traumatic brain injury and cerebral resuscitation
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Traumatic brain
injury and cerebralresuscitation
Ahmad Syahir Abu Sahmah
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OUTLINE
Anatomy
Scalp injury
Craniocerebral injury
Skull fracture
rimary T!I
Secondary T!I
"ana#ement
Cerebral resuscitation
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$e%nition
&ead injury is de%ned as blunt and'or penetratin#injury to the head (abo)e the neck* and'or brain dueto e+ternal force, -ith temporary or permanentimpairment in brain function -hich may or may notresult in underlyin# structural chan#es in the brain.
To de%ne traumatic head injury/ three criteria must bepresent0
i. mechanism 1 presence of e+ternal force, ii. anatomical 1 scalp and'or face and'or skull -ith or
-ithout brain injury (internal and e+ternal*
iii. physiolo#ical 1 alteration in physiolo#y of the brainsuch as LOC or amnesia
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Anatomy
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SCAL
S 2 S3IN
C 2 CONNECTI4E TISSUE
A 2 AONEU5OSISL 2 LOOSE A5EOLA5 TISSUE
1 E5IC5ANIU" '
E5IOSTEU"
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Ethiolo#y 5oad1tra6c accidents
7alls
$omestic Accident
5ecreational accidents
Industrial accidents
Assaults
8un shot
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Scalp injury Scalp injury are common and may #i)e rise to
e+san#uinate hemorrha#e if not controlled due to theblood )essels in the dense %brous layer/ super%cial tothe #alea aponeurotica/
The abundance of blood )essel also help in speedin# upthe reco)ery at the -ound here.
The loose areolar tissue under the aponeuritica is adan#erous 9one for infection since pus can spread freelyin this layer and reach the intracranial sinuses throu#h
the emissary )eins.
In infant/ this can cause se)ere shock.
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Skull fracture
There are many types of skull fractures/ usually causeby an impact or a blo- to the head that:s stron# enou#hto break the bone. An injury to the brain can also
accompany the fracture/ but that:s not al-ays the case.A fracture isn:t al-ays easy to see.
&o-e)er/ symptoms that can indicate a fracture include0
s-ellin# and tenderness around the area of impact facial bruisin#
bleedin# from the nostrils or ears
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Type 0
Simple linear fracture
$epressed fracture
!ase of skull fracture
Orbital blo-1out fracture
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Simple linear fracture
5e;uire no neurosur#ical mana#ement but usuallyare indicators of the force to -hich the head -assubjected.
7racture crossin# s;uamous temporal bone may
lacerate medial menin#eal )essel and can causee+tradural hematoma
Should be admitted forobser)ation to e+clude secondaryintracranial hematoma orde)elopin# cerebral s-ellin#.
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$epressed skull fracture Usually result from sharper trauma or
hi#h )elocity assault.
If the corte+ belo- is dama#ed/ there is of risk de)elopin# epilepsy andsi#ni%cant risk of de)elopin# infections.
Need suturin# before referral fordebridement and ele)ation.
Contaminated -oundre;uire debridement/irri#ation and duraplastybefore clossure.
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!ase of skull fracture
5elati)ely fre;uent fractures/ often occultsradiolo#ically but dia#nosed on clinical #round.
resent -ith subconjucti)al hematoma/ anosmia/
epista+is/ nasal paraesthesia/ CS7 rhinorrhoea/and occasionally caroticoca)ernous %stula.
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eriorbital hematoma or ?Raccoon eyes: indicatesub#aleal hemorrha#e and not necessarily base ofskull fracturin#.
"iddle fossa fracture in)ol)in# petreous temporal
bone presented -ith ?Battle sign / CS7 otorrhea orrhinorrhea / ossicular disruption or cranial ner)e4II (facial* and 4III ()astibulocochlear* palsies.
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Orbital blo- out fracture
!lunt trauma to the eye
@ mechanisms
18lobe1to -all1 direct force to eye
#lobe 1!uckin# 2 force to lo-er rim of orbit
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!rain injury
$e%nition
Traumatic brain injury (T!I* is a nonde#enerati)e/ noncon#enitalinsult to the brain from an e+ternal mechanical force/ possiblyleadin# to permanent or temporary impairment of co#niti)e/physical/ and psychosocial functions/ -ith or -ithout an
associated diminished or altered state of consciousness.
