Академический Документы
Профессиональный Документы
Культура Документы
Scalp injury
Skull injury
Meningeal injury
Traumatic Brain Injury
WHAT
IS THE DEFINITION OF A
TRAUMATIC BRAIN INJURY
(TBI)?
During birth
Non-traumatic
Brain Injury
Open Head
Injury
Stroke
Brain Infection
Tumor
Anoxia
Exposure to Toxic Substances
Important note:
Brain injuries
that result from either an
external
or internal force
may have similar effects.
Epidemic in Indonesia
Major cause of death and permanent
disability
70% of all road fatalities
50% of trauma death
10-20% of head injury: death on arrival
Degree
10% mild head injury
10% moderate head injury
80% severe head injury
Fall
Penetrating
GSW
Stab
Fragment
Coup-Contra Coup
Axon
1.
2.
3.
4.
Headache
Vomiting
Papilloedema occur in chronic condition
Cushing response
Bradicardia
Hipertension
Alteration of ventilatory pattern
5. Herniation
- ipsilateral dilated pupil
Uncal
- contralateral hemiparesis
- ipsilateral hemiparesis
(Kernohans notch phenomenom)
Central - rostrocaudal sign
Subfalcine
Tonsiller herniation
Severity
GCS
LOC
PTA
Mild
Moderate
1415
<20 min-1 hr
<24 hr
913
1 24 hrs.
> 24 hrs.
- <7days
Severe
38
>24 hrs.
>7 days
Primary
Scalp
contusion, abrasion, laceration
Skull fracture
open, closed (note-compound base of skull fracture
without a scalp laceration), linier, depressed
Meningeal injury
dural tear
Brain injury
concussion
contussion
diffuse axonal
focal contusion
laceration and penetration
Secondary
Intracranial haemorrhage
Cerebral swelling
cerebral hypoxia
CSF leakage and pneumocephalus
methabolic disorders
infection
epilepsy
Orbitofrontal cortex
(emotional and social responding)
Ventral brainstem
Hippocampal-Entorhinal
Complex (declarative
memory)
COGNITIVE
Decreased Concentration
Memory Problems
NEUROPSYCHIATRIC
Anxiety
Depression
Irritability
Mood Swings
Sleep Disturbances
Attention/Concentration
Speed of Mental Processing
Learning/Information Retrieval
Executive Functions (e. g., Planning,
Problem Solving, Self Monitoring) May see
judgment problems, apathy, inappropriate
behaviors
breathing
control of haemorrhage
prevention and shock treatment
avoidance of factors ICP
vomiting
The indication:
Airway is inadequate
GCS 8
Herniation
Rapid deterioration
Primary survey
Airway with cervical spine immobilized in neutral
position
Breathing pattern and adequacy
Circulation and haemorrhage
Disability, minineurological examination:
GCS
Pupils
Motor deficit
Resuscitation
Airway
Ensure patient airway
Unconscious patient: intubated if skilled
Note: maintain cervical spine immobilization
until radiological examination excludes
spinal injury
Breathing and oxygenation
Ensure adequate ventilation
Mechanically ventilate if intubated
Give supplemental oxygen initially
Secondary survey
Special neurosurgical assessment including
History
Cause of injury. This will help in determining
CNS examination
Glasglow Coma Scale (GCS)
Pupillary responses
Eye opening
Orientated
V5
Confused conversation
Inappropriate words
Incomprehensible sound
Nil
1
4
3
2
E4
Verbal response
Spontaneous
To speech3
To pain 2
Nil
1
Obeys
M6
Localizes 5
Withdraws
4
Abnormal flexion 3
Extension
2
Nil
1
Comment
A CT scan is the investigation of choice
where available. Except for an
uncomplicated minor head injury, all
patients ideally should have a CT scan.
As lesions may develop after an initial
normal scan, serial CT scans may be
required if neurosurgical deterioration
occur
Indications
Loss of consciousness, amnesia
Persisting headache
Focal neurological signs
Scalp injury
Suspected penetrating injury
CSF or blood from nose or ear
Palpable or visible skull deformity
Difficulty in clinical assessment
Patient with GCS 15, essntially asymptomatic
Comment
The presence of a skull fracture may influence
treatment, i.e.
A skull fracture is associated with an increased risk of
aerial transport
Vomiting
Complains of severe headache or dizziness
Becomes restless, drowsy or unconscious
Had a convulsion or fit
hematoma, if necessary
Monitor ICP with implanted pressure gauge
Medically manage cerebral edema to maintain
cerebral perfusion pressure > 70 mmHg
Perform serial head CT Scans
20% of cerebral contusions may enlarge to
surgical hematoma
Concussion
Brief loss of consciousness with normal
Skull fracture
May or not have associated underlying brain injury
Linier or non-depressed-observe
Open or compound-irrigate, close, antibiotic coverage
Depressed-require surgical repair
matter tracts
Cause immediate deep coma
Often associated with severe cerebral edema and ICP elevation
Mortality is 30-40%, good outcome 20-30%
Gunshot wound-GSW
Cause mixtures of skull fracture, DAI,
atrophy
Minor trauma causes small, often minimally
symptomatic subdural hemorrhage. As clot
liquifies over next 1-3 weeks, the hemorrhage
may expand into a significant mass.
CT apperance, hypodense crescent shaped
mass between dura and brain
Presenting symptoms: elevated ICP often
associated with hemiparesis. May also cause
TIA-like episodes or seizures
Treatment consists of surgical drainage of
hematoma via burrholes and irrigation. Most
patients make excellent recovery
neurosurgical consultation
intradural haematomas,
dural laceration with cortical injury,
depressed fractures,
a post-traumatic amnesia period of 24 h early post traumatic
epilepsy
Scalp Wounds
1. shave at least 3 cm around the wound
2. gently palpate the laceration with a gloved finger.
This may provide information regarding an
underlying fracture
3. if a fracture is found unexpectedly, do not remove
bone fragments: contact your neurosurgeon at
once.
4. Scalp wounds may bleed profusely and cause
hypertension. Secure haemostasis by pressure or
suturing early
5. if the wound edges are badly torn, excise non
viable scalp and where possible suture the scalp in
two layers