颅脑损伤英文版

“Boy,doIhaveanExcedrinheadache!!”

managingtheheadinjuredpatientLeaugeayWebreBS,CCEMT-P,NREMT-P第1页ScenarioWhiledescendingMtHoodinOregon,Bobtumbledheadoverheels,andcametoastopdanglingoffaprecipicebyhisTelemarkskiat11,000ft.OnarrivaltheskipatrolparamedicsBob’sbreathingwassonorousandshallow,andhehadaGCSof3-4.Theonlyobviousinjuriesweretohishead.HisBPwas87/55,HR100andRR16第2页

Howshouldtheparamedicstreatthispatient?Shouldhebeintubated?Shouldhebefluidresuscitated?第3页Commonmajortrauma4millionpeopleexperienceheadtraumaannuallySevereheadinjuryismostfrequentcauseoftraumadeathGSWtocranium:75-80%mortalityAtRiskpopulationMales15-24InfantsYoungChildrenElderlyIntroductiontoHead,Facial,

&NeckInjuries第4页TIMEISCRITICALIntracranialHemorrhageProgressingEdemaIncreasedICPCerebralHypoxiaPermanentDamageSeverityisdifficulttorecognizeSubtlesignsImprovedifferentialdiagnosisImprovessurvivabilityIntroductiontoHead,Facial,

&NeckInjuries第5页ScalpStrongFlexiblemassofSkinFasciaMuscularTissueHighlyVascularHairprovidesInsulationStructuresBeneathGaleaAponeuroticaBetweenscalpandskullFibrousconnectivesheathSubaponeurotica(Areolar)TissuePermitsvenousbloodflowfromtheduralsinusestothevenousvesselsofscalpEmissaryVeins:PotentialrouteforInfectionAnatomy&Physiology

oftheHead第6页ParietalSutureLineFrontalTemporalOrbitsMaxillaeMandibleTemporalMandibularJointOcciptalNasalBonesZygomaticArchSphenoidForamenMagnum(HoleinBase)Cranium第7页第8页第9页BrainOccupies80%ofcraniumComprisedof3MajorStructuresCerebrumCerebellumBrainstemHighmetabolicrateReceives15%ofcardiacoutputConsumes20%ofbody’soxygenRequiresconstantcirculationIFBloodsupplystopsUnconsciouswithin10secondsDeathin4-6minutesAnatomy&Physiology

oftheHead第10页CerebralPerfusionPressurePressurewithincranium(ICP)resistsbloodflowandgoodperfusiontotheCNSPressureusuallylessthan10mmHgMeanArterialPressure(MAP)Mustbeatleast50mmHgtoensureadequateperfusionMAP=DBP+1/3PulsePressureCerebralPerfusionPressure(CPP)PressuremovingbloodthroughthecraniumCPP=MAP-ICPAnatomy&Physiology

oftheHead第11页CalculatingMAP(meanarterialpressure)DBP+1/3PPPP(pulsepressure)=SBP-DBPSBP+2(DBP)3CalculatingCPP(cerebralperfusionpressure)MAP–ICPICPnormally<10Anatomy&Physiology

oftheHead第12页CerebralPerfusionPressureAutoregulationChangesinICPresultincompensationIncreasedICP=IncreasedBPThiscausesICPtorisehigherandBPtoriseBraininjuryanddeathbecomeimminentExpandingmassinsidecranialvaultDisplacesCSFIfpressureincreases,braintissueisdisplacedAnatomy&Physiology

oftheHead第13页FaceMusclesMChewingmusclesMPosteriorpalateandpharynxMFaceMusclesMSightSOpticIIPupilConst,Rectus&ObliquesMOculomotorIIIOpthalmic(FH),Maxillary(cheek)Mandible(chin)STrigeminalVLateralrectusmuscleMAbducensVITastetoposteriortongueSVagusXTongueMHypoglossalXIITrapezius&Sternocleido.MusclesMAccessoryXIHearingbalanceSAcousticVIIISuperiorObliquesMTrochlearIVTongueSFacialVIIPosteriorpharynx,tastetoanteriortongueSGlossopharyn-

