1 / 27

Management of Closed Head Injuries in an Austere Environment

Explore pathophysiology, intracranial pressure, TBI severity, skull fractures, brain bleeds, and treatment strategies in challenging environments. Learn evaluation, classification, and evacuation suggestions.

wwilkinson
Download Presentation

Management of Closed Head Injuries in an Austere Environment

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Management of Closed Head Injuries in an Austere Environment 1LT Greg Nix, APA-C //UNCLASSIFIED//

  2. Overview • Pathophysiology of an injured brain • Intracranial Pressure • TBI • Mild/Mod/Severe • Skull Fx • Brain Bleeds • Diffuse Axonal Inj. • Eval & Tx • Evacuation suggestions //UNCLASSIFIED//

  3. Pathophysiology of Brain Inj. -Terms: • CPP Cerebral Perfusion Pressure • CBF Cerebral Blood Flow • Auto regulation • MAP Mean Arterial Pressure • ICP Intracranial Pressure //UNCLASSIFIED//

  4. Intracranial Pressure • Pressure changes • Increase • Decrease • Cushing's Reflex (triad) • HTN • Bradycardia • Irregular Respirations //UNCLASSIFIED//

  5. Specific Injuries • TBI • Head trauma + AMS/LOC/PTA • Mild (Concussion) • Mod • Severe • Skull Fx • Brain Bleeds • Diffuse Axonal Injuries //UNCLASSIFIED//

  6. TBI • Mild/Concussion • Classification: LOC < 30m, AMS < 1d, PTA < 1d • s/sx: • HA/Vis disturb/N/V/Irritability • GCS: 14-15 • Dx: • Physical exam & MACE • Tx: • Supportive, brain rest, monitor //UNCLASSIFIED//

  7. TBI • Moderate • Classification: LOC 30m24hrs, AMS >1d, PTA 1-7d • s/sx: • HA/Vis disturb/N/V/Irritability • GCS: 9-13 • Dx: • AMS, PTA/RTA, MACE • Tx: • +/- Airway, Supportive, +/- Evac, Brain rest, non-operational //UNCLASSIFIED//

  8. TBI • Severe • Classification: LOC > 24hrs, AMS > 24hrs, PTA > 7d • s/sx: • HA/Vis disturb/N/V/Irritability • GCS: <9 • Dx: • AMS, PTA/RTA, MACE • Tx: • RSI Airway, ASAP Evac, Brain rest, non-operational //UNCLASSIFIED//

  9. Skull Fx • Linear & Comminuted • s/sx: • May be obvious or occult • Basilar • Ascending/Descending point of many vessels & nerves. • s/sx: • Raccoon eyes, Battle signs, CSF leak, CN def. • Tx: • Airway, Supportive, ASAP Evac //UNCLASSIFIED//

  10. //UNCLASSIFIED//

  11. Brain Bleeds • Cerebral Contusion • s/sx: • Exaggerated Concussion sx • Intracerebral Hemorrhage • Focal Neuro def. often present • Pt may have residual effects • Dx: • RTA/PTA without resolution • AMS • Tx: • +/- Airway, Supportive, ASAP evac //UNCLASSIFIED//

  12. Brain Bleeds • Subarachnoid Hemorrhage (SAH) • s/sx: (often sudden/aneurysm) • Profound photophobia, HA, N/V • Textbook: “Worst HA of life” • Dx: • Abrupt onset of sx mod/severe TBI • Tx: • Control BP do not allow to exceed 140 Syst. • CCB & CT would be preferred but prob not avail. (Nimodipine to stop vasospasm. Vasospasm stops flow to brain) • Airway & Evac! //UNCLASSIFIED//

  13. Brain Bleeds • Epidural Hematoma • s/sx: • MOI: blast/fall, sports, MVA • Probable skull fx • Middle Meningeal Artery! • HA, AMS, Sz • Dx: • S/sx, MOI, LOC with lucid interval • Tx: • EVAC! Be prepared for RSI! • Control Sz //UNCLASSIFIED//

  14. Brain Bleeds • Subdural Hematoma (SDH) • s/sx: • LOC, AMS • Becomes sx within x14d • Dx: • Acceleration/Deceleration MOI • Increase of sx over period of time • Venous Hemorrhage • Tx: • Evac, CT • Beware of death within x14d; usually 72hrs. //UNCLASSIFIED//

