Craniocerebral Traumas

Posted by e-Medical PPT Thursday, February 16, 2012
Traumatic brain injury Primary : penetrating injuries through the cranial bone can cause direct brain damage locally, or at the opposite (contralateral) side (contrecoup) Secondary : brain edema, extradural hematoma, subdural hematoma (brain compression)

Consequences of cranial traumas - Brain edema,Skull fractures,Extradural (epidural) hematomas,Subdural hematomas, Intracerebral hematomas,Subarachnoid hemorrhage

Clinical presentation of brain damage
Cerebral concussion: transient loss of consciousness following a blow to the head, quick recovery, amnesia Cerebral contusion: morphological damage to cerebral tissue from focal bleeding or edema, slower recovery, may be incomplete with neurological deficit Cerebral compression: bleeding into the skull spaces (epidural, subdural, subarachnoid, intracerebral, intraventricular)

Signs and symptoms of head traumas Galea lesions: bruising or laceration of the skin, scalp wounds, galeal hematomas Meningeal irritation: neck stiffness, Kernig´s sign Increasing intracranial pressure: headaches, nausea, vomiting, optic disc edema Impaired conscious level: amnesia, drowsy, reacts to movement, reacts to painful stimulus, no reaction Glasgow Coma Scale (GCS) Pupil differences, ocular movement disorders

Raised intracranial pressure Normal ICP < 10 mmHg Mild ICP increase 10-20 mmHg Moderate > 20 mmHg Severe > 40 mmHg « Monro-Kellie » doctrine: - rigid skull bone - CSF, blood, brain are incompressible, an increase in one constituent results in an increase in the intracranial pressure

Raised ICP: brain edema Mechanism: - vasogenic: impairment of blood-brain barrier, fluid escapes to the extracellular space - cytotoxic: damage of cell metabolism, intracellular Na + increases, fluid accumulates within cells Signs and symptoms: meningeal irritation, headaches, nausea, vomiting, papilledema, impaired conscious level Treatment: - diuretics (Furanthral) - hyperosmotic infusions (Mannitol) - hyperventilation (drop in PCO2 >> vasoconstriction >> reduction in cerebral blood volume) - CSF drainage (ventricular puncture and CSF withdrawal) - barbiturate therapy (reduces neuronal activity and depresses cerebral metabolism) - steroids (cell membranes are stabilised >> decrease in perifocal peritumoral edema, no benefit in traumatic brain swelling)
Raised ICP: cerebral blood flow (CBF) Systemic blood flow = blood pressure / vascular resistance CBF = cerebral perfusion pressure / cerebral vascular resistance Cerebral perfusion pressure = systemic blood pressure – ICP
Raised ICP: symptoms and signs Headaches Nausea, vomiting Optic disc swelling (papilledema) Pupil difference (tentorial herniation, irritation and compression of the III. nerve): pupils initially small (excitement), later dilated and fixed to light (palsy) Gaze disturbances (upward gaze is initially lost) Deterioration of conscious level (tentorial or tonsillar herniation >> compression of ascending reticular activating system in the brainstem and midbrain) Respiratory and circulatory irregularities, arrest Cushing-reflex: initial increase in blood pressure and a fall in pulse rate (bradycardia) associated with expanding intracranial mass

Skull fractures Closed fractures: the scalp (skin and galea) intact Open fractures: penetration of skin and galea, open scalp wound (risk of infection) Linear fractures: no dislocation between fractured bony edges (usually single) Depressed fractures: dislocated bone fragments into the cranial space (single or multiple)..

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