gealIXSmellSOlfactoryIInnervationFNameCN第14页TypesofTraumaSofttissueSkullfracturePrimarybraininjuriesSecondarybraininjuries第15页Thepatientpresentedtotheemergencydepartmentwiththegolfcubinhishead,whichwasremovedintheoperatingroom第16页Lateralskullx-rayofapatientwhopresentedwithasevereintracranialinjuryproducedbyagolfclub第17页ScalpInjuryContusionsLacerationsAvulsionsSignificantHemorrhageALWAYSReconsiderMOIforsevereunderlyingproblems第18页BrainInjuryAsdefinedbytheNationalHeadInjuryFoundation“atraumaticinsulttothebraincapableofproducingphysical,intellectual,emotional,socialandvocationalchanges.”ClassificationDirectPrimaryinjurycausedbyforcesoftraumaIndirectSecondaryinjurycausedbyfactorsresultingfromtheprimaryinjury第19页DirectBrainInjuryTypesCoupInjuryatsiteofimpactContrecoupInjuryonoppositesidefromimpact第20页IntracranialPerfusionReviewCranialvolumefixed80%=Cerebrum,cerebellum&brainstem12%=Bloodvessels&blood8%=CSFIncreaseinsizeofonecomponentdiminishessizeofanotherInabilitytoadjust=increasedICP第21页IntracranialPerfusionCompensatingforPressureCompressvenousbloodvesselsReductioninfreeCSFPushedintospinalcordDecompensatingforPressureIncreaseinICPRiseinsystemicBPtoperfusebrainFurtherincreaseofICPDangerouscycleICPBP第22页IntracranialPressureRoleofCarbonDioxideIncreaseofCO2inCSFCerebralVasodilationEncouragebloodflowReducehypercarbiaReducehypoxiaContributesto

ICPCausesclassicHyperventilation&HypertensionReducedlevelsofCO2inCSFCerebralvasoconstrictionResultsincerebralanoxia第23页FactorsAffectingICPVasculatureConstrictionCerebralEdemaSystolicBloodPressureLowBP=PoorCerebralPerfusionHighBP=IncreasedICPCarbonDioxideReducedrespiratoryefficiency第24页IncreasedpressureCompressesbraintissueAgainst&aroundFalxCerebriTentoriumCerebelliHerniatesbrainstemCompromisesbloodsupplySigns&SymptomsUpperBrainstemVomitingAlteredmentalstatusPupillarydilationMedullaOblongataRespiratoryCardiovascularBloodPressuredisturbancesPressure&StructuralDisplacement第25页AlteredMentalStatusAlteredorientationAlterationinpersonalityAmnesiaRetrogradeAntegradeCushing’sReflexIncreasedBPBradycardiaErraticrespirationsSigns&Symptoms

ofBrainInjuryVomitingWithoutnauseaProjectileBodytemperaturechangesChangesinpupilreactivityDecorticateposturing第26页PathophysiologyofChangesFrontalLobeInjuryAlterationsinpersonalityOccipitalLobeInjuryVisualdisturbancesCorticalDisruptionReducementalstatusorAmnesiaRetrogradeUnabletorecalleventsbeforeinjuryAntegradeUnabletorecalleventsaftertrauma“RepetitiveQuestioning”FocalDeficitsHemiplegia,WeaknessorSeizuresSigns&Symptoms

ofBrainInjury第27页UpperBrainstemCompressionIncreasingbloodpressureReflexbradycardiaVagusnervestimulationCheyne-StokesrespirationsPupilsbecomesmallandreactiveDecorticateposturingNeuralpathwaydisruptionSigns&SymptomsofBrainInjury

PhysiologicalChanges第28页MiddleBrainstemCompressionWideningpulsepressureIncreasingbradycardiaCNSHyperventilationDeepandRapidBilateralpupilsluggishnessorinactivityDecerebrateposturingSigns&SymptomsofBrainInjury

PhysiologicalChanges第29页LowerBrainstemInjuryPupilsdilatedandunreactiveAtaxicrespirationsErraticwithnopatternIrregularanderraticpulserateECGChangesHypotensionLossofresponsetopainfulstimuliSigns&SymptomsofBrainInjury

