PTCPTC

Primary TraumaPrimary TraumaCareCare

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PTCPTC

objectivs :objectivs :

1- Early diagnosis & management of traumatic brain injury

• 2- prevent causes of secondary brain injury during resuscitation ( hypoxia, hypovolemia, hypocarbia , anemia , hypo/hyperglycemia)

• 3- To rapidly identify & treat mass lesions

• 4- indications for ICP/CPP monitoring & management of intracranial hypertension

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Head TraumaHead 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

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Head TraumaHead TraumaApproachApproach

Airway

Breathing

Circulation

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Airway :Airway :

• 1-intubate all unconscious patient (GCS <9 ) to secure airway

• 2- Maintain cervical spine immobilization in all unconscious or symptomatic (neck pain or tenderness ) patients

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BreathingBreathing

• 1- administer high flow oxygen to all patient with suspected head injury

• 2- monitor oxygen saturation• Avoid hypoxia (SaO2<90% or PaO2 <60 mmhg

• 3- ventilation• Avoid hyperventilation , unless sign of herniation are present• Maintain PaCO2 35-40 mmhg

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CirculationCirculation

• 1- prehospital : avoid SBP < 90 mmHg

• 2- maintain MAP > 90 mmHg to maintain CPP >60 mmHg

• 3- Fluid : infuse 0.9 NaCl & or blood

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Head TraumaHead TraumaPhysiologyPhysiology

CPP = MAP - ICP

CPP = cerebral perfusion pressureMAP = mean arterial pressure

ICP = intracranial pressure

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Cerebral Blood FlowCerebral Blood FlowDepends on:Depends on:

• CPP (MAP-ICP)

• PaCO2

• PaO2

• Local metabolites

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Intracranial Pressure (ICP) Intracranial Pressure (ICP)

• 10 mm Hg = Normal

• > 20 mm Hg = Abnormal

• > 40 mm Hg = Severe

• Sustained ICP leads to brain

function and outcome

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cerebral Perfusion Pressurecerebral Perfusion Pressure

MBP - ICP = CPP

• Normal 90 - 10 = 80

• Cushing’s 100 - 20 = 80

Response

• Hypotension 50 - 20 = 30

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TreatmentTreatment

• Minimize secondary brain injury• - ABCDE• - Maintain CPP• - Maintain blood pressure (systolic > 90 mm

Hg)• - Reduce ICP

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TreatmentTreatment

• Maintain MAP• – Euvolaemic fluid resuscitation• – Isotonic fluids• – Inotropes

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TreatmentTreatment

• Reduce ICP• – Controlled ventilation• Goal: PaCO2 at 35 mm Hg• – Head up tilt• – Paralysis• – Mannitol• – Surgery

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TreatmentTreatment

• Mannitol• Use with signs of tentorial

herniation• Dose: 1.0 g / kg IV bolus

Consult with neurosurgeon first

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Head TraumaPathophysiology

• Primary Injury

occurs at time of injury

• Secondary Injury

occurs after injury

may be preventable

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Head TraumaPrimary injury

Diffuse axonal injury - Acceleration

- deceleration Cerebral contusion Penetrating injury

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Head Trauma Secondary injury

Hypoxia Hypoperfusion (↑ ICP, ↓ MAP) Hypoglycaemia Hyperthermia (fever) Seizures

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Head TraumaHead TraumaInitial assessmentInitial assessment

Airway (+ C-spine)

Breathing

Circulation

Disability (AVPU, pupils)

Exposure

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Head TraumaHead TraumaExaminationExamination

• Glasgow Coma Score• Pupils• Corneal reflex• Eye position • Fundi

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Head TraumaHead TraumaExaminationExamination

• Tympanic membrane• Scalp and skull• Respiratory Pattern• Muscle tone• Posture• Tendon reflexes

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Head Trauma Head Trauma Glasgow Coma Score (GCS)Glasgow Coma Score (GCS)

• Grades severity of head injury• Score out of 15• Subject to inter-observer variation• Trend of GCS over time very useful• Also important to describe responses

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Head Trauma Head Trauma GCS Eye openingGCS Eye opening

Open spontaneously 4

Open to command 3

Open to pain 2

None 1

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Head Trauma Head Trauma GCS Best Verbal Response GCS Best Verbal Response