Can be classify on se)erity 0 mild(
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!ased on the "onroe13ellie $octrine/ the intracranial )olumeDbrain (>*/ cerebral spinal Fuid (CS7* (*/ and cerebralblood )olume (*G is %+ed by the con%nes of the cranial)ault.
Cerebral edema/ tumor/ hematoma/ or abscess may impin#e
upon normal compartment )olumes/ raisin# intracranialpressure (IC*.
Since brain tissue is capable of minimal compensation inresponse to abnormal intracranial lesions/ the CS7 and cerebralblood )olume compartments must decrease accordin#ly tominimi9e IC ele)ations.
CS7 compensates by drainin# throu#h the lumbar ple+us anddecreasin# its intracranial )olume. Cerebral blood )olume andcerebral blood Fo- (C!7* are directly related to IC and arenormally closely controlled by autore#ulation throu#h a -ideran#e of systolic blood pressures/ aCO@ and aO@
C H "A 2 IC
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rimary brain injury $iused a+onal head injury
Cerebral concussion
Cerebral contusion and laceration
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$iused a+onal braininjury 5esult from mechanical shearin# at the #rey1-hite
matter interface follo-in# se)ere acceleration1deceleration type forces due to dierental brainmo)ement
This causes disruption and tearin# of a+ons/ myelinsheaths and capillaries.
Se)erity can ran#e
from mild dama#e-ith confusion tocoma or e)en death.
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Cerebral concussion
clinical dia#nosis manifested -ith temporarycerebral dysfunction/ -hich is more se)ereimmediately after injury and #radually resol)es aftera period of time.
"aybe accompanied -ith autonomicabnormalities/ bradycardia/ hypotension/s-aeatin# and loss of consciousness
ost concussion syndrome is a comple+ ofsymptoms persistin# months after head injuryconsist of )ariable combinations of headache/
irritabilities / depression/ lassitude and )erti#o.
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Cerebral contusion andlacerations Cerebral contusion and lacerations
-hen a sudden physical assault on the headcauses bruisin# of the brain tissue.
$emonstrated -ithcoup1contrecoup
$emonstrated as small area of hemorrha#e inthe cerebral parenchyma.
!lood brain barrier defect and cerebral edemaare in)ariably associated -ith cerebralcontusion
The pia meter and arachnoid may be torn andintracerebral hemorrha#e may accompanythis lesion.
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Cerebralcontusion
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Secondary brain injury
Intracranial hematomas
Cerebral edema
&ypo+emia
Ischemia
Infection
Epilapsy
"etabolic or endocrine electrolytes disturbances
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Intracranial hematoma
Epidural hematoma Occurs more common in youn#er a#e J K=y'o. $ura able to strip of
more readily in youn#er a#e.
!uild up of blood occurs bet-een the dura mater and the skull )ia the
menin#eal artery
blood accumulation de)eloped by the e+pendin# hematoma allo-in# it totake con)e+ con%#uration due to adherence of dura to the skull bone.
Clasically a lucid inter)alfollo-in# the trauma. patient tends to present -ith a
fall -ith a brief loss of consciousness. The person -akes up/ perfectly %ne/seems to be #reat/ and not ha)e any di6culties. After @1 hours/ the ptstarted to #et dro-sy and )omitin# and symptoms starts to de)elop. Thecollection of blood in that space has #otten so bi# that its no- pushin# thebrain across in the skull/ and pushin# the brain do-n into the skull andcompressin# the brain stem so that thr heart becomes irre#ular/ breathin#
becomes irre#ular/ and patient is slippin# into a coma.
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7re;uently patient presented in coma and re;uire ur#entcraniectomy.
Epidural is considered sur#ical emer#encies that -ill
result in death if the bleedin# does not stop and thehematoma is not remo)ed promptly.
ro#nosis is better if delay in sur#ical inter)ention isminimi9ed.
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Subdural hemorrha#e
Acccumulation of blood in the space bet-een thedura and arachnoid.
$isruption of a cortical )essel or brain laceration/a'- a si#ni%cant primary brain injury
resentation0 an impaired conscious le)el fromthe time of injury/ but further deterioration canoccur as the hematoma e+pands
Classi%ed into 0 1Acute S$& 2 less then daysSubacute S$& 1 K1@
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