PhysiologicalChanges第30页DifferentpathologythanolderpatientsSkullcandistortduetoanteriorandposteriorfontanellesBulgingSlowsprogressionofincreasingICPIntracranialhemorrhagecontributestohypovolemiaDecreasedbloodvolumeinped’sGeneralManagementAvoidhyperextensionofheadTonguepushessoftpalletclosedVentilatethroughmouthandnoseSigns&SymptomsofBrainInjury

PediatricHeadTrauma第31页Signs&SymptomsofBrainInjury

GlasgowComaScale第32页PhysiologicalIssuesIndicatepressureonCN-II,CN-III,CN-IV,&CN-VICN-III(OculomotorNerve)Pressureonnervecauseseyestobesluggish,thendilated,andfinallyfixedReducedperipheralbloodflowPupilSize&ReactivityReducedPupillaryResponsivenessDepressantdrugsorCerebralHypoxiaFixed&DilatedExtremeHypoxiaSigns&SymptomsofBrainInjury

EyeSigns第33页SkullFracturesTheskullwillnotfracturewithoutextremeforceClosed/openlineardepressedcomminutedbasilarimpaledobject第34页CranialInjuryTraumamustbeextremetofractureLinearDepressedOpenImpaledObjectBasalSkullUnprotectedSpacesweaken

structureRelatively

easiertofracture第35页CranialInjuryBasalSkullFractureSignsBattle’sSignsRetroauricularEcchymosisAssociatedwithfractureof

auditorycanalandlower

areasofskullRaccoonEyesBilateralPeriorbital

EcchymosisAssociatedwithorbital

fractures第36页CranialInjuryBasilarSkullFractureMaytearduraPermitCSFtodrainthroughanexternalpassagewayMaymediateriseofICPEvaluatefor“Target”or“Halo”sign第37页BasilarSkullFractureCribiformplatefractureBattle’ssignPeriorbitalecchymosisCSFleakage第38页PrimaryBrainInjuryResultsfromdirecttraumaFocalDiffuse第39页DirectBrainInjuryCategoriesFocalOccurataspecificlocationinbrainDifferentialsCerebralContusionIntracranialHemorrhageEpiduralhematomaSubduralhematomaIntracerebralHemorrhageSubarachnoidHemorrhageDiffuseConcussionModerateDiffuseAxonalInjurySevereDiffuseAxonalInjury第40页FocalContusionsIntracerebralhematomaSubduralhematomaSubarachnoidhematomaEpiduralhematoma第41页ContusionsLOCwithresultantcellulardamage“bruising”Temporalinjuryoftenpresentswithrepetitivequestioning第42页Ayoungmalearrivedintheemergencydepartmentafterexperiencingagunshotwoundtothebrain.Theentrancewasontheleftoccipitalregion.ACTscanshowstheskullfractureandalargeunderlyingcerebralcontusion.Thepatientwastakentotheoperatingroomfordebridementofthewoundandskullfracture,withrepairoftheduramater第43页FocalBrainInjuryCerebralContusionBlunttraumatolocalbraintissueCapillarybleedingintobraintissueCommonwithbluntheadtraumaConfusionNeurologicdeficitPersonalitychangesVisionchangesSpeechchangesResultsfromCoup-contrecoupinjury第44页EpiduralHematomaLocatedbetweenskullandduramaterUsuallyinvolvesarterialbleeding-middlemeningealarterySharplydefinededgesonCTUsuallynounderlyingbraininjuryClassicalpresentationis“lucidinterval”Mayquicklyevolveintoherniation第45页LucidIntervaltransientLOCfollowedbyalucidperiodwherepatientisneurologicallyintactfollowedbyasecondaryonsetofHAanddecreasingLOC第46页EpiduralHematomaBleedingbetweenduramaterandskullInvolvesarteriesMiddlemeningealarterymostcommonRapidbleeding&reductionofoxygentotissuesHerniatesbraintowardforamenmagnumFocalBrainInjury

