Case Presentation and Discussion on Craniofacial Injury

1. Case Presentation and Discussion on Craniofacial Injury Jeffy G. Guerra, MD Level III Surgery Resident Department of Surgery Ospital ng Maynila Medical Center 24 January 2006

2. General Data: B.A 6-year-old female Sta. Ana, Manila

3. Chief Complaint: “Loss of consciousness”

4. History of the Present Illness: Eight hours PTA Patient while riding on her bicycle was allegedly hit by a moving vehicle sustaining head injury (+) Loss of consciousness, (+) Vomiting 2x apparently recovered no consult, no meds taken

5. History of the Present Illness: One hour PTA Patient became lethargic and had an episode of vomiting Consult

6. Primary Survey for Trauma • Airway – intact no obstruction • Breathing – spontaneous, clear breath sounds • Circulation – BP = 90/50, HR = 90, RR 18

7. Primary Survey for Trauma • Deficits/Deformity – GCS= 13, no limb deformities • Exposure – none, cleared from site of injury motor sensory DTR

8. Initial Neurological Evaluation • GCS 13 (E3V4M6) • PERL 2-3mm • Full extraocular eye movement • No motor deficits on all extremities • (+) hematoma, Parietal area, right

9. Physical Examination

10. Cerebrum: drowsy Cerebellum: n/a E3M6V4 GCS= 13 Neurological Exam Cranial Nerves: I n/a II-III PERTL III,IV,VI Full EOMs V (+) bicorneal reflex VII no facial assymetry VIII (+) auditory stimulus IX, X (+) gag reflex XI Shrug shoulders XII no tongue deviation

11. Neurological Exam • Pathologic Reflex: (-) Babinski motor sensory DTR

12. Past Medical History: No previous hospitalization No other pertinent medical condition Family History Unremarkable

13. Growth and Development Patient’s development at par with age Immunization History Complete Immunization

14. Salient Features 6-year-old female (+) Loss of consciousness* (+) Lucid interval* (+) Vomiting GCS= 13 (+) hematoma, parietal area, right

15. Head Injury ↓ Traumatic Hematoma ↓ ↓ Epidural * Intradural ↓ ↓ Subdural* Intracerebral *Jamieson, KG (epidural: 50%, intradural: 45%)

16. Clinical Diagnosis

17. Ensure Airway: Intubate for GCS<9 Ensure breathing: Keep O2 Saturation >94% Surgeon directed trauma team initial evaluation of Head Injury Ensure Circulation: Keep Systolic BP >100mmHg Signs of Elevated ICP? (increasing obtundation, dilated pupils) No GCS<15, Prolonged LOC, or Focal Neuro Signs? Yes Observation, other studies as necessary No Yes Hyperventilation to PaCO2 30-35mmHg<2 hours) Mannitol 1g/kg Consider IVC placement Consider hypertonic NaCl Consider barbiturate therapy Head CT Scan Normal Abnormal Consult Neuro Surgery Surgical Lesion? No Yes Admit to ICU Operating Room

18. Paraclinical Diagnostic Procedure Do I need a paraclinical diagnostic procedure? yes

19. Goal • Determine location and size of hematoma, and accompanying brain injury • Determine treatment plan

20. PARACLINICAL DIAGNOSTIC PROCEDURE

21. CT Scan

22. CT Scan Result • There is a lentiform hyperdense focus in the right occipital convexity, measuring about 2.26 x 4.27 cm • No shift in the midline • No fracture EPIDURAL HEMATOMA, RIGHT OCCIPITAL CONVEXITY

23. Pre-Treatment Diagnosis Epidural Hematoma, right occipital area secondary to Vehicular accident

24. Ensure Airway: Intubate for GCS<9 Ensure breathing: Keep O2 Saturation >94% Surgeon directed trauma team initial evaluation of Head Injury Ensure Circulation: Keep Systolic BP >100mmHg Signs of Elevated ICP? (increasing obtundation, dilated pupils) No GCS<15, Prolonged LOC, or Focal Neuro Signs? Yes Observation, other studies as necessary No Yes Hyperventilation to PaCO2 30-35mmHg<2 hours) Mannitol 1g/kg Consider IVC placement Consider hypertonic NaCl Consider barbiturate therapy Head CT Scan Normal Abnormal Consult Neuro Surgery Surgical Lesion? No Yes Admit to ICU Operating Room

25. Critical Factors for Surgical evacuation • Patient’s neurologic status • Imaging findings • Extent of extracranial injury

