cranio cerebral injuries for medical students
DESCRIPTION
This is a simple outline of traumatic injuries which occures to the scalp, skull and brain with some simplified classifications and outlined managementTRANSCRIPT
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MANAGEMENT OF CRANIO-CEREBRAL INJURIES
WALID S. MAANI
PROFESSOR AND CHAIRMAN OF NEUROSURGERY
UNIVERSITY OF JORDAN
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Head injuries are a major cause of morbidity and mortality in the community
Trauma is the 3rd most common cause of death
in the Jordan, preceded only by cardiovascular diseases and cancer
Head injuries contribute to over half of traumarelated death.
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EPIDIMIIOLOGY
DEATHS: 9:100.000 in UK. 25:100.000 in USA. And Jordan 12:100.000 OF ALL DEATHS = 1% OF TRAUMA DEATHS = 25% MEN > WOMEN YOUNG > OLD
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EPIDIMIIOLOGY
CAUSES IN CIVIL LIFE ROAD TRAFFIC 60% DOMESTIC 30% INDUSTRIAL ASSSAULTS SPORTS
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PATHOLOGY
CLOSED, PENETRATING OR MISSILE SCALP SKULL BRAIN
PRIMARY SECONDARY COMPLICATIONS
EARLY LATE
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PATHOLOGY (cont.)
SCALP INJURIES1. CLEAN CUT WOUNDS2. LACERATIONS3. AVULSIONS4. CONTUSIONS5. HEMATOMAS
a- SUB-GALEALb- SUB-PERICRANIAL
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PATHOLOGY (cont.)
SKULL INJURIES (FRACTURES)SIMPLE OR COMPOUNDTYPES: LINEAR DEPRESSED POND BASAL
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PATHOLOGY (cont.)
BRAIN INJURIES PRIMARY
CONCUSSION CONTUSION LACERATION
SECONDARY LOCALIZED DIFFUSE
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CLINICAL PICTURE
HISTORY TIME OF TRAUMA TYPE OF TRAUMA HISTORY OF CONVULSIONS HISTORY OF L.O.C. (LUCID INTERVAL) POST TRAUMATIC AMNESIA (PTA) RETROGRADE AMNESIA
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CLINICAL PICTURE (cont.)
EXAMINATION PATENCY OF AIRWAYS LEVEL OF CONSCIOUSNESS
GLASGOW COMA SCALE (GCS) TRAUMA SCALE (SCORE)
PUPILLARY SIZE BLOOD PRESSURE AND RESPIRATION SHOCK IS RARE EXCEPT IN ENFANTS OR
SEVERE SCALP INJURIES
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ASSESSMENT OF THE SEVERITY IN HEAD INJURIES
(Glasgow Coma Scale: GCS)
Points Eye Opening Best Verbal Best Motor
6 … … Follows commands
5 … Appropriate Localizes pain
4 Spontaneous Inappropriate Withdraws to pain
3 In response to voice Moaning Flexion (decorticate)
2 In response to pain Incomprehensible Extension
(decerebrate) 1 None None None
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CLINICAL PICTURE (cont.)
SCALP EXAMINATION SCALP WOUNDS SCALP HEMATOMAS BATTLE’S SIGN RACOON EYE
NEUROLOGICAL EXAMINATION EXAMINATION OF OTHER
SYSTEMS
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MANAGEMENT
EXAMINATION MAKE SURE AIRWAY IS PATENT PUT I.V. LINE SKULL X-RAYS: 3 VIEWS CERVICAL SPINE X-RAYS: 16% ASSOCIATED CT AS INDICATED
FRACTURES DISTURBED LEVEL OF CONSCIOUSNESS NEUROLOGICAL DEFICITS
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MANAGEMENT (cont.)
INDICATIONS OF ADMISSIONS PTA ( POST TRAUMATIC AMNESIA) LONGER
THAN 5 MINUTES OR GCS LESS THAN 14 SKULL FRACTURES POSITIVE CT SCAN NEUROLOGICAL DEFICITS CHILDREN DRUNKEN IF IN DOUBT ASSOCITAED SYSTEM INJURIES
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SCALP INJURIES
TYPES CONTUSIONS HEMATOMAS CLEAN CUT WOUNDS LACERATED
WOUNDS AVULSED SCALP SUB-GALEAL
HEMATOMA SUB-PERIOSTEAL
HEMATOMA
MANAGEMENT FIRST AID BY
COMPRESSION BANDAGE SHAVE HAIR CLEAN WOUND WITH
ANTISEPTIC INSPECT WOUND AND
REMOVE FB CLOSE IN LAYERS DRESSING ANTIBIOTICS
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LINEAR SKULL FRACTURES
IS INTERRUPTION TO THE CONTUINUITY OF THE SKULL BONES.
