4.BRAIN and SPINAL CORD INJURY 2012.pptx

8/9/2019 4.BRAIN and SPINAL CORD INJURY 2012.pptx

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Central nervoussystem injury

CNS trauma involves injury to the brain or spinal cord.

Brain injury:

Traumatic brain injury accounts for approximately half of

prehospital deaths from motor vehicle collisions.

Late survival from brain injury is dependent on avoidingsecondary brain injury due to hypoxia and hypotension.


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Physiology. The skull is nonexpandable after closure offontanelles. !t contains the brain" cerebrospinal#uid and blood. The $onro%ellie doctrine states the intracranialpressure !CP is proportional to the volume of thecontents of the skull. Conse&uently" !CP can be

altered only by changing the volume ofintracranial contents.'esulting perfusion pressure to any organ is thedi(erence bet)een the driving pressure and theresisting pressure. *or the brain" cerebral perfusion pressure

e&uals mean arterial pressure minus !CP.CPP=MAP-ICP Cerebral boold #o) e&uals CPP divede bycerebral vascular resistance.

CBF=CPP/CVR


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C+* remains relatively constant" bet)een $,P of - to /-mm0g.

T0!S ,1T2'341L,T!2N !S ,C0!3536 T0'2140 L2C,L '3L3,S32* $36!,T2'S S1C0 ,S N!T'!C 27!63 ,N6 3N62T03L!NS80!T0 ,C1T3L9 ,LT3' C5'. ,utoregulation is deranged insevere brain injury and C+* becomes ex&uisitely sensitive tochanges in $,P and !CP. ,dditionally !CP is fre&uently elevated )ith brain injury. Thus incresead $,P may be re&uired to maintain ade&uateCPP.


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Pathology.!ntracranial abnormalities related

to trauma can be classi:edaccording to involvement of thebrain or potential spaces arroundthe brain. 2f these lesions" spaceoccupying extraaxial subdural

and epidural haematomas aremost amenable to surgicaltherapy.


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lasgo! "oma s"ale:4CS is )idely used for early aseementof the severity of brain injury. , scoreof ; or less is usually referred to ascoma.

These pacients have severe brain

injuries and are at high risk of mortalityand log term disability.


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Initial management!mmediate priorities include securing theair)ay" supporting ventilation andoxygenation" and optimising circulation andorgan perfusion. Pacients )ith severe brain injury from blunttrauma often have associated injuries"particularly of spine and spinal cord.

CT of the brain and spinal cord is useful inevaluating pacients )ith suspected headinjury" allo)ing diagnosis of the intra andextraaxial pathologies.


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#reatment.

Treatment of brain injury hinges uponavoidance of secondary hypoxic injury.!mportant goals are maintaining

ade&uate CPP mm0g? and bloodoxygen contents )hile striving tominimise cerebral metabolicre&uirements. CPP may be maintained by increasing$,P )ith drugs such as phenylephrineand noradrenaline or by decreasing !CP.


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,n !CP can be decreased evacuation of spaceoccupying lesion such as

epidural and subduralhaematomas" drainage of CS* )ith aventriculostomy catheter removal of a portion of theskull" osmotic diuresis )ithmannitol.


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Sedation and neuromuscularblockade may decrease metabolicre&uirements. +arbiturate or propofol induced comamay be bene:cial in the :rst @AA;h.$ild hypothermia B-B= has sho)npromise in several studies" butremains an experimental intervention.$aintaining normoglycaemia has

been associadet )ith improvedneurological outcome.


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C-$%ine Injuries

Cervical *racture or 6islocation◦ 8eakness or Paralysis

Cervical Nerve 'oot !njury◦

0erniated 6isc◦ Laceration

◦ Cord Shock


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Spinal Nerves◦ C/T/

◦ Cervical Plexus C/CA

CA Phrenic Nerve +reathing

◦ +rachial Plexus C-T/

CB


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C-$%ine/'e"( Injuries

Cervical Strain◦ ,ctive motion most painful

Cervical Sprain


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)valuation #e"hni*ues

02PS◦ 0istory" 2bservation" Palpation" Special Tests

9our :rst priorityD◦ 3stablish the integrity of the spinal cord and

nerve roots

◦ 0istory and several speci:c tests provideinformation


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Cervi"al Injuries

*airly uncommon in athleticsE? but greaterthan FE of all fatalities are cervical related.

Cervical injuries are primarily techni&ue related◦ $%earing

◦ Tackling or falling head :rst. $ust have an emergency plan

◦ ,ll personnel kno) roles and e&uipment use.

◦ ,ll unconscious athletes suspect headGneck

◦ ,l)ays suspect the )orse until proven other)ise


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Cervi"al Injuries

◦ ,xial Loading

◦ *lexion *orce

◦ 0yperextension *orce

◦ *lexion'otation *orce

◦ 0yperextension'otation

◦ Lateral *lexion


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'eurologi"al #esting

6ermatomes 'e#exes

◦ +abinski

◦ 2ppenheim

◦ +iceps

◦ +rachioradialis

◦ Triceps

$yotomes


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Classi+"ationSpinal cord injuries are either"om%lete" )ith loss of all sensory andmotor function distal to the injury" or

in"om%lete. The last ones can be divided eitherfunctionally or pathologically. *unctional scales are based on thedegree of loss of sensory and motorfunction.


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Initial management!f tracheal intubation is re&uired" inline stabiliHationof the cervical spine must be maintainted. Pacient)ith cervical spinal cord injuries are unable to

breathe if the level of the injury is above CBC-.3ven )ith lo)er lesion" respiratory compromise canbe important o)ing to denervation of theintercostals muscles and paradoxical chest )allmotion )ith negative pressure ventilation.


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Parental infusion ofcorticosteroids should beinitiated as soon as spinal

cord injury is suspectedfollo)ing the improvedneurological outcomesdemonstradet in the N,SC!S

studies.


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The recommended regimen ismethylprednisolone B mgGkgover over / h )ithin ;h of injury

follo)ed by continuous infusionof -"A mgGkgGh over the next@Bh. 'ecently" the bene:t ofroutine administration of

corticosteroids has been&uestioned.


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Com%li"ation.Spinal cord injury can a(ect manyorgan systems. Neurogenic or spinalshock may occur )ith high thoracic

lesion )here sympathetic out#o) isinterrupted. This should be treated )ithperipheral vasoconstrictors andade&uate #uid resuscitation. This

problem typically resolves )ithin >@ hof injury.


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Pulmonary and urinary tractinfection are common" theformer because of diIcultyclearing secretion fre&uent

need for tracheal intubationand latter secondary toind)elling urinary cathetersor fre&uent bladder

catheteriHation .


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Prophylactic administration ofproton pump inhibitors or histaminereceptor blocker may decrease the

occurrence of stress ulcers.6eep venous thrombosisandpulmonary embolism arefre&uent and potentially lethal

complications of paralysis.


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)ye o%ening:

pointsSpontaneous

A To speech

B

To pain@

None/

4CS


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Ver,al"ommuni"ation2riented-Confused

A!nappropriated )ordsB!ncomprehensible sounds@None

/


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Motor res%onse

2beys commands =

LocaliHed to pain -8ithdra)s to pain A,bnormal #exion B,bnormal extension @

None /


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+est score is /- pointsJ)orst score is B points.increase brain oedema and

supporting ventilation tomaintain Pa Co@ bet)eenB- to A mm04.!

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4.BRAIN and SPINAL CORD INJURY 2012.pptx