CNS, Burns, Conclusion

8/8/2019 CNS, Burns, Conclusion

1/37

SECONDARY SURVEY:CNSSECONDARY SURVEY:CNS

Frequent ReevaluationFrequent Reevaluation

Prevent Secondary Brain InjuryPrevent Secondary Brain Injury

Imaging as IndicatedImaging as Indicated

Early Neurosurgical InterventionEarly Neurosurgical Intervention


2/37

GLASCOW COMA SCALEGLASCOW COMA SCALE

Eye Opening: Range 1Eye Opening: Range 1 44

BEST Motor Response: Range 1BEST Motor Response: Range 1 66

Verbal Response: Range 1Verbal Response: Range 1-- 55

SCORE = (E+M+V)SCORE = (E+M+V)

Best Score = 15Best Score = 15

Worst Score = 3Worst Score = 3


3/37

EYE OPENINGEYE OPENING

Spontaneous 4Spontaneous 4

To voice 3 To voice 3 To pain 2 To pain 2

None 1None 1


4/37

MOTOR RESPONSEMOTOR RESPONSE

Obeys commands 6Obeys commands 6

Localizes Pain 5Localizes Pain 5

Withdrawal (pain) 4 Withdrawal (pain) 4

Flexion (pain) 3Flexion (pain) 3

Extension (pain) 2Extension (pain) 2

None 1None 1


5/37

VERBAL RESPONSEVERBAL RESPONSE

ADULT CHILD SCOREADULT CHILD SCORE

Oriented Appropriate 5Oriented Appropriate 5

Confused Consolable cry 4Confused Consolable cry 4

Inappropriate Irritable 3Inappropriate Irritable 3

Noise Agitated 2Noise Agitated 2 NoneNone NoneNone 11


6/37

EFFECTS ofEFFECTS of

SKULL/CONTENTSSKULL/CONTENTSLack of Expansion RoomLack of Expansion Room

Contains Brain, Blood, CSFContains Brain, Blood, CSF

Cerebral Blood FlowAutoregulationCerebral Blood FlowAutoregulation

Compensatory Mechanisms DisruptedCompensatory Mechanisms Disrupted

by Injuryby Injury

Mass Effect of Intracranial BleedingMass Effect of Intracranial Bleeding


7/37

INTRACRANIALINTRACRANIAL

PRESSUREPRESSURE 20mm Hg-- DangerousDangerous

Many Pathologic Factors Influence OutcomeMany Pathologic Factors Influence Outcome

Sustained Increase in ICP Results inSustained Increase in ICP Results inDepressed Brain Function and PoorDepressed Brain Function and PoorPrognosisPrognosis


8/37

CEREBRAL PERFUSIONCEREBRAL PERFUSION

PRESSUREPRESSUREMean bloodMean bloodpressurepressure

IntracranialIntracranialpressurepressure

= CPP= CPP

(mm Hg)(mm Hg)

NormalNormal 9090 1010 8080

CushingsCushingsresponseresponse

100100 2020 8080

HypotensionHypotension 5050 2020 3030


9/37

AUTOREGULATIONAUTOREGULATION

IntactIntact-- Cerebral Blood Flow isCerebral Blood Flow isProtected at Mean Blood Pressures ofProtected at Mean Blood Pressures of

5050 160 mm Hg160 mm Hg ImpairedImpaired-- Moderate to Severe BrainModerate to Severe Brain

InjuryInjuryAbsentAbsent-- Brain is Sensitive toBrain is Sensitive to

Hypotension, Resulting in SecondaryHypotension, Resulting in Secondary

Brain InjuryBrain Injury


10/37

SKULL FRACTURESSKULL FRACTURES

VAULTVAULT

Depressed/NondepressedDepressed/Nondepressed

Open/ClosedOpen/Closed

BASILARBASILAR

With/Without CSF leakWith/Without CSF leak

With/Without Cranial nerve palsyWith/Without Cranial nerve palsy


11/37

BRAIN INJURYBRAIN INJURY

FOCALFOCAL

EpiduralEpidural

SubduralSubduralIntracerebralIntracerebral

DIFFUSEDIFFUSE

ConcussionConcussionMultiple contusionsMultiple contusions

Hypoxic InjuryHypoxic Injury


12/37

EPIDURAL HEMATOMAEPIDURAL HEMATOMA

GenerallyGenerally-- Skull fractureSkull fracture

Middle meningeal artery injuryMiddle meningeal artery injury

Biconvex/sizeBiconvex/size--limited/definedlimited/defined

Lucid interval commonLucid interval common

Rapidly fatalRapidly fatal------ Time is criticalTime is critical Early evacuation lifesavingEarly evacuation lifesaving