26. Indications for Surgical Evacuation • Subdural or epidural hematoma • >5mm thick • Midline shift • GCS<8

27. Controversial groups needing evacuation • Subdural or epidural hematoma • 5-10mm thick • GCS of 9 - 13

28. Goals of Treatment • Complete evacuation of hematoma • Resolution of neurologic deficit • Prevention of complications of herniation

29. Treatment Options *Laboto et al

30. Treatment Plan Craniotomy Evacuation of Hematoma

31. Pre-operative Preparation • Informed consent -Plan Carefully explained to relatives • Psychosocial support • Optimize patient’s health - Resuscitation • Screen for any condition that will interfere with treatment • Prepare materials for OR

32. Operative Technique • Patient supine under GETA • Asepsis/Antisepsis • Sterile drapes placed • Skin Incision carried from temporo-parietal area • Initial burr hole made over the temporal bone with a cone-shaped burr • Bone between burr holes were cut using a Gigli saw • Bone flap raised

33. Intraop Findings • Upon opening, noted a 50ml reddish to brown fluid at the occipital epidural layer.

34. Operative Technique • Hematoma evacuated • NSS wash • Hemostasis assured • Correct instrument and sponge count • Temporo-pareital bone fixed • JP drain placed • Closure of the scalp using Silk 3-0 • Dry sterile dressing • Patient tolerated the procedure

35. Operation Done Craniotomy Evacuation of Epidural Hematoma

36. Final Diagnosis Epidural Hematoma, occipital area, R secondary to Vehicular Accident Operation done Craniotomy Evacuation of Hematoma

37. Post-operative Management • Basic needs supplied • Antibiotics • Analgesia • Comfort • VS and NVS monitoring • Patient maintained on NPO

38. Post-operative Management • 1st HD NPO, mannitol 135 ml of PRBC was Transfused • 3rd HD GCS= 15 NGT, drain and Foley Cath removed, mannitol taperd • 5th HD DAT, D/C

39. Follow Up care • 1 week after discharge for ROS • 4 weeks after discharge to asses for any neurological changes

40. Sharing of Knowledge BRAIN -- invested by various membranes floated in a clear fluid and encased in a bony vault -- 1,200 – 1,400G -- 2% - 3% TBW

41. 3 Membranes Dura matter -- pachymaninx -- outermost layer Arachnoid -- middle layer -- delicate non vascular membarne Pia matter -- innermost layer -- follows contour of the brain * Leptomeninges- arachnoid and pia matter

42. Cerebro Spinal Fluid -- Clear colorless fluid -- containing small amount of CHON, glucose and potassium -- serves as support and cushion of the CNS against Trauma

43. Head Injuries- most common cause of traumatic death in children Main Causes: - Falls - Motor vehicular crashes - Pedestrian accidents - Bicycle injuries - Other injuries

44. Pathophysiology • Brain swelling • Increase mass effect • Increase Intracranial Pressure • Compromised brain perfussion • Herniation of brain tissue across the tentorium, falx or through the foramen magnum causing significant morbidity and often death

45. Moderate to Severe Head Injuries -- usually present in obtunded or combative state -- Late clinical Findings: unequal and non reactive pupils focal neurologic findings abnormal posturing

46. In-hospital resuscitation and evaluation of moderate head injuries • Rapid, systematic manner with diagnostic and therapeutic maneuvers proceeding simultaneously • ABC’s of Trauma (airway, ventilation, preventing hypoxia and hypotension)

47. Initial neurologic evaluation and management • In moderately injured, examination is abbreviated and should focus on • Level of consciousness • Pupillary light reflex • Extraocular eye movement • Motor examination • Head should be palpated • Signs of basal skull fracture(otorrhea)

48. Triad suggestive of transtentorial herniation • Deteriorating level of consciousness • Pupillary dilatation • Hemiparesis • Neurological exam: unreliable in accurately predicting intracranial pathology, tomography is usually indicated

49. Criteria for CT scanning following craniocerebral trauma • GCS 14 or less • GCS 15 with the following • Documented loss of consciousness • Focal neurologic deficit • Signs of basal skull fracture

50. Skull radiography and angiography • In the absence of CT scan, skull radiographs are helpful • Fractures are seen on • Epidural hematoma 66-100% • Subdural 18-60% • Intracerebral 40-80% • Presence of skull fracture, although suggestive of hematoma is not a reliable indicator of the type of intracranial injury