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![History
Mechanism of injury and detailed description of the injury
• loss of consciousness, amnesia, lucid periods
• seizures, confusion, deterioration in mental status
• vomiting or headache
Drug or alcohol use
• current intoxication: shown to have an increased association with
intracranial injury detected on CT[89]
• chronic: associated with cerebral atrophy, thought to increase risk of
shearing of bridging veins
• Past medical history, including any CNS surgery, past head trauma,
haemophilia, or seizures
• • Current medications including anticoagulants
• Age: TBI in older age has a poorer outcome in all subgroups](https://image.slidesharecdn.com/newmicrosoftpowerpointpresentation-151014071236-lva1-app6892/75/evaluation-of-patient-with-head-trauma-17-2048.jpg)
![Physical examination
Head and neck
• inspection for cranial nerve deficits, periorbital or
postauricular ecchymoses, CSF rhinorrhoea or
otorrhoea,haemotympanum (signs of base of skull fracture)
• fundoscopic examination for retinal haemorrhage (sign of
abuse)[90] and papilloedema (sign of increased
ICP)
• palpation of the scalp for haematoma, crepitance,
laceration, and bony deformity (markers of skull fractures)](https://image.slidesharecdn.com/newmicrosoftpowerpointpresentation-151014071236-lva1-app6892/75/evaluation-of-patient-with-head-trauma-18-2048.jpg)
Uploaded bybarun kumar
evaluation of patient with head trauma
The document provides an overview of evaluating and managing a patient with head injury. It discusses initial assessment according to ATLS guidelines focusing on airway, breathing, and circulation. It also covers neurological assessment including Glasgow Coma Scale and pupil examination. Indications for CT scan and referral to a trauma center are outlined. Management goals include maintaining adequate oxygenation, ventilation, blood pressure, ICP and CPP. Further management may involve therapies such as hyperosmolar treatment, hypothermia, nutrition, antiseizure medications, and antibiotics.
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Introduction to the evaluation process of a patient with head injury by Dr. Barun Kumar.
Estimates of head injury cases in India; 5-10 lakh cases yearly, 20% severe, and 1.5 lakh deaths.
Initial assessment adhering to ATLS guidelines focusing on airway, breathing, and circulation.
Techniques for airway management including intubation indications and goals for oxygenation.
Managing breathing issues and circulation goals including SBP maintenance to prevent brain injury.
Importance of immediate care and transport to a trauma center for better prognostic outcomes.
Quick evaluation methods such as Glasgow Coma Scale and pupil examination for neurological status.
Classification of traumatic brain injury based on GCS scores: mild, moderate, and severe.
Norms for pupil size, symmetry, reflexes, and implications of abnormal findings on ICP.
Mechanism of injury details, substance use, past medical history, and current medications affecting TBI.
Examination of head and neck for signs like ecchymosis and assessing neurological function.
Baseline lab tests required for TBI including CBC, electrolytes, glucose, and coagulation status.
Criteria for performing CT scans in TBI cases based on GCS scores and symptoms.
Indications for referral to trauma centers based on clinical assessment and worse outcomes.
Classification of traumatic brain injuries including fractures, hemorrhage types, and injury details.
Methods for calculating and monitoring intracranial pressure and its importance in TBI management.
Targets for ICP management emphasizing maintaining CPP and ICP below critical levels.
Listing additional management strategies for TBI patients like nutrition, hypoxia management, and more.
Citing texts and guides used for creating protocols and recommendations for head injury care.
Final thanks and conclusion of the presentation on head injury evaluation.
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evaluation of patient with head trauma
- 1. EVALUATION OF APATIENT WITH HEAD INJURY DR. BARUN KUMAR
- 2. Epidemiology • Estimated 5-10lakh cases of head injury every year • 20% moderate to severe • 1.5 lakh trauma deaths • 50% attributable to head trauma
- 3. Initial assessment • Theinitial management is in accordance to ATLS guidelines. • A - airway • B - breathing • C - circulation
- 4. Airway • Manual manoeuvres(chin lift, jaw thrust,recovery position, etc.) • Insertion of oral or nasal airway • Use of suction • Assisted ventilation using bag–valve–mask • Endotracheal intubation • Cricothyroidotomy (with or without tracheostomy)
- 5. Airway • Goals • MaintainSPO2 > 90% • Maintain PaO2 > 60mmHg
- 6. • Indication forintubation Indication for intubation Unable to maintain airway GCS ≤ 8 Loss of protective laryngeal reflexes Unstable facial bone # Bleeding into mouth Seizures Ventilatory insufficiency Spontaneous hyperventilation Irregular respiration
- 7. Breathing • Assessment ofrespiratory distress and adequacy of ventilation • Administration of oxygen • Needle thoracostomy • Chest tube insertion
- 8. Circulation Goals • Maintain SBP> 90mm of Hg • Prevention of secondary brain injury
- 9. Circulation • IV crystalloid •Hypotensive resuscitation • Colloid • Blood • Component transfusion
- 10. • Transport toequipped center • Prognosis depends on initiation of primary care • Enroute management
- 11. Neurological assessment • Glasgowcoma scale --Quick ,efficient • Examination of Pupil • history
- 13. Classification by clinicalseverity • Mild/Minor TBI: GCS 13-15; mortality 0.1% • Moderate TBI: GCS 9-12; mortality 10% • Severe TBI: GCS <9; mortality 40%.