Deficits quite specificDeficits quite specific


13/37

SUBDURAL HEMATOMASUBDURAL HEMATOMA

Venous injuryVenous injury

Associated with brain lacerationAssociated with brain laceration

Involves entire cerebral cortexInvolves entire cerebral cortex

Brain injury determines prognosisBrain injury determines prognosis

High morbidity and mortality ratesHigh morbidity and mortality rates

Evacuate if >5cm midline shiftEvacuate if >5cm midline shift


14/37

CONTUSION/HEMATOMACONTUSION/HEMATOMA

Coup/contracoup injuryCoup/contracoup injury

Frontal/temporal lobes most commonFrontal/temporal lobes most common

Progressive changes on CT scanProgressive changes on CT scan

Monitor intracranial pressureMonitor intracranial pressure

Conscious patients rarely needConscious patients rarely needoperationoperation


15/37

ASSESSMENTASSESSMENT

History/mechanism of injuryHistory/mechanism of injury

Alcohol or drug screensAlcohol or drug screens

Patient previous medical conditionPatient previous medical condition

Exclude/identify other injuriesExclude/identify other injuries

XX--rays as indicatedrays as indicated


16/37

BRAIN INJURYBRAIN INJURY

MILDMILD MODERMODER--ATEATE

SEVERESEVERE

GCSGCS 1414--1515 99--1313 8 or less8 or less--

ComaComa

CT ScanCT Scan As indicatedAs indicated AllAll All andAll andRepeatRepeat

AdmitAdmit AllAll ICUICU

CareCare ObserveObserve ObserveObserve IntubateIntubate?Operate?Operate


17/37


18/37

SECONDARYSECONDARY

SURVEY:SPINESURVEY:SPINE Complete Motor and Sensory ExamsComplete Motor and Sensory Exams

Imaging as IndicatedImaging as Indicated

Maintain InMaintain In--Line ImmobilizationLine Immobilization

Increased ICP with ManipulationIncreased ICP with Manipulation

Early Neurosurgical EvaluationEarly Neurosurgical Evaluation CAUTION:CAUTION:

Rapid DeteriorationRapid Deterioration


19/37

SPINAL PROTECTIONSPINAL PROTECTION

PROTECT FIRST, EVALUATEPROTECT FIRST, EVALUATESECONDSECOND

Deficit worsens frequently in hospitalDeficit worsens frequently in hospital Evaluation difficult with depressedGCSEvaluation difficult with depressedGCS

Padded long spine boardPadded long spine board

Remove spine board to logrollRemove spine board to logroll

Semirigid cervical collarSemirigid cervical collar

Remove collar only when CRemove collar only when C--spine clearedspine cleared


20/37

SPINAL EVALUATIONSPINAL EVALUATION

HemodynamicsHemodynamics

Glascow Coma ScaleGlascow Coma Scale

Neurologic examinationNeurologic examination

Assess for other injuriesAssess for other injuries

XX--ray of entire spineray of entire spineCT scan as neededCT scan as needed


21/37

CC--SPINE FILMSSPINE FILMS

Crosstable lateral to see allCrosstable lateral to see all 77vertebraevertebrae

Excludes 85% of injuriesExcludes 85% of injuries

AP and odontoid views very usefulAP and odontoid views very useful

May also needMay also need

Swimmers viewSwimmers viewCT scanCT scan


22/37

NEUROLOGIC EXAMNEUROLOGIC EXAM

Neurologic levelNeurologic level

Identify lowest functional levelIdentify lowest functional level

Motor and sensory levels oftenMotor and sensory levels often

differentdifferent

Sensory level can differ sideSensory level can differ side--toto--sidesideAssess sphincter functionAssess sphincter function

Bony level of injuryBony level of injury


23/37

NEUROGENIC SHOCKNEUROGENIC SHOCK

Injury to Descending SympatheticInjury to Descending SympatheticPathwaysPathways

Loss of Vasomotor ToneLoss of Vasomotor Tone Hypotension, BradycardiaHypotension, Bradycardia

