10/6/2017. Notice. Traumatic Brain Injury & Head Trauma

Transcription

1 Notice All EMS presentations will be recorded (both audio and video) and available for public viewing online. By participating in EMS you consent to audio and video recording and its/their release and or publication. You have been fully informed of your consent and release prior to your participation. Traumatic Brain Injury & Head Trauma Douglas Presta Spokane County EMS 1

2 Overview Head injury What to look for Appropriate management Facial injury Review Head and brain trauma ~ 1,500,000 head injuries annually ~ 230,000 hospitalized and survive ~ 50,000 deaths 1/3 all injury-related deaths Severity 75% mild 10% moderate 10% severe (35% mortality, 5% c-spine fx) 80,000-90,000 significant long-term disability Head injury Broad and Inclusive Term Traumatic insult to the head that may result in injury to soft tissue, bony structures, and/or brain injury Blunt Trauma Penetrating Trauma 2

3 A traumatic insult to the brain capable of producing physical, intellectual, emotional, social and vocational changes Three broad categories Focal injury Cerebral contusion Intracranial hemorrhage Epidural hemorrhage Subarachnoid hemorrhage Diffuse Axonal Injury Concussion Brain injury Mechanisms of head injury Motor vehicle crashes, MVC Sports injuries Falls Penetrating trauma Coup injury Categories of injury Contrecoup injury 3

4 Causes of brain injury Direct (primary) causes Indirect (secondary or tertiary) causes Secondary Edema, hemorrhage, infection, inadequate perfusion, tissue hypoxia, pressure Tertiary Apnea, hypotension, pulmonary resistance, ECG changes The brain is enclosed in a box Occupies 80% of intracranial space Brain Anatomy Divisions Cerebrum Cerebellum Brain Stem 4

5 Brain anatomy Cerebral spinal fluid, CSF Clear, colorless Circulates throughout brain and spinal cord Cushions and protects Brain anatomy Blood Supply Vertebral arteries Supply posterior brain (cerebellum and brain stem) Carotid arteries Most of cerebrum 5

6 Brain anatomy Meninges Dura mater: tough outer layer, separates cerebellum from cerebral structures, landmark for lesions Arachnoid: web-like, venous vessels that reabsorb CSF Pia mater: directly attached to brain tissue 6

7 Scalp lacerations Scalp laceration or avulsion Most common injury Vascularity = diffuse bleeding Generally does not cause hypovolemia in adults Can produce hypovolemia in children Skull fracture Skull fracture Present in 60% of pts with severe head injury Types: Linear: usually incidental finding on CT Depressed: mechanism is usually intense blow to scalp with object of small surface area. Surgical repair needed if depressed more than 5mm 7

8 Types Basilar: blow to temporal (most often), parietal, occipital area Signs Bloody ear discharge Skull fracture Battle s sign Racoon s eyes Closed head injuries Focal Contusion Epidural hematoma Subdural hematoma Intracerebral Diffuse (most common type of head injury) Mild concussion Classic concussion Blood between skull and dura Epidural hematoma Usually arterial tear Causes increased ICP 8

9 Epidural hematoma Unconsciousness followed by lucid interval Rapid deterioration Decreased LOC, headache, nausea, vomiting Hemiparesis, hemiplegia Unequal pupils (dilated on side of clot) Increase BP, decreased pulse (Cushing s reflex) Between dura mater and arachnoid Subdural Hematoma Usually venous Causes increased intracranial pressure 9

10 Subdural hematoma Slower onset Increased ICP Headache, decreased LOC, unequal pupils Increased BP, decreased pulse Hemiparesis, hemiplegia Transient loss of consciousness Concussion Retrograde amnesia, confusion Resolves spontaneously without deficit Usually due to blunt head trauma 10

11 Penetrating head injury Severity depends on Energy of missile Path Amount of scatter of bone and metal fragments Presence of mass lesion Accompanied by Severe face and neck injuries Significant blood loss Difficult airway Spinal instability 11

12 What the brain needs High metabolic rate Consumes 20% of body s oxygen Largest user of glucose Can not store nutrients 12

