Trauma Craniencefálico O Comitê de Trauma Apresenta Trauma Craniencefálico 6-1 Title Slide The instructor should introduce the topic and relate to the students that base don their preparation for the course, a series of questions will be asked throughout the lecture, and their active participation and responses are expected. The first mouse click causes the “Committee on Trauma” to “type” in and the second click causes the photograph and lecture title to stripe down to the right. This individual sustained a basal skull fracture. The corresponding Battle’s sign is apparent. Note: Pressing the down arrow key on the computer keyboard or left-clicking on the mouse initiates the animation on the slide. For brevity in this dialogue, mouse clicking is referenced. However, either method may be used. (Photograph: Courtesy of Charles Aprahamian, MD, FACS) ©ACS

Objetivos Descrever as bases da fisiologia cerebral. Reconhecer a importância de prevenir a lesão cerebral secundária. Fazer um exame neurológico dirigido. Estabilizar o paciente e encaminhá-lo para o tratamento definitivo. 6-2 Objectives The instructor should review the objectives with the students as provided on the slide, while emphasizing the important aspects in the approach to the brain-injured patient. Each objective appears with a mouse click, the preceding item dimming as the next one appears. ©ACS

Questões-Chave Quais são as características específicas da anatomia e da fisiologia do cérebro e como é que elas afetam os padrões de lesão cerebral? O que é um exame neurológico dirigido? Qual deve ser o tratamento ideal do paciente com lesão cerebral? Como é feito o diagnóstico de morte cerebral? 6-3 Key Questions The instructor indicates that these are the primary questions to be pursued during the presentation. Each question appears with a mouse click and then dims with the next mouse click. Note: To facilitate an interactive discussion, the instructor may wish to prepare additional, related questions to ask during the presentation. ©ACS

Efeitos da anatomia e da fisiologia? O crânio é uma estrutura rígida, não expansível, preenchida por cérebro, líquor e sangue Autorregulação do fluxo sanguíneo cerebral A lesão cerebral altera a autorregulação A hemorragia intracraniana leva a efeito de massa 6-4 What are the unique features of brain anatomy and physiology, and how do they affect patters of brain injury? The instructor should reveal the responses on the slide after the students have discussed the anatomic and physiologic affects on brain-injury care. The instructor should make these salient points. Cerebral blood flow (CBF) is autoregulated closely by vasodilatation and vasoconstriction, which allows for constancy over a wide range of blood pressures. Carbon dioxide changes in the blood also affect cerebral vasodilatation and vasoconstriction. Brain injury disrupts this autoregulatory mechanism. Intracranial bleeding causes a mass effect within the brain. This is initially compensated for by venous constriction and absorption of cerebrospinal fluid. Because the skull does not expand and as compensatory mechanisms begin to fail, blood flow to the brain is reduced. Although there is not a direct linear relationship between cerebral blood flow and cerebral perfusion pressure, the Monro-Kellie Doctrine describes the uncompensated state that is reached when a mass reaches a specific size. (See next slide with graphic depiction of the Monro-Kellie Doctrine. Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click. ©ACS

A Doutrina de Monro-Kellie Sangue venoso arterial Cérebro LCR Sangue venoso arterial Cérebro LCR Massa 6-5 Monro-Kellie Doctrine (See description for slide 6-4 and related text in manual.) The instructor should briefly review this graphic depiction of a mass’s effect on the brain. Note: This slide is not animated. Sangue arterial Cérebro LCR 75 mL Massa ©ACS

Curva Volume – Pressão PIC Volume da Massa Herniação Ponto de 60- 55- 50- 45- 40- 35- 30- 25- 20- 15- 10- 5- Herniação Ponto de Descompensação PIC (mm Hg) 6-6 Volume-Pressure Curve The instructor should relate to the students that an exponential increase in intracranial pressure (ICP) associated with a small increase in the volume of the mass, results in increased pressures in the rigid skull and reduced cerebral blood flow. The x and y axes are not animated on this slide. However the line of compensation, point of decompensation, and point of herniation are animated. The first click of the mouse causes the line of compensation to stretch from left to right to the point of decompensation. The second mouse click results in the line curving up to the right to include the point of decompensation and herniation. Compensação Volume da Massa ©ACS

Pressão Intracraniana (PIC) 10 mm Hg = Normal > 20 mm Hg = Aumentada > 40 mm Hg = Grave Alterada em muitos processos patológicos A PIC persistentemente  leva a piora da função cerebral e do prognóstico 6-7 Intracranial Pressure (ICP) Dr. Parks and Dr. Marion: Need narrative for this slide Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click ©ACS

Pressão de Perfusão Cerebral* – PAM PIC = PPC Normal 90 10 80 Resposta de Cushing 100 20 80 6-8 Cerebral Perfusion Pressure The instructor should relate to the students that intracranial pressure follows the Monro-Kellie Doctrine. The Cushing Response is compensation for increased ICP. If hypotension ensues for any reason, secondary brain injury occurs and the outcome is worsened significantly. This table graphically depicts these factors. The instructor also should relate to the students that cerebral perfusion pressure does not equate with cerebral blood flow. Note: This slide is not animated. Hipotensão 50 20 30 * PPC  Fluxo Sanguíneo Cerebral ©ACS

