PTC HEAD TRAUMA By Dr. Vashdev FCPS, Consultant Neuro and Spinal Surgeon & DEPARTMENT OF NEUROSURGERY LIAQUAT UNIVERSITY OF MEDICAL AND HEALTH SCIENCES. JAMSHORO

PTC Head Trauma Objectives To understand the structured approach to the patient with head trauma To learn how to identify serious and life-threatening head injuries 120

PTC 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

PTC Head Trauma Approach A irway B reathing C irculation 122

PTC Head Trauma Physiology CPP = MAP - ICP CPP = cerebral perfusion pressure MAP = mean arterial pressure ICP = intracranial pressure 123

PTC Cerebral Blood Flow Depends on: CPP (MAP-ICP) PaCO 2 PaO 2 Local metabolites 124

PTC Head Trauma Pathophysiology Primary Injury occurs at time of injury Secondary Injury occurs after injury may be preventable 125

PTC Head Trauma Primary injury  Diffuse axonal injury  Acceleration  deceleration  Cerebral contusion  Penetrating injury 126

PTC Head Trauma Secondary injury  Hypoxia  Hypoperfusion (↑ ICP, ↓ MAP)  Hypoglycaemia  Hyperthermia (fever)  Seizures 127

PTC Head Trauma Initial assessment Head Trauma Initial assessment A irway (+ C-spine) B reathing C irculation D isability ( pupils) E xposure 128

PTC Head Trauma Examination Glasgow Coma Score Pupils Corneal reflex Eye position Fundi 129

PTC Head Trauma Examination Tympanic membrane Scalp and skull (Raccoon eyes, Battle sign) Respiratory Pattern Muscle tone Posture Tendon reflexes 130

PTC Head Trauma GCS Eye opening Open spontaneously4 Open to command3 Open to pain2 None1 132

PTC Head Trauma GCS Best Verbal Response Oriented5 Confused4 Inappropriate words3 Inappropriate sounds2 None1 133

PTC Head Trauma GCS Best Motor Response Obeys command6 Localises to pain5 Withdraws to pain4 Abnormal flexion3 Extensor response2 None1 134

PTC Head Trauma Severity of Head Injury SevereGCS <8 ModerateGCS 9-12 MildGCS

PTC Head Trauma Pupillary signs Size Reactivity Equality 136

PTC Head Trauma Pupillary responses Fixed, dilated, unresponsive Severe hypoxia Severe brain Injury Hypothermia Seizures 137

PTC Head Trauma Pupillary responses Unilateral, dilated, unresponsive Expanding lesion on same side Tentorial herniation Seizures 138

PTC Head Trauma Acute extradural or subdural Potentially life-threatening Immediate recognition essential Require burr-hole decompression 139

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PTC Head Trauma Acute extradural LOC → lucid interval → deterioration Middle meningeal artery bleed Overlying skull fracture Contralateral hemiparesis Fixed pupil on side of injury 140

PTC Head Trauma Acute subdural Tearing of bridging vein between cortex and dura Underlying brain injury Usually no lucid interval Worse prognosis than extradural haematoma 141

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PTC Head Trauma Other injuries Base-of-skull fractures Cerebral concussion Depressed skull fracture Intracerebral haematoma Usually do not require urgent neurosurgery consultation 142

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PTC Airway Breathing (ventilation) Circulation + Avoid ↑ ICP Aim to prevent secondary injury Head Trauma Management 143

PTC Head Trauma Severe (GCS<8) Intubate Normal CO 2 Treat hypotension with fluid Sedation +/- paralysis 144

PTC Head Trauma Severe (GCS<8) Nurse head up 20 o Prevent hyperthermia Complete secondary survey Reassess frequently 145

PTC FINDINGS WITH LOW RISK OF ICI - asymptomatic - headache - dizzines - scalp hematoma - skull x-ray normal - DISCHARGE on instructions - change in level of consiousness - severe headache - persistent vomiting - bradycardia

PTC FINDINGS WITH MODERATE RISK ICI h/o loss of cons. progressing headache post traumatic seizures age <2 years post traumatic amnesia vomiting signs of BSF multiple trauma severe facial injuries CRITERIA FOR OBSERVATION AT HOME normal C.T scan GCS - >14 reasonable access to hospital

PTC FINDING WITH HIGH RISK OF ICI -Depressed level of Con. -Focal Neurologic Findings -Penetrating skull injuries

PTC Head Trauma Beware Deteriorating conscious state Penetrating injury Focal neurological signs - unequal, dilated pupils - seizures - posturing 146

PTC Head Trauma ? 147

PTC Head Trauma Summary ABCs Prevent secondary injury Isolated head trauma doesn’t cause hypotension Look for other injuries Deterioration → reassess 148

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