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CDR JOHN P WEI, USN MC MD 4th Medical Batallion, 4th MLG BSRF-12

CRANIO-CEREBRAL AND SPINAL CORD INJURIES. CDR JOHN P WEI, USN MC MD 4th Medical Batallion, 4th MLG BSRF-12. INTRODUCTION. Current military actions with high risk for neurologic trauma to head and spinal cord Isolated blunt force trauma Penetrating trauma

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CDR JOHN P WEI, USN MC MD 4th Medical Batallion, 4th MLG BSRF-12

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  1. CRANIO-CEREBRAL AND SPINAL CORD INJURIES CDR JOHN P WEI, USN MC MD 4th Medical Batallion, 4th MLG BSRF-12

  2. INTRODUCTION • Current military actions with high risk for neurologic trauma to head and spinal cord • Isolated blunt force trauma • Penetrating trauma • Combination of blunt and penetrating injuries

  3. TRAUMATIC BRAIN INJURY Closed head injury: an object or an external force has sufficient energy to damage brain tissue Open head injury: an object pierces the skull and enters the brain or when blunt force fractures the bony skull with soft tissue disruption

  4. TYPES OF BRAIN INJURIES Closed head injury Contusion / concussion Coup / Contre-Coup Cerebral edema Diffuse axonal injury Open head injury Gunshot wound Stab wound Compound skull fracture

  5. COMPLEX HEAD TRAUMA

  6. MANAGEMENT IN FIELD • Airway • Breathing • Circulation • Disposition • Cervical spine immobilization • Stop on going bleeding • Splint or bandage extremity injuries

  7. EPIDURAL HEMATOMA

  8. Guidelines for Prehospital Management of TBI • Aggressive airway management, hyperventilation (but not mannitol) only if signs of  ICP or herniation • Fluid resuscitation / glucose to achieve euvolemia / glycemia

  9. MANAGEMENT OF SEVERE BRAIN INJURY • Maintain MAP>90. • Hyperventilate only if neurologic deterioration • Mannitol (0.25-1gm/kg) if neurologic deterioration • No glucocorticoids • While awaiting surgery, Propofol vs LA NMB depending on MAP

  10. CONTUSION AND IPARENCHYMAL HEMMORHAGE

  11. TRANSCRANIAL GUNSHOT WOUND

  12. INCREASED INTRACRANIAL PRESSURE • The volume of the skull is a constant and contains: • Brain • Blood • CSF • An increase in the volume of any of these will raise intracranial pressue.

  13. INCREASED INTRACRANIAL PRESSURE • Initial ICP rises as volume is added (CSF and then blood exits the skull) • As volume increases, compliance worsens and ICP rises rapidly: • Arterial blood flow is impaired, producing ischemia • Focal increases in volume also cause herniation from high pressure compartments to lower pressure ones

  14. HERNIATION

  15. INCREASED INTRACRANIAL PRESSURE • Management • Correct the underlying pathology with surgery if possible • Airway control and prevention of hypercapnea • When intubating patients with elevated ICP use thiopental, etomidate, or intravenous lidocaine to blunt the increase in ICP associated with laryngoscopy and tube passage • ICP monitoring needed to guide therapy

  16. INCREASED INTRACRANIAL PRESSURE • Avoid jugular vein compression • Head should be in neutral position • Cervical collars should not be too tight • Elevate head and trunk to improve jugular venous return • Zero the arterial pressure transducer at the ear to measure the true cerebral perfusion pressure when the head is above the heart

  17. INCREASED INTRACRANIAL PRESSURE • Hyperventilation (PaCO2 < 35 mmHg) works by decreasing blood flow and reserved for emergency treatment and for brief periods • The major determinant of arteriolar caliber is the extracellular pH not measured PaCO2

  18. INCREASED INTRACRANIAL PRESSURE • Pharmacologic options • Mannitol 0.25 gm/kg q4h (may need to increase dose over time) • Hypertonic saline (requires central line) • 3% • 7.5% • 23.4% (30 mL over 10 min) • Steroids not for use in trauma

