Head trauma for general practitioners
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Head trauma for general practitioners
- 1. HEAD TRAUMA FOR GENERAL PRACTITIONERS HAPPY FRIDAY KNIGHT
- 2. OUTLINES • Anatomy review • Physiology review • Classifications of head injuries • Investigation: CT brain • Treatment guidelines
- 3. INTRODUCTION • Primary goal treatment is to prevent secondary brain insult • CT brain should not delay patient transfer to a trauma center
- 4. ANATOMY REVIEW • Scalp • Skull • Meninges • Brain • Ventricular system
- 6. SKULL AND MENINGES American college of surgeons committee on trauma. ATLS student course manual. 10th ed. Chicago: American college of surgeons, 2018.
- 7. BRAIN AND VENTRICULAR SYSTEM American college of surgeons committee on trauma. ATLS student course manual. 10th ed. Chicago: American college of surgeons, 2018.
- 9. Reilly P. Management of intracranial pressure and cerebral perfusion. Head injury. London, 1997.
- 10. PHYSIOLOGY REVIEW: MONROE-KELLIE DOCTRINE • Vother: volume of any abnormal component hematoma, tumor • Cranium is • Nonexpandable • incompressible
- 11. CEREBRAL BLOOD FLOW • CPP = MAP - ICP • Pressure autoregulation: MAP 50-150 mmHg is autoregulated to maintain constant CBF
- 14. CLASSIFICATION OF HEAD INJURIES • Severity • Morphology • Intracranial lesion
- 17. HOW TO READ CT BRAIN • ABCDEF • A – airspaces: pneumocephalus, trauma or sinus • B – blood, bone, brain • C – CSF • D – Dura • E – eyes • F - face
- 18. Anzai Y et al. Imaging of traumatic brain injury. New York: WL, 2015.
- 19. EPIDURAL HEMATOMA • Lens shape • Hyperdensity • Lucid interval • Injury to middle meningeal a. • Coup lesion Anzai Y et al. Imaging of traumatic brain injury. New York: WL, 2015.
- 20. SUBDURAL HEMATOMA • Tear bridging vein • Countercoup lesion • Crescent shape • Acute • < 1day • hyperdensity • Subacute • 1-3 days • Isodense • Chronic • Hypodense with septation
- 22. SUBARACHNOID HEMORRHAGE • Traumatic: Serpentine hyperdense lesion along sulci • Aneurysmal: maximum thickness at basal cistern
- 24. CEREBRAL CONTUSION • Fluffy appearance • Mixed hypo-hyperdense, inhomogenous • Ill-defined border • Adjacent to bony prominence
- 25. INTRACEREBRAL HEMORRHAGE • Well-defined borde • More homogenous
- 26. CEREBRAL CONCUSSION • GCS = 15 • No neurodeficit after recovery
- 27. DIFFUSE AXONAL INJURY • Unconscious > 24 hr • Spot hemorrhage along grey-white matter junction
- 28. CEREBRAL EDEMA • Midline shift • Slit ventricle • Herniation • Loss of sulci • Loss of grey-white junction
- 29. TREATMENT • According to severity • Mild head injury: low, moderate, high risk • Moderate to severe head injury • ABCDEs • Resuscitation and protect airway in severe head injury • CT brain with C-spine
- 30. MILD TBI: LOW RISK • GCS 15 • Asymptomatic • No headache Discharge with instruction
- 31. MODERATE TO HIGH RISK MILD TBI • Moderate risk • CT brain and observe 6 h • admit • High risk • CT brain + admit
- 33. MEDICATIONS: MANNITOL • Indication: signs of herniation, ICP > 22 mmHg • 20% mannitol 0.25 – 1 g/kg IV in 15 min, then 100 mg IV q8h
- 34. MEDICATION: DILANTIN • Early posttraumatic seizure prophylaxis • 7 days to 2 years if seizure presents • 15 – 20 mg/kg IV in 30 min, then 100 mg q8h x 7 days
- 35. • Indications: • Immediate posttraumatic seizure or history of seizure • Posttraumatic amnesia > 30 min • GCS ≤ 10 • Linear or depressed skull fracture • Penetrating head injury • Hemorrahge: EDH, SDH, SAH, ICH, IVH, contusion • Chronic alcoholism MEDICATION: DILANTIN
- 36. TIME TO SURGERY • EDH • 30 cm3 • Thickness > 15 mm • Midline shift > 5 mm
- 37. TIME TO SURGERY • SDH • > 10 mm thick • > 5 mm midline shift • GCS drop > 2 • Asymmetric pupil • ICP > 20 mmHg
- 38. TIME TO SURGERY • SAH • When hydrocephalus presents
- 39. TIME TO SURGERY • ICH • > 30 cm3
- 40. TIME TO SURGERY • Depressed skull fracture • Depress more than thickness of cranium or > 1 cm • Dural penetration • Significant intracranial hemorrhage • Frontal sinus involvement • Cosmetic • Infection and contamination • Pneumocephalus
- 42. REFERENCES American college of surgeons committee on trauma. ATLS student course manual. 10th ed. Chicago: American college of surgeons, 2018. Carney N et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. 2016 Anzai Y et al. Imaging of traumatic brain injury. New York: WL, 2015. Winn, H. Richard. Youmans and Winn’s Neurological Surgery. Phildelphia: Elsevier, 2017.