THE TRAUMA IS SIGNIFICANT AND MAYPROVIDE AN INDICATION TO THE PRESENCE
OF AN EXTRADURAL HEMATOMA
THE PATIENT SHOULD BE ADMITTED FOR OBSERVATION AND CT SCAN SHOULD BE
PERFORMED.
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LINEAR SKULL FRACTURES
IF THEY EXTEND TO INVOLVE THE BASE OF THE SKULL THEN THEY ARE CALLED
BASAL SKULL FRACTURES THEY TEND TO RUN ALONG THE FORAMINA OF
CRANIAL NERVES, MAINLY IN THE ANTERIOR AND MIDDLE CRANIAL FOSSAE IN CLOSE
PROXIMITY TO PARANASAL AIR SINUSES.
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BASAL SKULL FRACTURES
PRESENTATION IN ANTERIOR CRANIAL FOSSA FRACTURES IS WITH: BRUISING AROUND THE EYE
“RACOON EYE” OR SUBCONJUNCTIVAL
HEMORRHAGE OR CSF LEAK “ RHINORRHEA” OR CRANIAL NERVE DEFICIT
PRESENTATION IN MIDDLE CRANIAL FOSSA FRACTURES IS WITH: BRUISING BEHIND THE EAR “BATTLE
SIGN” OR HEMOTYMPANUM OR CSF LEAK “OTORRHEA”
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MANAGEMENT OF LINEAR & BASAL SKULL FRACTURES
There is no specific management for linear skull fractures. Just admit for observation and do CT scan to rule out hematomas.
Basal skull fractures should be covered with antibiotics and the nose and ear should be observed for CSF leak
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DEPRESSED SKULL FRACTURES
ARE DEPRESSIONS OF THE BONE OF THE SKULL.
THEY COULD BE: SIMPLE WITH SKIN
INTACT COMPOUND WITH CUT
SKIN EITHER COULD BE:
ONE DEPRESSED SEGMENT
COMMINUTED
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MANAGEMENT OF DEPRESSED SKULL FRACTURES
THEY NEED TO BE OPERATED UPON IF: THE DEPRESSION IS MORE THAN
THE THICKNESS OF THE SKULL
THERE IS CSF LEAK THERE WERE SEIZURES THEY OVERLIE AN IMPORTANT
AREA THEY WERE COMPOUND
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MANAGEMENT OF DEPRESSED SKULL FRACTURES
THEY NEED TO BE OPERATED UPON .
THE OPERATION COULD BE: Simple elevation Craniectomy, this will need to
be repaired later by an operation called Cranioplasty
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BRAIN INJURIES
BRAIN INJURIES PRIMARY INJURIES
CONCUSSION CONTUSION LACERATION DIFFUSE AXONAL INJURY
SECONDARY EVENTS BRAIN OEDEMA
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MANAGEMENT OF BRAIN INJURIES
BRAIN INJURIES SEVERE
GCS 8 OR BELOW MODERATE
GCS BETWEEN 9 AND 13 MILD
GCS 14
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MANAGEMENT OF BRAIN INJURIES
BRAIN INJURIES PRIMARY INJURIES
CONCUSSION: OBSERVE FOR 24 HOURS
CONTUSION & LACERATION:
?STERIODS, DIURETICS, ANTICONVULSANTS, MAY NEED
ICP MONITOR OR EXCISION DIFFUSE AXONAL INJURY:
AS ABOVE, BUT REQUIRES ALSOICP MONITORING AND VENTILLATION
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MANAGEMENT (cont.)