No Response to Fluids AloneNo Response to Fluids Alone

Massive Infusion Can Cause OverloadMassive Infusion Can Cause Overload

Administer Atropine & PressorsAdminister Atropine & Pressors

NOT Spinal ShockNOT Spinal Shock


24/37

SPINAL SHOCKSPINAL SHOCK

MisMis--namednamed-- NOTNOT shockshock

Neurologic phenomenon, not circulatoryNeurologic phenomenon, not circulatory

Immediately after injuryImmediately after injury

Temporary loss of neurologic functionTemporary loss of neurologic function

Flaccidity and loss of reflexesFlaccidity and loss of reflexesVariable durationVariable duration

Recovery is commonRecovery is common


25/37

TREATMENT of SPINALTREATMENT of SPINAL

INJURYINJURY Prevent secondary injuryPrevent secondary injury

Maintain hemodynamicsMaintain hemodynamics

Assure oxygenationAssure oxygenationTreat neurogenic shockTreat neurogenic shock

Protect the spineProtect the spine-- immobilize as neededimmobilize as needed

Prevent decubitiPrevent decubiti Steroids to decrease edemaSteroids to decrease edema

Laminectomy for decompressionLaminectomy for decompression


26/37

SECONDARYSECONDARY

SURVEY:ADJUNCTSSURVEY:ADJUNCTSBlood TestsBlood Tests

UrinalysisUrinalysis

XX--RaysRays

CT ScanCT Scan

UrographyUrographyAngiographyAngiography

UltrasonographyUltrasonography

EchoEcho--

cardiographycardiography

BronchoscopyBronchoscopy

EsophagoscopyEsophagoscopy


27/37

BURNS and COLDBURNS and COLD


28/37

BURN INJURYBURN INJURY

Inhalation Injury: Intubate &Inhalation Injury: Intubate &Administer 100% OxygenAdminister 100% Oxygen

Administer 2Administer 2--4mL/kg/Body Surface4mL/kg/Body SurfaceArea Burn in 24 HoursArea Burn in 24 Hours

MonitorU

rinary OutputMonitorU

rinary OutputDress & Prevent HypothermiaDress & Prevent Hypothermia

Chemical Burns:Brush & IrrigateChemical Burns:Brush & Irrigate


29/37

BURN SIZEBURN SIZE

SiteSite ChildrenChildren Adults

Head& NeckHead& Neck 19%19% 9%

TrunkTrunk 26%26% 26%

ButtocksButtocks 6%6% 6%

ArmsArms 19%19% 19%

LegsLegs 30%30% 40%


30/37

BURN DEPTH

First Degree EpidermisFirst Degree Epidermis

Second Degree Epidermis,DermisSecond Degree Epidermis,Dermis

Third Degree SubquThird Degree Subqu

Fourth Degree Muscle/BoneFourth Degree Muscle/Bone


31/37

COLD INJURYCOLD INJURY

Frostbite: Rewarm with Moist Heat;Frostbite: Rewarm with Moist Heat;

Wait for DemarcationWait for Demarcation

Hypothermia: Passive or ActiveHypothermia: Passive or ActiveRewarmingRewarming

Monitor: Not Dead Until Warm andMonitor: Not Dead Until Warm andDeadDead


32/37

CONCLUSIONSCONCLUSIONS


33/37

MISSED INJURIESMISSED INJURIES

High Index of SuspicionHigh Index of Suspicion

Frequent ReevaluationFrequent Reevaluation

Continuous MonitoringContinuous Monitoring

Rapidly Recognize DeteriorationRapidly Recognize Deterioration


34/37

PAIN MANAGEMENTPAIN MANAGEMENT

Relieve Pain and AnxietyRelieve Pain and Anxiety

Administer IntravenouslyAdminister Intravenously

ShortShort--Acting and Reversible AgentsActing and Reversible Agents

Careful Patient MonitoringCareful Patient Monitoring


35/37


36/37


37/37

SUMMARYSUMMARY

AABBCCDDEE

One Safe WayOne Safe Way

Do No Further HarmDo No Further Harm

Treat Greatest Threat to Life FirstTreat Greatest Threat to Life First

Reevaluate OftenReevaluate OftenTeamworkTeamwork

Documents

CNS, Burns, Conclusion