IntracranialHemorrhage第47页CTscanofanacuteleft-sidedepiduralhematoma.Notethetypicalconvexorlens-shapedappearance.Thehematomatakesthisshapeasthedurastripsfromtheundersurfaceofthecranium,limitedbythesuturelines.Amidline

shiftoftheventricularsystemexists.第48页SubduralHematomaLocatedbetweentheduramaterandpiamaterAllvenousbleeds,usuallypresentwithslowonsetIndistinctonCTUnderlyingbraininjuryMaynotpresentwithSxforhoursordays第49页SubduralHematomaBleedingwithinmeningesBeneathduramater&withinsubarachnoidspaceAbovepiamaterSlowbleedingSuperiorsagitalsinusSignsprogressoverseveraldaysSlowdeteriorationofmentationFocalBrainInjury

IntracranialHemorrhage第50页Acutesubduralhematoma:notethebright(white)imagepropertiesofthebloodonthisnoncontrastcranialCTscan.Notealsothemidlineshift.第51页Subacutesubduralhematoma:thecrescent-shapedclotislesswhitethanonCTscanofacutesubduralhematoma

第52页IntracerebralHemorrhageRupturebloodvesselwithinthebrainPresentationsimilartostrokesymptomsSignsandsymptomsworsenovertimeFocalBrainInjury

IntracranialHemorrhage第53页IntracerebralHematoma LocatedinthebrainparenchymaDifficulttodistinguishfromcontusion第54页Intracranialhemorrhage.CTscanofrightfrontalintracerebralhemorrhagecomplicatingthrombolysisofanischemicstroke.第55页SubarachnoidHemorrhageMaynotpresentwithphysicalfindingsHAstiffnecknuchalrigidityBloodinCSF第56页BrainCTscanshowssubtlefindingofbloodattheareaofthecircleofWillisconsistentwithacutesubarachnoidhemorrhage.第57页DiffuseBrainInjuryDuetostretchingforcesplacedonaxonsPathologydistributedthroughoutbrainTypesConcussionModerateDiffuseAxonalInjurySevereDiffuseAxonalInjury第58页ConcussionTransientLOCUsuallycompleterecoveryMildformofdiffuseinjuryOftenpresentswithabriefperiodofconfusionPtmayexhibitretrogradeorposttraumaticamnesia第59页DiffuseAxonalInjuryRapid,profound,prolongedunconsciousnessOftenleadstoincreasedICP第60页MildtomoderateformofDiffuseAxonalInjury(DAI)NervedysfunctionwithoutanatomicdamageTransientepisodeofConfusion,Disorientation,EventamnesiaSuspectifpatienthasamomentarylossofconsciousnessManagementFrequentreassessmentofmentationABC’sDiffuseBrainInjury

Concussion第61页“ClassicConcussion”SamemechanismasconcussionAdditional:MinutebruisingofbraintissueUnconsciousnessIfcerebralcortexandRASinvolvedMayexistwithabasilarskullfractureSigns&SymptomsUnconsciousnessorPersistentconfusionLossofconcentration,disorientationRetrograde&AntegradeamnesiaVisualandsensorydisturbancesMoodorPersonalitychangesDiffuseBrainInjury

ModerateDiffuseAxonalInjury第62页BrainstemInjurySignificantmechanicaldisruptionofaxonsCerebralhemispheresandbrainstemHighmortalityrateSigns&SymptomsProlongedunconsciousnessCushing’sreflexDecorticateorDecerebrateposturingDiffuseBrainInjury