SECONDARY EVENTS
HYPOVOLAEMIA HYPOXIA BRAIN OEDEMA
? STEROIDSOSMOTIC DIURETICS (MANNITOL)HYPERVENTILLATIONICP MONITORINGANTICONVULANTS
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COMPLICATIONS & THEIR MANAGEMENT
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COMPLICATIONS OF HEAD INJURIES EARLY
HYPONATRAEMIA EPILEPSY HEMATOMA CSF LEAKS
LATE EPILEPSY INFECTION HYDROCEPHALUS POST TRAUMATIC SYNDROMES
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EPILEPSY
DEPENDS ON LOCATION OF INJURY, EXTENT OF INJURY AND AGE
MAY LEAD TO HYPOXIA AND ICP COULD BE PREDICTED AND SCORED TREATED BY
CARBAMAZEPINE ( TEGRETOL) PHENYTOIN (EPANUTIN) PHENOBARBITONE
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EPILEPSY:TWO CATEGORIES
EARLYWITHIN FIRST WEEK OF INJURY5% OF CASES10% IN CHILDREN BELOW 5 YEARS
LATEAFTER FIRST WEEK OF INJURY5% OF CASES50% DEVELOP DURING FIRST YEAR
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INTRACRANIAL HEMATOMAS
EXTRADURAL (EPIDURAL) HEMATOMA BETWEEN DURA AND BONE ARTERIAL OR VENOUS MAINLY MMA ADULTS 90% ASSOCIATED WITH FRACURE 25% OF CHILDREN HAVE FRACTURES MOSTLY WITHEN 8 HOURS OF INJURY, (STEM OF MMA) 8-24 HOURS (FROM ANTERIOR BRANCH) 24-36 HOURS (FROM POSTERIOR BRANCH)
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TRAUMA LOC (CONCUSSION) WAKE UP ( LUCID INTERVAL) LOC (HEMATOMA)
LEADS TO ICP AND NEUROLOGICAL DAMAGE INVESTIGATIONS
IF THERE IS TIME DO CTIF NO TIME DO SURGERY
TREATMENT BURR-HOLESCRANIOTOMY OR CRANIECTOMY
EXTRADURAL(EPIDURAL) HEMATOMA
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EXTRADURAL HEMATOMAS
ACUTE EXTRADURAL HEMATOMA
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BETWEEN BRAIN AND DURA FROM BRAIN VESSELS PART OF SEVERE INJURY AND LACERATION PRESENT AS EDH BUT CLINICAL PICTURE IS
OVELAPPED BY THE SEVERE HEAD INJURY
INVESTIGATIONS AS EDH TREATMENT
THAT OF HEAD INJURYEVACUATE HEMATOMA
MAY BECOME CHRONIC
ACUTE SUBDURAL HEMATOMA
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CHRONIC SUBDURAL HEMATOMA
IN ELDERLY RISK FACTORS: ALCOHOLISM, SEISURES, CAOGULOPATHY BILATERAL IN 30% APPEARS HYPODENSE ON CT STARTS AS ACUTE AND TURNS TO CHRONIC IN 3 WEEKS. SYMPTOMS HEADACHE, CONVULSIONS,SEIZURES, DEFICITS, COMA TREATMENT IS SURGERY IF SYMPTOMATIC OR MORE THAN 1 CM THICK
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CHRONIC SUBDURAL HEMATOMA
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ACUTE AND CHRONIC SUBDURAL
HEMATOMA
ACUTE SUB DURAL HEMATOMACHRONIC SUBDURAL HEMATOMA
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DUE TO BRAIN MOVEMENT OR DIRECT TRAUMA
MAINLY AT POLES OF CEREBRUM MAY BE AT SITE OF TRAUMA OR FAR AWAY USUALLY A PART OF SEVERE HEAD INJURY DIAGNOSED BY CT. MAY LOOKS LIKE
CONTUSION TREATMENT
THAT OF HEAD INJURY EVACUATE HEMATOMA IF IT IS RESPOSIBLE FOR
CONTINUED DETERIORATION
INTRACEREBRAL HEMATOMA
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INTRACEREBRAL HEMATOMA
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REQUIRES FRACTURES AND DURAL TEARS TYPES
CSF RHINORRHEA IF FROM NOSECSF OTORRHEA IF FROM EAR
DIAGNOSED BYCSF LEAKPRESENCE OF AEROCELEDEVELOPMENT OF MENINGITISAPPROPRIATELY PLACED FRACTURE
CEREBRO-SPINAL FLUID LEAKS
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CEREBRO-SPINAL FLUID LEAKS