Autorregulação Quando a autorregulação está intacta, o fluxo sanguíneo cerebral mantém-se constante para valores de PAM entre 50 e 160 mm Hg. Lesão cerebral moderada a grave: Muitas vezes há comprometimento da autorregulação. O cérebro fica mais vulnerável a episódios de hipotensão  lesão cerebral secundária. 6-9 Autoregulation The instructor may query the students about the autoregulatory mechanism of the brain. The instructor should emphasize that if autoregulation is impaired due to brain injury, the brain is significantly more vulnerable to secondary brain injury. Therefore, brain-injury treatment focuses on the prevention of secondary brain injury. Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click ©ACS

Classificação das Lesões Cerebrais Quanto ao Mecanismo Trauma fechado: Alta e baixa velocidade 6-10 Classification of Head Injury by Mechanism of Injury Two mechanisms of injury may cause brain injury, blunt and penetrating. Blunt trauma can be of high or low velocity, eg, motor vehicle crashes, falls, and blunt assault. Depicted here is a patient with Battle’s sign resulting from blunt trauma and basilar skull fracture. (Photo used with permission of Trauma.org. Adrian Caceres. Neurotrauma Images – neuro0014. Trauma.org, http://www.trauma.org/imagebank/imagebank.html.) Gunshot wounds are almost always lethal. Depicted here is a patient with a gunshot wound to the left frontoparietal region. (Photo used with permission of Trauma.org. Author unknown. Neurotrauma Images – neuro0004a. Trauma.org, http://www.trauma.org/imagebank/imagebank.html.) The first mouse click results in the first bulleted item with photograph to stretch from left to right across the screen. The second mouse click causes the same to occur with the second bulleted item. Ferimentos penetrantes: Arma de fogo e outros ©ACS

Classificação das Lesões Cerebrais Quanto à Morfologia: Fraturas de Crânio Com / sem afundamento Exposta / fechada Calota 6-11 Classifications of Head Injury by Skull Morphology This slide is not animated. Drs. Marion and Parks: The text discusses linear and stellate, but not depressed / nondepressed. Will this inconsistency be confusing to the students? The instructor should relate to the students that linear fractures increase the incidence of intracranial hematoma by 400 times in an awake patient and 20 times in a comatose patient, the latter of which already has a higher incidence of intracranial hematoma. Open fractures are associated with an increase risk of meningitis. Basal fractures have an associated risk of CSF leak. Clinical symptoms (raccoon eyes, Battle’s sign, otorrhea, and rhinorrhea) should increase the index of suspicion in identifying basal skull fractures. Com / sem perda de LCR Com / sem paralisia do VII par craniano Base ©ACS

Classificação das Lesões Cerebrais Quanto à Morfologia: Cérebro Epidural (extradural) Subdural Intracerebral Focal 6-12 Classifications of Head Injury by Brain Morphology Drs. Parks and Marion: Need narrative for this slide Concussão Contusões múltiplas Lesão hipóxica / isquêmica Difusa ©ACS

Lesão Cerebral Difusa Concussão leve  Lesão isquêmica, grave CT Normal Lesão Difusa 6-13 Diffuse Brain Injury The key point for the instructor to make here is that diffuse brain injury may range from a mild concussion to a severe, ischemic insult. The instructor might query the students about symptoms of a concussion. Typically, these include a transient loss of consciousness and retrograde or antegrade amnesia. Nausea, vomiting, and headache symptoms may worsen before lessening. Sequellae are common. The instructor may query the students about the cause of severe diffuse brain injury. This latter type of injury usually results from a combination of trauma and hypoxia, due to airway and breathing problems at the time of injury. A normal CT scan (mouse click to reveal normal CT scan) is common, but diffuse edema (click mouse to reveal diffuse injury) may exist. The instructor should emphasize that the CT should be repeated for any significant symptoms, eg, persistent or worsening headache, somnolence, and change in GCS score. Note: Need CT of diffuse injury ©ACS

Hematoma Epidural Associado a fratura de crânio Clássico: Ruptura da artéria meníngea média Forma de lente / biconvexa Intervalo lúcido Pode ser rapidamente fatal O esvaziamento precoce é essencial 6-14 Epidural (extradural) Hematoma The instructor may query the students about factors related to epidural hematomas. Once the students have provided their responses, the instructor reveals the items on the slide in summary of the discussion. Each mouse click reveals a bulleted item and dims the preceding item. The instructor should emphasize that with early evacuation of the hematoma, the patient can recover completely. The instructor also should note that sometimes the patient is unconscious and will not have a lucid interval. The corresponding CT scan of an epidural hematoma is on the next slide and is the same as that in the students’ manual. ©ACS

Hematoma Epidural Temporal Herniaçãodo úncus 6-15 Epidural Hematoma The instructor should explain that on CT an epidural hematoma appears lenticular / biconvex due to the dura’s adherence to the skull. ©ACS

