Central Nervous System Trauma Estrada Bernard, MD Division of Neurosurgery UNC Chapel

Central Nervous System Trauma n U.S fatalities >150,000/yr n SCI>10,000/yr n Disabled (prev)>200,000

Central Nervous System Trauma –Incidence (San Diego) Head Inj All Head Inj Mod/Sever Spinal

Central Nervous System Trauma n Assume spinal injury n Maintain alignment n Watch for spinal shock

Head Injury n Primary n Secondary

Secondary Head Injury n Elevated ICP n Hypotension n Hypoxemia/Hypercapnia n Ischemia n Seizures

Central Nervous System Trauma – Acute Evaluation n Primary survey (ABC) n Initial neurological exam n Post resuscitation exam

Central Nervous System Trauma – Airway Mgmt n Avoid hypoxia n Avoid hypercarbia n Avoid aspiration

Central Nervous System Trauma - Resuscitation n Goals ä BP > 90 mm Hg ä PaO2 > 60 mm Hg

Central Nervous System Trauma – Acute Mgmt n ??? Sedation n ??? Neuromuscular blockade n ??? Mannitol n ??? Hyperventilation

Cranial Nerve Injury Olfactory Optic Abducens Facial Vestibulocochlear

Central Nervous System Trauma - Pathophysiology n Mediators ä Mechanical ä Neuroexcitation ä Free radical production

Skull Fractures n Types n Risk factors

Skull Fractures n Linear ä 62% of severe HI n Depressed ä Simple ä Compound n Basilar ä csf fistula

Head Injury Mechanisms Contact n Skull deformation ä Local - skull fx, EDH, coup ä Remote - vault, basilar fxs n Shock wave ä Contrecoup ä ICH

Head Injury Mechanisms Acceleration n Surface strain ä SDH ä Contrecoup n Deep strain ä Concussion ä Dai

Focal Injury n Hematoma ä Extradural ä Subdural ä Intracerebral n Contusions ä Coup ä Contrecoup

Diffuse Injury n Concussion n Diffuse axonal injury ä Mild ä Moderate ä Severe

Central Nervous System Trauma – Clinical Trials n Cholinergic agents n Corticosteroids n Barbiturates n Neuroexcitatory antagonists n Free radical scavengers n Calcium channel antagonists n Hypothermia

Central Nervous System Trauma – Elevated ICP Rx n Progressive neurologic deterioration n Transtentorial herniation

Steroids for Spinal Cord Injury n 8 hour therapeutic window n Methylprednisolone 30 mg/kg bolus n 5.4 mg/kg/hr infusion over 23 hours

Cervical Spine Injuries n Atlanto-occipital dislocation n Odontoid fractures n Hangman’s fracture n Jefferson’s fracture

n Burst fractures n Hyperflexion-anterior subluxation n Facet dislocations n Hyperextension injuries Cervical Spine Injuries

Central Nervous System Trauma n Prevention is better than cure