|
|
| (13 intermediate revisions by the same user not shown) |
| Line 1: |
Line 1: |
| == Background ==
| | #REDIRECT[[Head trauma (main)]] |
| *Classification based on [[GCS]]
| |
| **14-15: Mild
| |
| **9-13: Moderate
| |
| **3-8: Severe
| |
| *B/l pinpoint pupils suggests opiate use or pontine lesion
| |
| *Pretreatment w/ lidocaine has not been shown to improve outcomes
| |
| *All pts on coumadin should have head CT performed
| |
| | |
| == Clinical Decision Rules ==
| |
| See: [[Head CT in Trauma (Clinical Decision Rules)]]
| |
| | |
| == Diagnosis ==
| |
| *Monitor for increased ICP
| |
| **HA, N/V, sz, lethargy, HTN, bradycardia, agonal respirations, posturing
| |
| *Monitor for herniation
| |
| **Ipsilateral fixed and dilated pupil
| |
| **Contralateral motor paralysis
| |
| ===Skull Fracture===
| |
| *All skull fx require [[Head CT]]
| |
| *ABX indicated for:
| |
| **Open fx
| |
| **Depressed fx
| |
| **Involves sinus
| |
| **Leads to pneumocephalus
| |
| *CTX 2gm IV + metronidazole 500mg +/- Vancomycin 1gm IV
| |
| | |
| ===Cerebral Contusion / Intracerebral Hemorrhage===
| |
| *Often a/w SAH
| |
| *ICH can occur days after trauma often at site of resolving contusions
| |
| **More common in pts w/ coagulopathy
| |
| ===Subarachnoid Hemorrhage===
| |
| *Most common CT abnormality in moderate-severe TBI
| |
| *+Meningeal signs
| |
| *Associated with nonaccidental trauma in infants
| |
| ===Epidural Hematoma===
| |
| *Due to trauma to temporoparietal area w/ associated skull fx and meningeal artery damage
| |
| *Classic presentation of LOC > lucid interval > LOC only occurs in 20%
| |
| *Injury to brain is often absent so good recovery if hematoma evacuated in time
| |
| ===Subdural Hematoma===
| |
| *Often assoc w/ underlying parenchymal damage
| |
| *More common in elderly, alcoholics, children <2yr
| |
| *May be acute (rapid LOC) or chronic (AMS w/ gradual decrease in consciousness)
| |
| | |
| == DDx ==
| |
| #DAI
| |
| #Contusion/intracerebral hematoma
| |
| #Epidural
| |
| #Subdural
| |
| #Traumatic [[SAH]]
| |
| #[[Concussion]]
| |
| | |
| ==Treatment==
| |
| ===Prevent further brain injury===
| |
| #Head of bed @ 30 degrees
| |
| #Prevent:
| |
| ##Hypotension
| |
| ##Hypoxia
| |
| ##Anemia
| |
| ##Hyperthermia
| |
| ##Coagulopathy
| |
| #[[Seizure Prophylaxis (Trauma)]]
| |
| | |
| ===[[Increased ICP]]===
| |
| #Ensure adequate sedation (prevent gag reflex)
| |
| #IVF to goal MAP >80 (maintains cerebral perfusion)
| |
| #Mannitol
| |
| ##If SBP>90
| |
| ###If SBP>90 in adults use hypertonic saline NaCl 5% 150ml over 10 min
| |
| ##Reduces ICP w/in 30min; duration of action of 6-8hr
| |
| ##Bolus 20% @ 0.25-1 gm/kg as rapid infusion
| |
| ##Monitor I+O to maintain euvolemia
| |
| #Hyperventilation
| |
| ##No longer recommended as prophylactic intervention
| |
| ###Hyperventilation to PaCO2 <25 never indicated
| |
| ##Brief course only recommended if impending herniation (i.e., Cushing reflex)
| |
| ####Maintain PaCO2 28-35 (20 breaths/min)
| |
| #Seizure
| |
| ##Treat immediately
| |
| ##Seizure prophylaxis reduces sz but does not improve long-term outcomes
| |
| #Goal CPP ~60mmHg
| |
| ##If MAP <80, then CPP<60
| |
| ###consider crystalloids or colloids (plasma if INR>1.3)
| |
| ###phenylephrine 10-100mcg/min, or other pressors prn
| |
| ###transfuse PRBCs, Hb>7
| |
| | |
| == See Also ==
| |
| *[[Head Trauma (Main)]]
| |
| *[[Glasgow Coma Scale (GCS)]]
| |
| *[[Concussion]]
| |
| *[[Maxillofacial Trauma]]
| |
| | |
| == Source ==
| |
| *Annals 2/09, Stein
| |
| *Tintinalli
| |
| | |
| [[Category:Trauma]]
| |
| [[Category:Neuro]]
| |