13 What goes wrong in head injury Pressure exerted downward on brain Brain stem Bradycardia 2 vagal stimulation Irregular respirations or tachypnea Unequal/unreactive pupils 2 oculomotor nerve paralysis Increased pressure back ups caroid atery Increasing BP Seizures dependent on location of injury 13

14 What you see on exam Levels of increasing ICP BP rising and pulse rate slowing Pupils reactive/ nonreactive or sluggish/pupil blown (side of injury) Irregular respirations LOC = best indicator Global function: assessment Altered LOC = Intracranial trauma UPO Trauma patient unable to follow commands = chance of intracranial injury needing surgery AVPU scale A = Alert V = Responds to Verbal stimuli P = Responds to Painful stimuli U = Unresponsive Global function 14

15 General brain function Glasgow Coma Scale, GCS Eye opening Verbal response Motor response Reliable measure, repeatable Glasgow Coma Scale Eyes Verbal Motor 1: Spontaneous 1: Oriented 1: Spontaneous 2: Voice 2: Confused 2: Localizes 3: Pain 3: Inappropriate 3: Withdraws 4: Unresponsive 4: Incomprehensible 4: Decorticate 5: Nonverbal 5: Decerebrate 6: Unresponsive Immobilization Spinal motion restriction If BP normal or elevated, spine board head elevated

16 Movement Is patient able to move all extremities? How do they move? Decorticate Decerebrate Hemiparesis or hemiplegia Paraplegia or quadraplegia Vital Signs Cushing s triad Suggests increased intracranial pressure Increased BP Decreased pulse Irregular respiratory pattern 16

17 Glucose Assess blood glucose Administer only if hypoglycemic Hyperglycemia can harm injured brain secondary to osmotic shifts Pupils Eyes to the Soul Check for responsiveness Unequal reactions 17

18 Most important sign = LOC Summary for assessment Direction of changes more important than single observations Trending Vitals/Reassessment UPO, altered LOC in trauma = intracranial injury Maintain adequate oxygenation Goals for treatment Maintain sufficient BP for good brain perfusion Avoid secondary brain damage Hypoxemia is a strong predictor of poor outcome Oxygenation 18

19 Open Assume C-spine trauma Jaw thrust with C-spine control Clear Suction as needed Maintain or secure Intubation if no gag reflex RSI, lidocaine and vecuronium Avoid nasal intubation Airway management Breathing Oxygenate 94-99% O 2 Ventilate No routine hyperventilation Adults BPM Children BPM Infants BPM Ventilation Hyperventilation recommended only for signs of cerebral herniation! Posturing Neurologic deterioration after correction of hypotension or hypoxemia Decrease in GCS of more than two points 19

20 Benefits Decreased PaCO 2 Vasoconstriction Decreased ICP Risks Decreased cerebral blood flow Decreased oxygen delivery to tissues Increased edema Hyperventilation Transport of head injuries Choose trauma center Any moderate and severe (GCS 3-13) need to go to trauma center where neurosurgery is available Air medical transport if needed Severe injuries need to be recognized quickly and transported rapidly as early surgical intervention is often only truly lifesaving treatment Spinal precautions Avoid hypoxia Consider intubation early Avoid hypotension Frequent reassessment Hyperventilate for herniation Triage wisely Summary 20

21 Any questions? Post Test 1. What is the most reliable predictor of intracranial injury? a. Level of Consciousness b. Movement of extremities c. Blood Glucose levels d. Past medical history Post Test 2. What portion of the brain controls breathing and heart rate? a. Spinal cord b. Cerebrum c. Brain stem d. Cerebellum 21

22 Post Test 3. All are signs of basilar skull fracture except: a. Raccoon's eyes b. Levine s sign c. Battle s sign d. Halo sign Post Test 4. Which type of brain injury has a quick onset with rapid deterioration? a. Epidural hematoma b. Concussion c. Subdural hematoma d. Intracellular injury Post Test 5. Cushing s Triad has all the following except: a. Increased blood pressure b. Decreased heart rate c. Irregular breathing rate d. Decreased blood pressure 22

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