BRAIN TRAUMA
BRAIN TRAUMA
dr.Tommy J Numberi,Sp.BS
CURRICULUM VITAE
DR. TOMMY JACK NUMBERI, SP.BS
ADDRESS :JL. PASIFIK INDAH RT/RW 004/001 TANJUNG RIA, JAYAPURA UTARA
E-MAIL: [email protected] / [email protected]
FORMAL EDUCATION
• FK UNCEN 2002, PROFESI DOKTER
• FKKMK UGM 2012, SPESIALIS BEDAH SARAF
NON FORMAL EDUCATION/ TRAINING-SEMINAR
• 2013, BASIC SURGERY SKILL
• 2015, MICROSURGERY SKILL
• 2017, TOT ATLS PAPUA INSTRUCTOR
• 2019, ATLS INSTRUCTOR
• 2019, BANDUNG, TRAINER FOR BSS INSTRUCTOR
• 2019, BSS GP INSTRUCTOR
• 2019, BANGKOK, RACS 88TH ANNUAL SCIENTIFIC CONGRESS PARTICIPANT
JOB EXPERIENCES
•PRECLINICAL AND CLINICAL TEACHING STAFF T HE UNCEN / JAYAPURA DISTRICT MEDICAL SCHOOL
•GENERAL PRACTITIONER AT JAYAPURA REGIONAL HOSPITAL
•NEUROSURGEON AT JAYAPURA REGION HOSPITAL
•NEUROSURGEON AT PROVITA HOSPITAL
•NEUROSURGEON AT BHAYANGKARA HOSPITAL
GOAL OF TREATMENT
THE PRIMARY GOAL OF TREATMENT FOR PATIENTS WITH
SUSPECTED TBI IS TO PREVENT SECONDARY BRAIN INJURY
PANDEMIC PRINCIPLE
1. SAFETY
2. QUICK IN - QUICK OUT
ANATOMY AND PHYSIOLOGY
WHAT ARE THE UNIQUE FEATURES OF BRAIN
ANATOMY AND PHYSIOLOGY, AND HOW DO THEY
AFFECT PATTERNS OF BRAIN INJURY?
ANATOMY AND PHYSIOLOGY
WHAT ARE THE UNIQUE FEATURES OF BRAIN ANATOMY AND PHYSIOLOGY, AND
HOW DO THEY AFFECT PATTERNS OF BRAIN INJURY?
• Rigid, nonexpansile skull filled with brain, CSF, and blood
• Cerebral blood flow (CBF) usually autoregulated
• Autoregulatory compensation disrupted by brain injury
• Mass effect of intracranial hemorrhage
MONRO-KELLIE DOCTRINE
VOLUME-PRESSURE CURVE
INTRACRANIAL PRESSURE (ICP)
10 mm Hg = Normal
>20 mm Hg = Abnormal
>40 mm Hg = Severe
• Sustained increased ICP leads to decreased brain function and poor
outcome
• Hypotension and low saturation adversely affect outcome
AUTOREGULATION
• If autoregulation is intact, CBF is maintained constant between a
mean BP of 50 to 150 mm Hg.
• In moderate or severe brain injury, autoregulation is impaired so CBF
varies with mean BP.
• The injured brain is more vulnerable to episodes of hypotension,
causing secondary brain injury.