Oriented 5

Confused 4

Inappropriate words 3

Inappropriate sounds 2

None 1

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Head TraumaHead TraumaGCS Best Motor ResponseGCS Best Motor Response

Obeys command 6Localises to pain 5Withdraws to pain 4Abnormal flexion 3Extensor response 2None 1

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Head Trauma Head Trauma Severity of Head InjurySeverity of Head Injury

Severe GCS <8

Moderate GCS 9-12

Minor GCS 13-15

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Head Trauma Head Trauma Pupillary signsPupillary signs

• Size• Reactivity• Equality

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Head Trauma Head Trauma Pupillary responsesPupillary responses

Fixed, dilated,

unresponsive

• Severe hypoxia• Hypothermia• Seizures

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Head Trauma Head Trauma Pupillary responsesPupillary responses

Unilateral, dilated,

unresponsive

• Expanding lesion on same side

• Tentorial herniation

• Seizures

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Head TraumaHead TraumaAcute extradural or subduralAcute extradural or subdural

• Potentially life-threatening• Immediate recognition essential• Require burr-hole decompression

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Head TraumaHead TraumaAcute extraduralAcute extradural

• LOC → lucid interval → deterioration• Middle meningeal artery bleed• Overlying skull fracture• Contralateral hemiparesis• Fixed pupil on side of injury

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Head TraumaHead TraumaAcute subduralAcute subdural

• Tearing of bridging vein between cortex and dura

• Underlying brain injury• Usually no lucid interval• Worse prognosis than extradural

haematoma

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Head TraumaHead TraumaOther injuriesOther injuries

• Base-of-skull fractures• Cerebral concussion• Depressed skull fracture• Intracerebral haematoma

Usually do not require neurosurgery

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AirwayBreathing (ventilation)Circulation + Avoid ↑ ICP

Aim to prevent secondary injury

Head TraumaHead TraumaManagementManagement

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Head TraumaHead TraumaSevere (GCS<8)Severe (GCS<8)

• Intubate• Normal CO2

• Treat hypotension with fluid • Sedation +/- paralysis

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Head TraumaHead TraumaSevere (GCS<8)Severe (GCS<8)

• Nurse head up 20o

• Prevent hyperthermia• Complete secondary survey• Reassess frequently

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Head TraumaHead TraumaBewareBeware

• Deteriorating conscious state• Penetrating injury• Focal neurological signs

- unequal, dilated pupils

- seizures

- posturing

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Head TraumaHead Trauma

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Head TraumaHead Trauma

Summary• ABCs• Prevent secondary injury• Isolated head trauma doesn’t cause

hypotension • Look for other injuries• Deterioration → reassess

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Spinal TraumaSpinal Trauma

Objectives• To understand the structured

approach to the patient with spinal trauma

• To learn how to identify serious and life-threatening spinal injuries

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Spinal TraumaSpinal TraumaPrimary surveyPrimary survey

Airway + Cervical spine

Breathing

Circulation

Disability

Exposure

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Spinal TraumaSpinal TraumaSecondary surveySecondary survey

• Examine in neutral position• Log-roll to examine back• Immobilise

- stiff neck collar

- sandbags + tapes

- in-line immobilisation

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Spinal TraumaSpinal TraumaSecondary surveySecondary survey

• Local tenderness• Swelling• Deformity and stepping

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Spinal Trauma Spinal Trauma Assessment of levelAssessment of level

• Motor response• Sensory response

• Especially sacral sparing

• Reflexes• Autonomic function

• Bowel control• Bladder control

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Spinal Trauma Spinal Trauma High risk for C-spineHigh risk for C-spine

• Head injury• Paradoxical (diaphragmatic)

breathing• Flaccid limbs• No reflexes (check rectal sphincter)• Hypotension (+bradycardia)

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normals

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Dens #

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Unifacet dilocation

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Spinal TraumaSpinal TraumaTransportTransport

• Never transport in sitting or prone position

• Stabilise spine prior to movement• Log roll for transfer

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Spinal TraumaSpinal Trauma

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Spinal TraumaSpinal Trauma

Summary• Immobilise until injury is excluded• Initial management is ABC• Thorough neurological examination

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