Wednesday, July 30, 2008
Head Injury-Overview
Head injuries are a major cause of morbidity and mortality in all communities. Trauma is the third most common cause of death in the United States, exceeded only by cerebrovascular disease and cancer. Trauma is the leading cause of death in youth and early middle age and the death is often associated with major head trauma. Head injury contributes significantly to the outcome in over half of trauma-related deaths.
There are approximately 2.5 deaths from head injury per 10 000 population in Australia and neurotrauma causes approximately 3.5% of all deaths. Road traffic injuries (RTI) are responsible for about 65% of all fatal head injuries in Australia. In developing economies, trauma is the leading cause of death with many of them resulting from road traffic injuries (motor vehicles or motor cycles {AKA Okada in Nigeria}).Other causes include fall from heights (particularly in children), sports injuries and assault.
There is a wide spectrum of head injury from mild concussion to severe brain injury resulting in death. The management of the patient following a head injury requires the identification of the pathological processes that have occurred. Adequate attention must be paid to associated injuries whose management may sometimes take precedence over the head injury management.
CLASSIFICATION
The various ways of classifying head injury are:
1. According to aetiology e.g RTI, fall, sports
2. According to mode of injury:
a. Blunt
b. Penetrating
3. According to the state of the scalp and skull
a. Closed: in which scalp and skull are intact
b. Open: in which both are breached
4. According to the Glasgow Coma Score (GCS)
a. Mild: GCS 13-15
b. Moderate: GCS 9-12
c. Severe: GCS 3-8
NB: a. Coma is GCS < 8
b. Some workers classify GCS 3 - 4 as critical head injury
Monday, July 28, 2008
ABC of Resuscitation
Resuscitation of the injured patient is often an Herculean task for the untrained health workers. Similarly, some students find it difficult answering questions on the initial care of the acutely injured patient. In this entry I have tried to summarise, in simple language, the essential components of resuscitation, specifically for use in head injury, but with wide-ranging applications in other trauma cases. This information is also useful to the members of the public who may at one time or the other find themselves at accident scenes and have to provide initial care for the injured.
The components are:
• Airway and cervical spine control: check for, and maintain airway patency. Remove debris or food particles which may occupy the mouth and the upper airway thereby preventing adequate air entry. Jaw thrust and/or traction on the tongue might be needed to keep the airway patent. Insertion of oropharyngeal airways, and when indicated/available, oro- or nasotracheal intubation are essential in keeping the airways open. The patient may die rapidly from asphyxia if this initial step is not quickly and meticulously carried out. In doing all these, it is essential to protect the cervical spine which must be assumed to have been injured in all unconscious patients and in those who have sustained significant impact to the cranium, face, neck and upper chest as well as those involved in high-velocity impacts and falls from height.
C-spine protection can be achieved with:
o Rigid neck collars
o Head strappings
o Supportive sand bags placed on each side of the neck
• Breathing: If there is no spontaneous breathing, assisted breathing is essential once airway patency is confirmed. Mouth-to-mouth breathing (Kiss of life; through an handkerchief), ambu-bagging and mechanical ventilation are done as necessary
• Circulation: a quick assessment of the patient’s circulation is done; radial pulse is palpated and BP measurement carried out. Maintenance of the circulation is done using intravenous fluids (crystalloids and colloids) as necessary. This is particularly important in the poly-traumatized patients with haemorrhage. If the initial circulation is not optimal, a search must be made for extracranial bleeding sites as intracranial bleed is not sufficient to cause circulatory collapse except in infants and very young children.