  15. Diffuse Axonal Injury (DAI) • s/sx: • Sudden LOC/Unresponsive • Shearing MOI • Dx: • MOI, Prolonged unresponsiveness • Tx: • Respectful care, Irreversible. //UNCLASSIFIED//

  16. //UNCLASSIFIED//

  17. Pt Eval/Exam • Eval • Determine MOI, Level of consciousness • PE & HEENT • MACE/AVPU/GCS • Cognition • Coordination • CN II-XII exam • Look for focal deficits //UNCLASSIFIED//

  18. Pt Eval/Exam • Ultrasound of Ocular nerve sheath • Place tegaderms over pt’s eyes • Visualize the Optic nerve • Approx x3mm from the globe, the nerve should be 5mm in width • 3x5 • >5mm = increased ICP • Watch if tx are efficacious!!!!! //UNCLASSIFIED//

  19. Interventions • Packaging • Trendelenburg 30-45* • Increases venous flow • non-constricting C-spine protection • Temp • Increased ICP pts tend to have elevated temps • Increased metabolic needs!!! • Keep pt cool • Fluids • Isotonic vs. Hypotonic //UNCLASSIFIED//

  20. Interventions • Diuretics • Mannitol • Decreases ICP via Increasing Outflow and stimulating Autoregulation • 1g/kg • Use Foley to measure pt’s outflow… • Replace fluids to avoid HoTN(hypotension) • Best used for HTN pts with increased ICP //UNCLASSIFIED//

  21. Interventions • Diuretics • Hypertonic Saline 3% • Increases CO2 • Increases Na+ gradient • Decreases ICP by pulling fluid • Admin 250mg over 10min • Best utilized in nml/HoTN pts //UNCLASSIFIED//

  22. Interventions • RSI: • Succinylcholine • Etomidate/Ketamine/Propofol • Steroid use • No longer used • Especially not used with hemorrhage • CO2 • Watch End-tidal carefully • 33-38 ideal //UNCLASSIFIED//

  23. Interventions • Hyperventilation? • No longer advocated due to ischemia • Still acceptable with s/sx of Herniation. • Life > perm. Adverse effects • Pain Control • Fentanyl/Ketamine • Helps prevent excess metabolic needs //UNCLASSIFIED//

  24. To Evac, or Not to Evac? • PECARN/New Orleans Trial //UNCLASSIFIED//

  25. Case Study • GSWface • Massive post. Neck bleed • Unresponsive • Anisocoric • No Resp. drive • Tachycardic //UNCLASSIFIED//

  26. References • Auerbach, Paul S., Howard J. Donner, and Eric A. Weiss. "Head Injury." Field Guide to Wilderness Medicine. 4th ed. St. Louis: Mosby, 1999. 139-44. Print. • Lenhart, Martha K., Eric Savitsky, and Brian Eastridge. "Traumatic Brain Injury Management." Combat Casualty Care: Lessons Learned from OEF and OIF. N.p.: n.p., n.d. 33-378. Print. • "Medicolegal Visuals." Medical Illustrator Medical Illustration Scientific Illustration. N.p., n.d. Web. 20 Feb. 2015. • "Minor Head Trauma in Infants and Children: Evaluation." Minor Head Trauma in Infants and Children: Evaluation. UpToDate.com, 17 Oct. 2014. Web. 20 Feb. 2015. • Papadakis, Maxine A., Stephen J. McPhee, and Michael W. Rabow. Current Medical Diagnosis & Treatment 2014. 2014 ed. N.p.: n.p., n.d. Print. • "Pictures." TeachMeAnatomy. N.p., n.d. Web. 20 Feb. 2015. • "Subarachnoid Hemorrhage vs. Subdural Hematoma." Galleryhip.com Images of Hemorrhage Types. N.p., n.d. Web. 20 Feb. 015. • Swisher, Linda, and Kevin T. Patton. Study and Review Guide to Accompany Anatomy & Physiology, 7th Edition: Kevin T. Patton, Gary A. Thibodeau. 7th ed. St. Louis, MO: Mosby Elsevier, 2010. Print. • Tintinalli, Judith E., Gabor D. Kelen, and J. Stephan. Stapczynski. "Ch. 255 HEAD INJURY." Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York: McGraw-Hill, Medical Pub. Division, 2004. 1557-569. Print. • "Welcome - EMCrit CME Site." EMCrit CME Site. N.p., n.d. Web. 21 Feb. 2015. //UNCLASSIFIED//

  27. QUESTIONS? //UNCLASSIFIED//

More Related