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CSF RHINORRHEA IN 25% OF CASES WITH ANTERIOR BASAL SKULL
FRACTURE IN FIRST WEEK IN 60% OF CASES MAY BE MISSED DUE TO SWALLOWING FLUID COULD BE ANALYESD FOR SUGAR 50%STOP SPONTANEOUSLY TREATMENT: ANTIBIOTICS FOR 2 WKS OR
SUERGERY FI IT DOES NOT STOP
CEREBRO-SPINAL FLUID LEAKS
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CSF OTORRHEA IN 2% OF CASES WITH BASAL SKULL FRACTURE MAY BE VERY PROFUSE 95% DRY UP IN 10 DAYS EXAMINATION OF THE EAR MUST BE AVOIDED REQUIRES ANTIBIOTIC COVER EXTERNAL EAR DRESSING FEW NEED SURGICAL REPAIR
CEREBRO-SPINAL FLUID LEAKS
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HYDROCEPHALUS
DUE TO BLOOD IN CSF USUALLY OF COMMUNICATING TYPE SHOULD BE SUSPECTED IN DELAYED RECOVERY MAY LEAD TO:
HEADACHE DETERIORATION IN MENTAL FUNCTION ATAXIA INCONTINENCE
MAY REQUIRE SHUNTING
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HYDROCEPHALUS
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POST CONCUSSION SYNDROME
COLLECTION OF SYMPTOMS DUE TO MINOR HEAD TRAUMA
CONTROVERSIAL WHETHER ORGANIC OR PSYCHOLOGICAL
SYMPTOMS: SOMATIC:
HEADACHE DIZINESS VISUAL DISTURBANCES HEARING PROBLEMS BALANCE DIFFICULTIES
COGNITIVE: CONCENTRATION DIFFICULTY DEMENTIA
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POST CONCUSSION SYNDROME
PSYCHOLOGICAL: EASY FATIGABILITY LOSS OF LIBIDO EMOTIONAL DISTURBANCES PERSONALITY CHANGES INSOMINIA PHOTOPHOBIA
TREATMENT REASSURANCE SUPPORT
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MISSILE INJURIES
THE LINES OF MANAGEMENT
ARE SIMILAR TO THOSE OF CIVILIAN LIFE HEAD
INJURIES, BUT HAVE CERTAIN
SPECIFIC POINTS WHICH REQUIRE
SPECIAL ATTENTION.
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MISSILE INJURIES
THERE ARE USUALLY OTHER ASSOCIATED INJURIES.
THERE IS INCREASED RISK OF INFECTION
THEY MAY ARRIVE IN BIG NUMBERS WHO NEED ATTENTION
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MANAGEMENT OF HEAD INJURIES DUE TO BULLETS
STANDARD EXAMINATION AND EVALUATION ATTEND TO AIRWAYS SECURE PROPER I.V. LINES SKULL X-RAYS AND CT SCANS MANAGEMENT WILL DEPEND ON THE NEUROLOGICAL
STATUS OF THE PATIENT
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MANAGEMENT OF HEAD INJURIES DUE TO BULLETS
DEBRIDEMENT AND CLOSURE OF SCALP WOUNDS
CRANIECTOMY FOR COMMINUTED SKULL FRACTURES
CRANIOTOMY AND EXCISION OF CONTUSED SWOLLEN SUPERFIACIAL BRAIN AREA
REMOVAL OF ACCESSABLE FRAGMENTS EVACUATION OF LIFE THREATENING
HEMATOMAS BURR HOLE FOR INSERTION OF ICP
MONITOR
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MANAGEMENT OF HEAD INJURIES DUE TO BULLETS
MANNITOL FOR BRAIN OEDEMA HYPERVENTILLATION BROAD SPECTRUM ANTIBIOTICS ATTENTION TO COMPLICATIONS
LIKE: EPILEPSY INFECTION SPECIALLY BRAIN
ABCESSES.
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MANAGEMENT OF HEAD INJURIES DUE TO BULLETS
THE FOLLOWING HAVE HIGH MORTALITY RATE: GCS OF 4 OR LESS ON ARRIVAL HIGH VELOCITY WOUNDS TRANSLOBAR PATH OF PROJECTILE TRANSVENTRICULAR COURSE IF ASSOCIATED WITH SHOCK
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MANAGEMENT OF HEAD INJURIES DUE TO BULLETS
REMOVAL OF DEEPLY SITUATED BULLETS OR FRAGMENTS IS NOT REQUIRED.
REMOVAL AT A LATER STAGE, IF THE PATIENT SURVIVES IS ONLY REQUIRED IF COMPLICATIONS ARISE.