• Drugs may need to be administered. Commonly used drugs in head injury includes mannitol, analgesics, H2-receptor blockers/proton pump inhibitors, inotropic agents, anaesthetic agents, tetanus prophylaxis, etc. Watch-out for a review of these drugs. It is important to also adequately assess the dysfunction of the nervous system
• Environment: it is important to ensure that the environment in which care of the patient is done is safe to prevent further injuries to the patient as well as the care givers
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The components are:
• Airway and cervical spine control: check for, and maintain airway patency. Remove debris or food particles which may occupy the mouth and the upper airway thereby preventing adequate air entry. Jaw thrust and/or traction on the tongue might be needed to keep the airway patent. Insertion of oropharyngeal airways, and when indicated/available, oro- or nasotracheal intubation are essential in keeping the airways open. The patient may die rapidly from asphyxia if this initial step is not quickly and meticulously carried out. In doing all these, it is essential to protect the cervical spine which must be assumed to have been injured in all unconscious patients and in those who have sustained significant impact to the cranium, face, neck and upper chest as well as those involved in high-velocity impacts and falls from height.
C-spine protection can be achieved with:
o Rigid neck collars
o Head strappings
o Supportive sand bags placed on each side of the neck
• Breathing: If there is no spontaneous breathing, assisted breathing is essential once airway patency is confirmed. Mouth-to-mouth breathing (Kiss of life; through an handkerchief), ambu-bagging and mechanical ventilation are done as necessary
• Circulation: a quick assessment of the patient’s circulation is done; radial pulse is palpated and BP measurement carried out. Maintenance of the circulation is done using intravenous fluids (crystalloids and colloids) as necessary. This is particularly important in the poly-traumatized patients with haemorrhage. If the initial circulation is not optimal, a search must be made for extracranial bleeding sites as intracranial bleed is not sufficient to cause circulatory collapse except in infants and very young children.
• Drugs may need to be administered. Commonly used drugs in head injury includes mannitol, analgesics, H2-receptor blockers/proton pump inhibitors, inotropic agents, anaesthetic agents, tetanus prophylaxis, etc. Watch-out for a review of these drugs. It is important to also adequately assess the dysfunction of the nervous system
• Environment: it is important to ensure that the environment in which care of the patient is done is safe to prevent further injuries to the patient as well as the care givers
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Symptoms of Brain Tumour
A brain tumour takes up space within the skull and
interferes with normal brain activity. A tumour
can cause damage by increasing pressure in the brain,
shifting the brain or pushing against the skull, and invading
and damaging nerves and healthy brain tissue. The location
of a brain tumor influences the type of symptoms that occur.
This is because different functions are controlled by different
parts of the brain.
A brain tumor can block the flow of cerebrospinal fluid (CSF) between
the ventricles, causing a buildup of CSF and swelling,
called brain oedema. Oedema can lead to symptoms including
headaches, seizures, or focal deficits. Focal deficits include
damage to sensory or movement abilities, problems in the ability
to process information, personality changes, and speech disorders.
A tumour of the spinal cord can block the communication
between the brain and nerves throughout the body. This can
lead to problems with movement or physical sensation.
The most common symptoms include:
• Headaches, which can be most severe at nights
• Seizures or convulsions
• Difficulty thinking, speaking, or finding words
• Personality changes
• Weakness or paralysis in one part or one side of the body
• Loss of balance
• Vision changes
• Nausea or vomiting, particularly early-morning
• Confusion and disorientation
interferes with normal brain activity. A tumour
can cause damage by increasing pressure in the brain,
shifting the brain or pushing against the skull, and invading
and damaging nerves and healthy brain tissue. The location
of a brain tumor influences the type of symptoms that occur.
This is because different functions are controlled by different
parts of the brain.
A brain tumor can block the flow of cerebrospinal fluid (CSF) between
the ventricles, causing a buildup of CSF and swelling,
called brain oedema. Oedema can lead to symptoms including
headaches, seizures, or focal deficits. Focal deficits include
damage to sensory or movement abilities, problems in the ability
to process information, personality changes, and speech disorders.
A tumour of the spinal cord can block the communication
between the brain and nerves throughout the body. This can
lead to problems with movement or physical sensation.
The most common symptoms include:
• Headaches, which can be most severe at nights
• Seizures or convulsions
• Difficulty thinking, speaking, or finding words
• Personality changes
• Weakness or paralysis in one part or one side of the body
• Loss of balance
• Vision changes
• Nausea or vomiting, particularly early-morning
• Confusion and disorientation
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