # ( craniectomy ) and dural suturing if teared . 4. comminuted # and dislatic # treated conservatively unless there is underlying hematoma .