- 14. Pupil Pupil size: • Thenormal diameter of the pupil is between 2 and 5 mm, and although both pupils should be equal in size, • a 1-mm difference is considered a normal variant. • Abnormal size is noted by anisocoria: >1 mm difference between pupils
- 15. Pupil Pupil symmetry: • Normalpupils are round, but can be irregular due to ophthalmological surgeries. • Abnormal symmetry may result from compression of CNIII can cause a pupil to initially become oval before becoming dilated and fixed.
- 16. Pupil Direct light reflex: •Normal pupils constrict briskly in response to light, but may be poorly responsive due to ophthalmological medications. • Abnormal light reflex may be seen in sluggish pupillary responses are associated with increased ICP • A non-reactive, fixed pupil has <1 mm response to bright light and is associated with severely increased ICP.
- 17. History Mechanism of injuryand detailed description of the injury • loss of consciousness, amnesia, lucid periods • seizures, confusion, deterioration in mental status • vomiting or headache Drug or alcohol use • current intoxication: shown to have an increased association with intracranial injury detected on CT[89] • chronic: associated with cerebral atrophy, thought to increase risk of shearing of bridging veins • Past medical history, including any CNS surgery, past head trauma, haemophilia, or seizures • • Current medications including anticoagulants • Age: TBI in older age has a poorer outcome in all subgroups
- 18. Physical examination Head andneck • inspection for cranial nerve deficits, periorbital or postauricular ecchymoses, CSF rhinorrhoea or otorrhoea,haemotympanum (signs of base of skull fracture) • fundoscopic examination for retinal haemorrhage (sign of abuse)[90] and papilloedema (sign of increased ICP) • palpation of the scalp for haematoma, crepitance, laceration, and bony deformity (markers of skull fractures)
- 19. Physical examination • auscultationfor carotid bruits (sign of carotid dissection) • evaluation for cervical spine tenderness, paraesthesias, incontinence, extremity weakness, priapism (signs of spinal cord injury) • Extremities should receive motor and sensory examination (for signs of spinal cord injury)
- 20. Baseline laboratory investigationsshould include: • CBC including platelets • serum electrolytes and urea • serum glucose • coagulation status: PT, INR, activated PTT • blood alcohol level and toxicology screening if indicated
- 21. Indications for CTscan • eye opening only to pain or not conversing (GCS 12/15 or less) • ƒconfusion or drowsiness (GCS 13/15 or 14/15) followed by failure to improve within • at most one hour of clinical observation or within two hours of injury (whether or not intoxication from drugs or alcohol is a possible contributory factor) • ƒbase of skull or depressed skull fracture and/or suspected penetrating injuries
- 22. Indications for CTscan • ƒa deteriorating level of consciousness or new focal neurological signs • ƒfull consciousness (GCS 15/15) with no fracture but other features, eg - severe and persistent headache - two distinct episodes of vomiting • ƒa history of coagulopathy (eg warfarin use) and loss of consciousness, amnesia or any neurological feature.
- 23. Referral • Any evidenceof major brain trauma should be managed at a trauma center and a neurosurgeon. Indications for referral • GCS<15 at initial assessment for two hours and refer if GCS score remains<15 after this time) • ƒpost-traumatic seizure (generalised or focal) • ƒfocal neurological signs • ƒsigns of a skull fracture (including cerebrospinal fluid from nose or ears,haemotympanum, boggy haematoma, post auricular or periorbital bruising
- 24. • ƒloss ofconsciousness • ƒsevere and persistent headache • ƒrepeated vomiting (two or more occasions) • ƒpost-traumatic amnesia >5 minutes • ƒretrograde amnesia >30 minutes • ƒhigh risk mechanism of injury (road traffic accident, significant fall) • ƒcoagulopathy, whether drug-induced or otherwise.
- 25. TRAUMATIC BRAIN INJURY Bonefracture Intracranial hemorrhage Diffuse axonal injury Open/ closed Linear/ comminuted Depressed/ nondepressed EDH SAH Intraparenchymal hemorrhage
- 26. ASSESSMENT OF INTRACRANIAL PRESSURE CPP= MAP – ICP CPP = cerebral perfusion pressure >70mmHg in adult > 60mmHg in children ICP= Intracranial pressure Range 5mmHg (infant) to 15mmHg (adult)
- 27. ASSESSMENT OF INTRACRANIAL PRESSURE ICPshould be monitored in : • Severe head trauma (GCS= 3-8 ) • Abnormal CT scan ( hematoma, contusion, swelling , herniation, compressed basal cistern)
- 28. • A ventricularcatheter connected to an external strain gauge transducer • Alternative- intraparenchymal transducer
- 29. GOALS • ICP <20 mm of Hg • CPP > 70 mm of Hg ( < 50 is critical )
- 30. FURTHER MANAGEMENT • HYPOXIA •HYPEROSMOLAR THERAPY • HYPOTHERMIA • NUTRITION • ANTISEIZURE • HYPERVENTILLATION • ANTIBIOTICS • ANALGESIA
- 31. Refrences 1. Sabiston textbookof surgery 19th edition 2. Bailey & love’s short practice of surgery 26th ed 3. BMJ, best practice assessment of head trauma, acute 4. Guidelines for the management of severe traumatic brain injury – BRAIN TRAUMA FOUNDATION 5.GUIDELINES FOR ESSENTIAL TRAUMA CARE World Health Organization Avenue Appia 201211 Geneva 27 6.NICE guidelines head injury 7.The Brain Trauma Foundation. Prehospital Emergency Care 8.The Brain Trauma Foundation. Early indicators of Prognosis in Severe Traumatic Brain Injury. 9.The Brain Trauma Foundation. Surgical Management of TBI Author Group.
- 32.