BRAIN INJURY MANAGEMENT

KHAMIM THOHARI

NEUROSURGEON

MARDI WALUYO GENERAL HOSPITAL BLITAR EAST JAVA INDONESIA

ACCIDENT (SPOT OF ACCIDENT)

BRAIN SCHOCK : (Seconds minutes)

* No pain reaction * Apnea * Bilateral pupil dilatation, negative light + corneal reflex * Poll is not clear predictable / papable

A1 B1 C

DEATH ON ARRIVAL * 17.5% 20% : Before admitted in hospital * Resuscitation : on the spot : - A , B , C - Transportation * Sending to the nearest hospital who has intensive care unit * Sending to the hospital who has department of neurosurgical ( neurosurgeon and equiptment )

Cases I : Spatula in the head Dont extraction curve of the end spatula

BRAIN INJURY

PBI Continuing process Unpreventable process

Reperfusion injury + Ery throcyte + Neurotransmitters (Spasmogen agents) + + + + + Inflammatory reaction Acidosis Opioid Endogen Free radicals Hormonal Edema cytotoxic SBI

Preventalbe process Good Resuscitation

BBB Disturb

Recover

Bad
Disturb of A1 B1 C

Hypoxia

Edema cytotoxic

Edema Vasogenic

MANAGEMENT

Brain Injury Resucitation ABC

Evaluation of GCS

Mild BI
Observation 2 hours in EM

Moderat BI
Insertion of NG tube, DC

Severe BI
Intubation Insertion of NG tube, DC

Dx : CT Scan CONSERVATIVE OPERATIVE

OBSERVATION 1. 2. 3. 4. 5. 6. GCS Neurologic Sign Vital Sign : BP, Pulse Position Fluid Temperature 7. 8. 9. 10. 11. 12. Restlessness Seizures Urinary Skin Care ICP Monitoring Drug / Medicine

Cases II : * Open fracture on the skull * Dont remove bone fragment * The first aid : TRACHEOSTOMY

MANAGEMENT
1. Head positioning
The tongue drops : losses the muscle strength The head and the body are placed aside

2. A : Airway
Clearance of respiratory tract

3. B : Breathing
Massage on the chest Oxygenation is given Mouth breathing artificial respiration

4. C : Circulation
Signs : + Pale + Decrease of pulse rate + Arterial pulse unpalpable Tx : * Stop bleeding * Infusion

PRIMARY SURVEY
HYPOXEMIA

80 120 A PAO2 B PACO2 25 35

PREVENT HYPEROXEMIA

Systole : 100 140 mmHg C BP Diastole : 70 90 mmHg Hypertension Hypotension Shock Anemia

Urgency

Immediately Treated

IMAGING :
Skull X Ray

Head CT Scan
Head MRI Cervical X Ray

Skull X RAY INDICATIONS

* Open fracture * Deformity

* Stab wound
* Corpus alienum * Scraped wound

Cases III : Klep gun in the eye + skull

Cases IV : Stick wood in the skull

Cases V : Bullet in the skull

CERVICAL SPINE X RAY INDICATIONS

* Scraped wound on the neck

* Neck pain

* Traumatic mechanism ( wisplash injury )

* Cervical signs : tetra plegia / paralytis

* Unconscious patients

CT SCAN INDICATIONS
* Seizures

* Continuous cephalgi, vomiting and vertigo with medicine

* Corpus alienum or stab wound * GCS < 15 * Lateralization ( anisocor / hemiparalysis ) * Decreased of GCS > 1 point

* Cushing response : hypertension + bradicardy

* Brain + multiple organ injury * Social indication

OUT PATIENTS CONDITION * Conscious + good orientation * No neurological deficit * Decreased of complain * No fracture * Social Problems nobody care at home hospital distance home / village from the hospital NOTES : Back to the hospital if patient has : * Seriously complain (severe complain) * Restlessness * Decreased of conscious ( GCS ) * Seizures * Lateralization

ICU OBSERVATION
* GCS < 8

* GCS 9 15 : with neurological deficit,

cushing respons * Progresive neurological deficit * Progresive of complain : cephalgie , vertigo and vomiting

OBSERVATION
ARTIFICIAL RESP.
Cushing Response
Neurologic Signs : Pupil, Motoric

PATIENT

WITHOUT
GCS Cushing Response

Neurologic Signs

1. OBSERVATION OF CONSCIOUSNESS based on GCS 1. Recover

15

2. SBI
15 FI 15 FI 15 FI

15

15

15

2. OBSERVATION OF NEUROLOGICAL DEFICIT

NO LATERALIZATION

LATERALIZATION

Pupil : isocoria
Motoric : normal

Anisocoria
Hemi/Tetra Phareses/Pharalyses

Caused by : Intracranial Processes Extracranial Process, ex. : Hypoxemia

CUSHING RESPONSE
Bradycardia : Pulse < 60/minute
Hypertension Cephalgia , Vertigo , Vomiting