  19. INCREASED INTRACRANIAL PRESSURE Sedation to decrease cerebral metabolic rate • Benzodiazepines • Propofol Requires autoregulation, which often fails in patients with elevated ICP Often causes drop in MAP, impairing cerebral perfusion and thus requiring vasopressors (e.g., norepinephrine)

  20. INCREASED INTRACRANIAL PRESSURE • Neuromuscular junction blockade • titrate with train-of-four stimulator to 1 or 2 twitches • High-dose barbiturates • pentobarbital 5 – 12 mg/kg load followed by infusion to control ICP

  21. INCREASED INTRACRANIAL PRESSURE • Surgical options • Evacuate hematoma • Ventriculostomy to drain CSF • Resection of brain tissue, i.e. temporal lobectomy • Craniectomy • - Lateral for focal lesions • - Bifrontal for diffuse swelling

  22. CRANIOTOMY

  23. Secondary Injury in Head Trauma • Hypoxia and hypotension are the 2 major causes of secondary CNS injury following head trauma • Even in intensive care these complications occur frequently • Preventing hypoxia and hypotension could have the greatest effect of any available treatment for head trauma

  24. DIFFUSE AXONAL SHEAR • Process triggered by the injury that takes about 24 hours to develop • May occur without any radiographic abnormality • Seen in areas of radiographically apparent “shear injury”, usually occurs at the grey-white junction • Often with negative CAT scan, and will require MRI

  25. DIFFUSE AXONAL SHEAR

  26. TREATMENT OF BRAIN INJURY • Antiseizure drugs • phenytoin 20 mg/kg • Keppra 1000 mg/day • Nutrition and GI bleeding prophylaxis • Thromboembolism prophylaxis

  27. SPINAL CORD INJURIES • ABCs • If intubation needed, use in-line stabilization • Maintain blood pressure with volume, packed RBCs, vasopressors as needed • Prevent secondary injury • C-spine immobilization with C-collar • Log-rolling • Consider concomitant head injury

  28. SPINAL CORD INJURIES

  29. SPINAL CORD INJURIES

  30. COMPLETE SPINAL CORD INJURY • Loss of all function below level of the lesion • Typically associated with spinal shock

  31. INCOMPLETE SPINAL CORD INJURY • Central cord syndrome • Anterior cord syndrome • Brown-Sequard syndrome • Spinal cord injury without radiologic abnormality (SCIWORA)

  32. SECONDARY INJURY TO SPINAL CORD • After the initial macroscopic injury, secondary injuries are an important cause of disability: • Movement of unstable spine • Vascular insufficiency

  33. SPINAL CORD INJURIES AND THE CARDIOVASCULAR SYSTEM • “Spinal” shock • Acute loss of tendon reflexes and muscle tone below the level of spinal cord lesion • Neurogenic hypotension is very common and can be profound with spinal cord lesions above T1 • Hypotension in spinal shock accompanied by bradycardia

  34. SPINAL CORD INJURIES AND THE CARDIOVASCULAR SYSTEM • Treat hypotension with volume expansion • If conscious, making urine, and lactate is decreasing, MAP is adequate • Neurogenic pulmonary edema common in cervical spinal cord injuries • May develop pulmonary vascular redistribution and interstitial edema

  35. SPINAL CORD INJURIES AND THE CARDIOVASCULAR SYSTEM • Suspect associated injuries: • symptoms and physical findings absent due to the spinal cord injury • Resuscitation cannot be guided by physical findings: • Hypotension and bradycardia persist regardless of the volume of administered • Replace the missing adrenergic tone with -agonists (phenylephrine or norepinephrine depending on heart rate)

  36. SUMMARY • Trauma to head and spinal structures common in current military actions • Combination of blunt and penetrating injuries • Consideration for early medical intervention from field to definitive treatment center • Surgical intervention at earliest time

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