SevereDiffuseAxonalInjury第63页第64页PathwayofDeteriorationCranialinsultTissueedemaIncreasingICPCompressionofarteriesDecreasedcerebralbloodflowDecreasedO2withcellulardeathEdemaaroundnecrotictissue第65页Con’tIncreasingICPwithcompressionofbrainstemandrespiratorycenterAccumulationofCO2resultinginvasodilationIncreasingbloodvolumefurtherincreasingICPDeath第66页AnyswellingorbleedingdecreasesthecirculatingbloodvolumeandcerebralbloodflowDecreasedcerebralbloodflowresultsinhypoxiaandCO2risesHypercarbiadilatescerebralbloodvesselscausingincreasingBPAttemptstoperfusebrainresultinginincreasedICP第67页HerniationDepressionof3rdcranialnerveresultsinpupillarydilation-aniscoriaLateralparesisCushing’striadDecorticateposturingDecerebrateposturing第68页DecorticatePosturingResultsfromlesionsofinternalcapsules,basalganglia,thalamusorcerebralhemisphereInterruptscorticospinalpathwaysPresentswithflexedarmsandextendedlowerextremities第69页DecerebratePosturingResultsfrominjurytomidbrainandponsIndicativeofbrainstemdysfunctionPresentswithextendedupperextremitiesandpronationExtendedlowerextremitiesUsuallyindicativeofgraverinjury第70页Cushing’sReflexLatesignofincreasingICPBradycardiaWideningpulsepressure/increasingBPChangesinrespiratorypatterns第71页RespiratoryPatternsMaybeindicativeofinjurylocationinthebrainCheyne-StokesCentralNeurogenichyperventilationApneusticClusterbreathingAtaxicbreathing第72页Cheyne-StokesRespirationsPeriodicbreathinginwhichdepthofeachbreathincreasestopeakthendecreasestoaperiodofapneaHyperpneicstageusuallylastslongerthanapneicphaseBilaterallesionsincerebralhemispheres第73页CentralNeurogenicRespirationsSustainedregular,rapidanddeepbreathingMidbrainandupperponsinjury第74页ApneusticRespirationsBreathingwithalongpauseatfullinspirationorfullexpirationRespiratoryfunctionpresentatbrainstemlevelonly第75页ClusterBreathingGaspingbreathswithirregularpausesLesionhighmedullaorlowpons第76页AtaxicBreathingTotallyirregularconsistingofbothdeepandshallowbreathsassociatedwithirregularpausesConsistentwithmedullainjurysincetheinspiratoryandexpiratorycentersarelocatedhere第77页GlascowComaScaleWidelyusedtomeasureseverityofinjuryinapatientandprognosisUsebestpossibleresponseMostpredictivesubsequenttoresuscitation第78页GCSEyeopening1-4Verbalresponse1-5Motorresponse1-6第79页TraumaScoreRespiratoryrateBloodpressureMaybeincorporatedintotheGCS第80页SecondaryBrainInjuryHYPOXIAHYPOTENSION

AnemiaHyperglycemiaHypoglycemiaHyperthermiaIntracranialmass第81页SignificanceSurvivingtheinitialinjuryisasmallpartofthebattleforthetraumaticbraininjuredpersonSecondaryinjurymayhaveagreaterinfluenceoverthefinaloutcomethantheprimaryinjuryTwomostcommonhypoxiaandhypotensionandmaybeasdevastatingastheprimaryinjury第82页HypotensionSinglemostprognosticfactorAsingleepisodeofdecreasedBPhasbeencorrelatedwithpooreroutcomeBrainrequiresbloodflowforperfusionKeepBP>90systolicCPP=MAP-ICPMostimportanttokeepMAP=/>70第83页HypotensioninthefaceofcerebraledemaresultsindecreasedCPP(cerebralperfusionpressure)第84页MAP(2)DBP+SBP