Cases VI : EDH ( Epidural Hemorrhage )

4. POSITION
Head Elevation : + 10 30 + CBF : N + ICP : Mechanical Not > 30 : + CBF + Mechanical effect () CSF cant move to spine space

5. FLUID, ELECTROLYTE AND NUTRITION IMBALANCE

DAY 1 2 : * 2 liters isotonic fluid

* has an electrolyte : osmolar stabilization

DAY 3

: * nasogastric tube : - no gastric retention (100 cc/day) - good peristaltic - no abdominal distension - no nausea and vomiting - start low go slow

SOME FACTORS NEED TO BE CONSIDERED IN FLUID ADMINISTRATION ARE

1. Extra fluid 10 15% must be given for every increased 1C temperature 2. Urinary production : * diabetes insipidus : 1 ltr negative balance * progressive urinary production and prolonged urine production ( > days) vasopression administration is needed and electrolytes is periodically examined 3. Its not recommended to give glucose 5% glucose rapidly metabolize solution changes into hypotonic

6. TEMPERATURE
* Rectal temperature * Hyperthermia brain Hypermetabolism * Causes of hyperthermia 1. Intracranial : Primary 2. extracranial : Secondary infection drug reaction transfusion reaction * Treatment + intracranial : without antipyretics + antibiotic + increasing of fluid : > 1 C (+) 10 15% (extra)

7. RESTLESSNESS
Factors : 1. Intracranial : + start to be alert

+ ICP : intracranial
2. Extracranial : Pain : + full bladder, bone fracture + uncomfortable feeling due to dirty bed/ clothing + patient is tightened + hyperthermia + respiratory disturbance Treatment : + etiologic factors must be found and treated + medical : chlorpromazine : 25 mg diazepam : 5 10 mg

8. SEIZURES
* Occurred due to iritative of brain and Ca
2+ IC * Treatment : 1. Diazepam : 10 40 mg iv during attack Phenitoin : 3 5 mg Kg/BW/Dose Phenobarbital : 3 5 mg Kg/BW/Dose 2. In epileptic status : should be more intensively treated 3. Until EEG normal or 2 years seizures free * Prevent : - Severe BI - ICH Traumatic - Edema - Depressed Fracture - Foreign Bodies - Acute Seizures

Cases VII : Severe brain injury complication : brain athropy

9. URINARY : MICTURATION

Dauer catheter is inserted with the aim * to monitor urinary production * to calculate the fluid balance * to keep the bed clean and dry * to prevent restlessness due to full bladder

10. SKIN CARE

* Skin area with continuous pressure decubitus * Dangerous : - infection sepsis - serum fluid hypoalbumin * Treatment - turning position periodically - giving soft pillows beneath parts of the body which are under continuos pressure

11. ICP MONITORING

ICP : Monitoring Out Come Prediction Intraventricular Monitoring < 20 mm H2O CPP : MAP ICP

CPP : + 75 mmHg
MAP ICP Slight Hypertension Mechanical : Position CSFIC

Medical :

Acetazolamic
Mannitol Corticosteroid

12. DRUG MEDICINE

Ca2+ Blocker Antioxidant Dehydration Agent Nootrophic : Nicholin

Piracetam :
* Rheology

* CBF

HEMORRHAGE
SMALL HEMORRHAGE
BRAIN COMPENSATED : MILD COMPLAIN : Cephalgi, Vertigo, Restlessness, Vomiting, Amnesia UNCOMPENSATED :

LARGE HEMORRHAGE

CURABLE

OPERATIVE

HEAVIER : * Lateralization anisocoria hemiparese/paralytic * Cushing response hypertension bradycardia

* Apnea * Hyperthermi * Bilateral pupil mydriasis * Decerebration * Cardiac arrest

HERNIATION : REPERFUSION INJURY REBLEEDING

POST OPERATIVE DECOMPRESSION

OPERATIVE DECOMPRESSION

POSITIVE PRESSURE

NEGATIVE PRESSURE POOLING OF BLOOD

INTRAVASCULAR PRESSURE
EDEMA RUPTURE HEMORRHAGE

Teknik operasi drainase ventrikel

Diffuse Brain Injury

Normal CT

Diffuse Injury

Range from mild concussion to severe ischemic insult

Intracerebral Hematoma / Contusion

Large Frontal Contusion with Shift

Subdural Hematoma

Epidural Hematoma
Temporal Epidural Hematoma

Uncal herniation

SUMMARY
1. It is important to observe the changes of consciousness, especially when the patient is firstly seen, during transportation to / at the hospital 2. 17.5 20% patient expected to die before arriving in the hospital 3. In the hospital : ( recent management) * primary survey : stabilization : A B C * diagnostic * definitive treatment - operative - conservative - observation 12 points 4. Goal of brain injury treatment a. curable b. to prevent of SBI c. to minimize invalidity and death d. the end results of treatment is good outcome

THANK YOU