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HEAD TRAUMA

Oleh : Litany alamudi

Pembimbing : Dr. Jovizal,Sp.S

Layers of the Cranial Vault

Anatomy of the Brain www.neurosurgery.org/pubpgages/patres/anatofbrain.html# micro

Definition Traumatic Brain Injury


Traumatic brain injury (TBI) is a serious neurodisorder commonly caused by car accidents, sports related events or violence

Review molecular mechanisms in the pathogenesis of traumatic brain injury http://www.hh.um.es

Mechanisms of Injury for TBI

Traumatic Brain Injury


Primary Brain Injury Results from what has occurred to the brain at the time of the injury
Secondary Brain Injury Physiologic and biochemical events which follow the primary injury

World journal of emergency surgery molecular mechanisms of traumatic brain injury:the missing link in management

Traumatic Head Injury

www.med.ub.es/All-Net/english/neuropage/trauma/head-8htm

HEAD INJURIES / BRAIN INJURIES

Skull fracture Diffuse Axonal Injury Epidural Hematoma Subdural Hematoma Coup contussion Contracoup contussion
World journal of emergency surgery molecular mechanisms of traumatic brain injury:the missing link in management

EPIDURAL AND SUBDURAL HEMATOMA

www.med.ub.es/All-Net/english/neuropage/trauma/head-8htm

SUBDURAL HEMATOMA

Coup and Contracoup Contusions


A combination of vascular and tissue damage leads

to cerebral contusion

Coup contusions occur at the area of direct impact

to the skull and occur because of the creation of negative pressure. contusions but are located opposite the site of direct impact

Contracoup contusions are similar to coup

World journal of emergency surgery molecular mechanisms of traumatic brain injury:the missing link in management

Severity of TBI using the Glasgow Coma Scale (GCS)


The severity of TBI according to the GCS score (within 48

hrs.) is as follows:

Severe TBI = 3-8


Moderate TBI = 9-12

Mild TBI = 13-15

World journal of emergency surgery molecular mechanisms of traumatic brain injury:the missing link in management

ASSESSMENT
Note: Monitor secure airway and protect c-

spine Assess breathing Assess circulation

Control major bleeding Prevent hypotension

Transport decision and interventions GCS

Guidelines for the management of severe traumatic brain injury 3rd edition

ASSESSMENT DETAILED
EXAM
Vital signs SAMPLE history Head-to-toe exam, including neurological

and GCS, fluid Continuous observation

Guidelines for the management of severe traumatic brain injury 3rd edition

Management of Traumatic Head Injury


Maximize oxygenation and ventilation Support circulation / maximize cerebral

perfusion pressure
Decrease intracranial pressure

Decrease cerebral metabolic rate


Guidelines for the management of severe traumatic brain injury 3rd edition

Primary vs. Secondary Brain Injury


Primary injury is immediate from bruising or

penetrating objects

Secondary injury is from hypoxia or

perfusion of the brain

Caused by swelling, hypoxia, or hypotension Hyperventilation decreases perfusion of the brain tissue Protect airway, give oxygen, maintain BP
Guidelines for the management of severe traumatic brain injury 3rd edition

Intracranial Pressure (ICP)


ICP is usually low (<15mmHg) If ICP found an >15mmhg was one of five

independent risk factors associated with death.

Guidelines for the management of severe traumatic brain injury 3rd edition

Lowering ICP

Evacuate hematoma Drain CSF

Intraventricular catheters use is limited by degree of edema

Craniotomy

Permanence, risk of infection, questionable benefit Reduce edema Promote venous return Reduce cerebral metabolic rate Reduce activity associated with elevated ICP

Guidelines for the management of severe traumatic brain injury 3rd edition

Diuretic Therapy
Osmotic Diuretic Mannitol (0.25-1 gm / kg) Increases osmolarity Vasoconstriction (adenosine)
Loop Diuretic Furosemide Decreased CSF formation Decreased systemic and cerebral blood volume (impairs sodium and water movement across blood brain barrier)

Guidelines for the management of severe traumatic brain injury 3rd edition

Hypertonic Fluid Administration


Hypertonic saline Comparing mannitol with barbiturates for control

ICP after TBI

Guidelines for the management of severe traumatic brain injury 3rd edition

Anesthetics, Analgetic and sedatives


High dose barbiturate therapy can result in control of

ICP when all others medical and surgical treatments have failed. Anticonvulsants - Prevent seizure activity Pentobarbital Adverse effects include hypotension and bone marrow dysfunction Used only after unsuccessful attempts to control ICP and maximize CPP with other therapies

Guidelines for the management of severe traumatic brain injury 3rd edition

Dose regimens

Factors that Effect Secondary Brain Injuries


Blood Pressure Oxygenation Temperature Control of Blood Glucose Fluid Volume Status Increased Intracranial Pressure

Guidelines for the management of severe traumatic brain injury 3rd edition

References
Dr. Baxter Larmon, Director of the UCLA CPC

and Professor of Medicine, UCLA School of Medicine Team, 2003

UCLA EMT Lectures, Barry Jensen and EMT

Brady / DOT paramedic lectures and curriculum www.emedicine.com

Evidence Supporting Normoventilation


Forbes et al. (1998) Journal of Neurosurgery, 88(3) Marion et al. (1995) New Horizons, 3(3)

McLaughlin & Marion (1996) Journal of Neurosurgery, 85(5) Muizelaar et al. (1991) Journal of Neurosurgery, 75(5) Newell et al. (1996) Neurosurgery, 39(1) Skippen et al. (1997) Critical Care Medicine, 25(8) Yundt & Diringer (1997) Critical Care Clinics, 13(1)