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Primary Trauma Care

Primary Trauma Care. 1. 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

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Primary Trauma Care

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  1. Primary TraumaCare 1

  2. 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

  3. Head 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 121

  4. Head TraumaApproach Airway Breathing Circulation 122

  5. 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

  6. Breathing • 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

  7. Circulation • 1- prehospital : avoid SBP < 90 mmHg • 2- maintain MAP > 90 mmHg to maintain CPP >60 mmHg • 3- Fluid : infuse 0.9 NaCl & or blood

  8. Head TraumaPhysiology CPP = MAP - ICP CPP = cerebral perfusion pressure MAP = mean arterial pressure ICP = intracranial pressure 123

  9. Cerebral Blood FlowDepends on: • CPP (MAP-ICP) • PaCO2 • PaO2 • Local metabolites 124

  10. Intracranial Pressure (ICP) • 10 mm Hg = Normal • > 20 mm Hg = Abnormal • > 40 mm Hg = Severe • Sustained ICP leads to brain function and outcome

  11. cerebral Perfusion Pressure MBP - ICP = CPP • Normal 90 - 10 = 80 • Cushing’s 100 - 20 = 80 Response • Hypotension 50 - 20 = 30

  12. Treatment • Minimize secondary brain injury • - ABCDE • - Maintain CPP • - Maintain blood pressure (systolic > 90 mm Hg) • - Reduce ICP

  13. Treatment • Maintain MAP • – Euvolaemic fluid resuscitation • – Isotonic fluids • – Inotropes

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

  15. Treatment • Mannitol • Use with signs of tentorial herniation • Dose: 1.0 g / kg IV bolus Consult with neurosurgeon first

  16. Head TraumaPathophysiology • Primary Injury • occurs at time of injury • Secondary Injury • occurs after injury • may be preventable 125

  17. Head Trauma Primary injury • Diffuse axonal injury • - Acceleration • - deceleration • Cerebral contusion • Penetrating injury 126

  18. Head Trauma Secondary injury • Hypoxia • Hypoperfusion (↑ ICP, ↓ MAP) • Hypoglycaemia • Hyperthermia (fever) • Seizures 127

  19. Head TraumaInitial assessment Airway (+ C-spine) Breathing Circulation Disability (AVPU, pupils) Exposure 128

  20. Head TraumaExamination • Glasgow Coma Score • Pupils • Corneal reflex • Eye position • Fundi 129

  21. Head TraumaExamination • Tympanic membrane • Scalp and skull • Respiratory Pattern • Muscle tone • Posture • Tendon reflexes 130

  22. Head Trauma 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 131

  23. Head Trauma GCS Eye opening Open spontaneously 4 Open to command 3 Open to pain 2 None 1 132

  24. Head Trauma GCS Best Verbal Response Oriented 5 Confused 4 Inappropriate words 3 Inappropriate sounds 2 None 1 133

  25. Head TraumaGCS Best Motor Response Obeys command 6 Localises to pain 5 Withdraws to pain 4 Abnormal flexion 3 Extensor response 2 None 1 134

  26. Head Trauma Severity of Head Injury Severe GCS <8 Moderate GCS 9-12 Minor GCS 13-15 135

  27. Head Trauma Pupillary signs • Size • Reactivity • Equality 136

  28. Fixed, dilated, unresponsive Severe hypoxia Hypothermia Seizures Head Trauma Pupillary responses 137

  29. Unilateral, dilated, unresponsive Expanding lesion on same side Tentorial herniation Seizures Head Trauma Pupillary responses 138

  30. Head TraumaAcute extradural or subdural • Potentially life-threatening • Immediate recognition essential • Require burr-hole decompression 139

  31. Head TraumaAcute extradural • LOC → lucid interval → deterioration • Middle meningeal artery bleed • Overlying skull fracture • Contralateral hemiparesis • Fixed pupil on side of injury 140

  32. Head TraumaAcute subdural • Tearing of bridging vein between cortex and dura • Underlying brain injury • Usually no lucid interval • Worse prognosis than extradural haematoma 141

  33. Head TraumaOther injuries • Base-of-skull fractures • Cerebral concussion • Depressed skull fracture • Intracerebral haematoma Usually do not require neurosurgery 142

  34. Head TraumaManagement Airway Breathing (ventilation) Circulation + Avoid ↑ ICP Aim to prevent secondary injury 143

  35. Head TraumaSevere (GCS<8) • Intubate • Normal CO2 • Treat hypotension with fluid • Sedation +/- paralysis 144

  36. Head TraumaSevere (GCS<8) • Nurse head up 20o • Prevent hyperthermia • Complete secondary survey • Reassess frequently 145

  37. Head TraumaBeware • Deteriorating conscious state • Penetrating injury • Focal neurological signs - unequal, dilated pupils - seizures - posturing 146

  38. Head Trauma ? 147

  39. Head Trauma Summary • ABCs • Prevent secondary injury • Isolated head trauma doesn’t cause hypotension • Look for other injuries • Deterioration → reassess 148

  40. Spinal Trauma Objectives • To understand the structured approach to the patient with spinal trauma • To learn how to identify serious and life-threatening spinal injuries 149

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