3Normal(70-100)第85页HypoxiaDefinedasSpO2<90%LeadstocelldamageandresultantswellingCloselyfollowshypotensionininfluenceRSIfasterandmorereliableLessthan8intubate第86页TreatmentProvideadequateventilationProvideadequatefluidresuscitationContinuallymonitorVSHOB@30degreesandheadmidlineConsidermannitolandhyperventilationifherniationimminentProphylacticseizuremedicationisnotindicated第87页VentilationRSIandventilateataratetomaintainEtCo2between35-45mmHgLidocaine1mg/kgpriortoanyintubationattempt第88页HyperventilationHasbecomeverycontroversialrecentlyandisnolongerautomaticallyrecommendedMayexacerbatebraininjuryinallbuttheherniatingpatientReceptorsrespondtoincreasedO2withvasoconstrictionInjuredtissueisnolongerperfusedResultsinincreasededemaandnecrosis第89页FluidResuscitationInitiateIVinfusiontomaintainSBP=/>90PreferablyMap>70mmHGFluidofchoiceLRorNSGlucosecausesfluidtobepulledintocellsresultingincerebraledema第90页MonitorContinuouslymonitorVSforSxofrisingICPChangesinbreathingpatternsIncreasingBPDecreasingHRUnequalpupilsPosturing第91页PositionElevatedHOBMidlineheadplacementAssistswithvenousdrainagefromtheheadwhichdecreasesICP第92页HyperthermiaCausesanincreaseinICPandshouldberegulatedHeadinjuredpatientsoftensufferfromincreasedbodytemperaturesandshouldbemonitoredAcetaminophenandothercoolingtechniquesmaybeusedDonotinducehypothermiawhichmayleadtoshiveringwhichresultsinincreasedICP第93页SeizuresIntheeventofseizurestreatmentshouldbeinitiatedimmediatelyduetoresultanthypoxiaandincreasedICPTreatmentmayincludetheuseofValiumandCerebyxValiumdoesnotterminateabnormalelectricaldischargeasfosphenytoindoesPatientsmayneedtobeinaninducedbarbituratecoma第94页TreatmentinHerniationHyperventilatetoEtCo2ofno<30mmHgMannitol-osmoticdiureticwhichmaybeusefulindecreasingICP1-1.5mg/kgLasixisaloopdiureticandnotusefulPurposeistokeepthepatientalivefordefinitivetreatmentsurgicalevacuationdrainplaced第95页Medications:OxygenPrimary1stlinedrugAdministerhighflowHyperventilationiscontraindicatedReducescirculatingCO2levelsNRB:15LPMBVM:12-20timesperminuteKeepSaO2>95%第96页Medications:DiureticsMannitol(osmotrol)MOALargeglucosemoleculeDoesnotleavebloodstreamOsmoticDiureticEffectiveindrawingfluidfrombrainContraindicationHypovolemia&HypotensionCHFDose1gm/kgCAUTIONFormscrystalsatlowtemperaturesReconstitutewithrewarming&gentleagitationUSEIN-LINEfilter&PREFLUSHline第97页Medications:DiureticsFurosemide(Lasix)MOALoopDiureticInhibitsreabsorptionofNa+inKidneysIncreasedsecretionofwaterandelectrolytesNa+,Cl–,Mg++,Ca++.Venousdilation&ReducescardiacpreloadMaybegivenincombinationwithMannitolNoteffectiveinreducingcerebraledemaContraindicationPregnancy:fetalabnormalitiesDoseSlowIVPorIMover1-2minutes0.5-1mg/kg:Commonly40or80mg第98页Medications:ParalyticsSuccinylcholine(Anectine)MOADepolarizingMedicationCausesFasciculationsOnset&DurationOnset:30-60secondsDuration:2-3minutesPrecautionParalyzesALLmusclesincludingthoseofrespirationIncreasesintraocculareyepressureContraindicationPenetratingeyeinjury&DigitalisDose1-1.5mg/kgIVConsideradministrationofdefasiculatingdoseofparalyticUsewithlidocaine1mg/kginheadinjuredpatients第99页Medications:ParalyticsPancuronium(Pavulon)MOANon-depolarizingagentDoesnotaffectLOCOnset&DurationOnset:3-5minDuration:30-60minDoseMustpremedwithsedative0.04-0.1mg/kgVecuronium(Norcuron)MOANon-depolarizingagentDoesnotaffectLOCOnset&DurationOnset:<1minDuration:25-40minDoseConsiderpremedwithsedative0.08-0.1mg/kg第100页Medications:SedativesDiazepam(Valium)MOABenzodiazepineAnti-anxietyMusclerelaxantOnset&DurationOnset:1-15minDuration:15-60minDose5-10mgMidazolam(Versed)MOABenzodiazepine3-4xpotentthanvaliumDoseSLOWIVP1mg/min1-2.5mgtitrated第101页Medications:SedativeMorphineMOAOpiumalkaloidAnalgesicSedationAnti-anxietyReducesvascularvolume&cardiacpreloadIncreasesvenouscapacitanceSide