Management of Closed Head Injuries in an Austere Environment - PowerPoint Presentation

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

Overview Pathophysiology of an injured brain Intracranial PressureTBI Mild/Mod/Severe Skull FxBrain BleedsDiffuse Axonal Inj.Eval & TxEvacuation suggestions //UNCLASSIFIED// 2

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

Intracranial Pressure Pressure changes Increase Decrease Cushing's Reflex (triad) HTN BradycardiaIrregular Respirations//UNCLASSIFIED//4

Specific Injuries TBIHead trauma + AMS/LOC/PTA Mild (Concussion) Mod SevereSkull FxBrain BleedsDiffuse Axonal Injuries //UNCLASSIFIED//5

Mild/ConcussionClassification: LOC < 30m, AMS < 1d, PTA < 1d s/ sx: HA/Vis disturb/N/V/Irritability GCS: 14-15Dx: Physical exam & MACETx: Supportive, brain rest, monitorTBI //UNCLASSIFIED// 6

TBI ModerateClassification: LOC 30m 24hrs , AMS >1d, PTA 1-7ds/sx:HA/Vis disturb/N/V/IrritabilityGCS: 9-13 Dx: AMS, PTA/RTA, MACE Tx: +/- Airway, Supportive, +/- Evac, Brain rest, non-operational //UNCLASSIFIED// 7

TBI SevereClassification: LOC > 24hrs, AMS > 24hrs, PTA > 7ds/sx:HA/Vis disturb/N/V/IrritabilityGCS: <9Dx: AMS, PTA/RTA, MACE Tx: RSI Airway, ASAP Evac, Brain rest, non-operational //UNCLASSIFIED// 8

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//9

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Brain Bleeds Cerebral Contusion s/sx: Exaggerated Concussion sx Intracerebral HemorrhageFocal Neuro def. often presentPt may have residual effectsDx: RTA/PTA without resolutionAMSTx: +/- Airway, Supportive, ASAP evac //UNCLASSIFIED// 11

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 TBITx: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// 12

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

Brain Bleeds Subdural Hematoma (SDH) s/sx: LOC, AMS Becomes sx within x14d Dx: Acceleration/Deceleration MOIIncrease of sx over period of timeVenous Hemorrhage Tx:Evac, CTBeware of death within x14d; usually 72hrs.//UNCLASSIFIED// 14

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

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Pt Eval/Exam EvalDetermine MOI, Level of consciousness PE & HEENT MACE/AVPU/GCS Cognition CoordinationCN II-XII examLook for focal deficits//UNCLASSIFIED//17

Pt Eval/Exam Ultrasound of Ocular nerve sheathPlace tegaderms over pt’s eyes Visualize the Optic nerveApprox x3mm from the globe, the nerve should be 5mm in width3x5>5mm = increased ICPWatch if tx are efficacious!!!!! //UNCLASSIFIED// 18

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

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

Interventions Diuretics Hypertonic Saline 3% Increases CO2 Increases Na+ gradient Decreases ICP by pulling fluidAdmin 250mg over 10minBest utilized in nml/HoTN pts//UNCLASSIFIED// 21

Interventions RSI:Succinylcholine Etomidate /Ketamine/ Propofol Steroid useNo longer used Especially not used with hemorrhageCO2Watch End-tidal carefully33-38 ideal//UNCLASSIFIED// 22

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

To Evac, or Not to Evac? PECARN/New Orleans Trial Normal mental status No LOC No severe mechanism of injury No vomiting No severe headache No signs of basilar skull fracture No Injuries superior to clavicles //UNCLASSIFIED// 24

Case Study GSW faceMassive post. Neck bleed Unresponsive Anisocoric No Resp. driveTachycardic//UNCLASSIFIED//25

ReferencesAuerbach, 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// 26

QUESTIONS? //UNCLASSIFIED// 27