Caution
CPP ≠ Cerebral Blood Flow
CLASSIFICATIONS OF HEAD INJURY
By Morphology – Skull Fractures
Vault
• Depressed or nondepressed
• Open / closed
Basilar
• With or without CSF leak
• With or without cranial nerve palsy
CLASSIFICATIONS OF HEAD INJURY
By Morphology – Brain Injuries
Focal
• Epidural (extradural)
• Subdural
• Intracerebral
Diffuse
• Concussion
• Multiple contusions
• Hypoxic / ischemic injury
EPIDURAL HEMATOMA
• Associated with skull
fracture
• Classic: middle
meningeal artery tear
• Lenticular / biconvex
• Lucid interval
• Can be rapidly fatal
• Early evacuation Uncal herniation
essential
SUBDURAL HEMATOMA
• Venous tear / brain laceration
• Covers cerebral surface
• Morbidity / mortality due to
underlying brain injury
• Rapid surgical evacuation
recommended, especially if > 5
mm shift of midline
INTRACEREBRAL HEMATOMA / CONTUSION
• Coup / contra coup injuries
• Most common: frontal /
temporal lobes
• CT changes usually
progressive
• Most conscious patients: no
operation
Large Frontal Contusion with Shift
DIFFUSE BRAIN INJURY
Normal CT Diffuse Injury
Range from mild concussion to severe ischemic insult
CLASSIFICATIONS OF HEAD INJURY
By Severity of Injury Based on GCS Score
• Mild
• Moderate
• Severe
MILD BRAIN INJURY
• GCS score = 13 – 15
• History
• Exclude systemic injuries
• Neurologic exam
• Radiographic investigation as indicated
• Alcohol / drug screens as indicated
Observe or discharge based on findings
MODERATE BRAIN INJURY
• GCS score = 9 – 12
• Initial evaluation same as for mild injury
• CT scan for all
• Admit and observe
• Frequent neurologic exams
• Repeat CT scan
• Deterioration: Manage as severe head injury
SEVERE BRAIN INJURY
• GCS score = 3 – 8
• Evaluate and resuscitate
• Intubate for airway protection
• Neurologic exam prior to intubation
• Focused neurologic exam
• Frequent reevaluation
• Identify associated injuries
INDICATIONS FOR CT SCAN
• GCS score still < 15 two hours after
injury
• Neurologic deficit
• Open skull fracture
• Sign of basal skull fracture
• Vomiting (> 2 episodes)
• Extremes of age
• Retrograde amnesia
• Severe headache
MANAGEMENT
WHAT IS THE OPTIMAL TREATMENT FOR PATIENTS WITH
BRAIN INJURIES?
Priorities
• ABCDE
• Minimize secondary brain injury
• Administer oxygen
• Maintain adequate ventilation
• Maintain blood pressure
(systolic > 90 mm Hg)
MANAGEMENT
WHAT IS A FOCUSED NEUROLOGICAL EXAMINATION?
• GCS score
• Pupils
• Lateralizing signs
“Consult neurosurgeon early”
MANAGEMENT
Medical
• Controlled ventilation
• Goal: PaCO2 at 35 mm Hg
• Intravenous fluids
• Euvolemia
• Isotonic
• Consult with neurosurgeon
MANAGEMENT
Medical
• Mannitol
• Use only with signs of tentorial herniation
• Avoid in patients with hypovolemia
• Dose 1.0 gram / kg IV bolus
• Hypertonic saline
• Anticonvulsants
• Sedation
• Paralytics Neurological examination
before prolonged
sedation/paralysis
MANAGEMENT
Surgical
• Scalp Wounds
• Possible site of major blood loss
• Direct pressure to control bleeding
• Occasional temporary closure
MANAGEMENT
Surgical
• Penetrating Trauma
• ABCs
• X-ray / CT scan
• Early neurosurgical consult
• Prophylactic antibiotics
• Do not remove penetrating object or probe the wound.
MANAGEMENT
Surgical
• Intracranial Mass Lesion
• Can be life-threatening if expanding rapidly
• Immediate neurosurgical consult
• Hyperventilation / medical therapy
• Damage control craniotomy: transfer to
neurosurgeon (rural / austere areas)
BRAIN DEATH
HOW DO I DIAGNOSE BRAIN DEATH?
• GCS score = 3
• Nonreactive pupils
• Absent brainstem reflexes (e.g.,
oculocephalic, corneal, and Doll’s eyes, and
no gag reflex)
• No spontaneous ventilatory effort on formal
apnea testing
SUMMARY
● MANAGEMENT OF HEAD INJURIES REQUIRES AN
UNDERSTANDING OF BASIC INTRACRANIAL
PHYSIOLOGY.
● EFFICIENT EVALUATION OF HEAD AND BRAIN INJURIES
INCLUDES ABCS, A NEUROLOGIC EXAMINATION AND
SEARCHING FOR ASSOCIATED INJURIES.
● ADEQUATE RESUSCITATION IS IMPORTANT IN LIMITING
SECONDARY BRAIN INJURY.
● MANAGEMENT BRAIN TRAUMA IN PANDEMIC ERA,
NEEDS SAFETY, QUICK IN AND QUICK OUT.