Hematoma Subdural Ruptura venosa / laceração do cérebro Espalha-se pela superfície do cérebro Morbidade / mortalidade devidas à lesão cerebral subjacente Recomenda-se o esvaziamento cirúrgico de urgência, especialmente se houver desvio da linha média > 5 mm 6-16 Subdural Hematoma The instructor may query the students about factors related to subdural hematomas. Once the students have provided their responses, the instructor reveals the items on the slide in summary of the discussion. Each mouse click reveals a bulleted item and dims the preceding item. The instructor should relate that bleeding from the surface of the brain and the amount of brain injury determine the patient’s mortality. Early evacuation is recommended, but outcome may be determined by the severity of the underlying brain injury. ©ACS

Hematoma Subdural 6-17 Subdural hematoma ©ACS

Contusão / Hematoma Lesões por golpe / contragolpe Mais freqüente: Lobos frontal / temporal Alterações tomográficas geralmente progressivas Maioria dos pacientes conscientes: Não é necessária cirurgia 6-18 Contusion/Hematoma The instructor may query the students about factors related to cerebral contusions and hematomas. Once the students have provided their responses, the instructor reveals the items on the slide in summary of the discussion. Each mouse click reveals a bulleted item and dims the preceding item. Contusions are fairly common and occur in up to 30% of severe brain injuries. Coup injury is where the brain is impacted and contrecoup injury is where the brain bounces off the skull on the opposite side of the impact. Cerebral contusions and hematomas are frequently progressive injuries and contusions may coalesce into hematomas. For this reason, repeat CT scans are important to follow the patient’s progress. ©ACS

Extensa contusão frontal, com desvio Contusão / Hematoma Extensa contusão frontal, com desvio 6-19 Large frontal contusion with shift ©ACS

Lesão Cerebral Leve Observar ou liberar conforme os achados Glasgow = 14-15 História Excluir outras lesões Exame neurológico Radiografias conforme o caso Investigar álcool / drogas Indicação liberal de tomografia de crânio 6-20 Mild Brain Injury The instructor should relate to the students that determining the GCS score is a good way to stratify brain injury by mild, moderate, and severe. The instructor should relate to the students that approximately 805 of the patients seen in the emergency department with a head injury have a mild brain injury. The instructor may discuss each salient point as it appears on the screen. If patients are to be discharged, they must be alert and oriented enough to understand the written discharge instructions and should have a companion to stay with them for the next 24 hours. Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click Observar ou liberar conforme os achados ©ACS

Lesão Cerebral Moderada Glasgow = 9-13 Avaliação inicial como na lesão leve Tomografia em todos os pacientes Internar e observar Exame neurológico freqüente Repetir a tomografia 6-21 Moderate Brain Injury The instructor reviews each salient point about moderate brain injury as it appears on the screen. Approximately 10% of brain-injured patients seen in the emergency department have a moderate brain injury. They are confused and somnolent, and may a have focal neurologic deficit. Between 10% and 20% of the patients with a moderate brain injury deteriorate neurologically and lapse into a coma. Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click Piora: Tratar como lesão cerebral grave ©ACS

Lesão Cerebral Grave Glasgow = 3-8 Avaliar e reanimar Intubar para proteção de vias aéreas Exame neurológico dirigido Reavaliação freqüente Diagnosticar as lesões associadas 6-22 Severe Brain Injury The instructor reviews each salient point about moderate brain injury as it appears on the screen. Patients with severe brain injury cannot protect their airway and need to be intubated. Secondary brain injury is disastrous. Hypotension alone increases mortality from 27% to 60%. Hypoxia, in addition to hypotension, is associated with a mortality of 75. Therefore, it is imperative that the patient’s cardiopulmonary status be optimized. Associated injuries that might result in hypotension or hypoxia must be identified early. Therefore, evaluation for occult injuries is routine, eg, CT of the abdomen, FAST, DPL, or chest x-ray. The instructor should emphasize the need for a CT scan, frequent neurologic revaluations, and repeat CT scans to identify progressive injuries. Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click ©ACS

Prioridades ABCDE Minimizar a lesão cerebral secundária Administrar O2 Manter a pressão arterial (sistólica > 90 mm Hg) 6-23 Priorities The instructor uses this slide to reemphasize the need to secure and maintain a patent airway, administer oxygen, and prevent secondary brain injury. These management measures provide optimal management of the brain-injured patient. Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click ©ACS

Exame Neurológico Dirigido? Pupilas Glasgow Sinais de lateralização Consultar precocemente o neurocirurgião ©ACS

Tratamento Clínico Soluções intravenosas Ventilação controlada Euvolemia Isotônicas Ventilação controlada 6-25 Medical Management The instructor should emphasize the need to maintain good circulating blood volume, adequate oxygenation, and controlled ventilation. The instructor also should emphasize the need to avoid hyperventilation and why. Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click. Objetivo: PaCO2 de 35 mm Hg ©ACS

Indicações de Tomografia? 6-26 Indications for CT Scan When this slide first appears on the screen, the instructor may ask the students what the indications are for obtaining a head CT scan. The students should respond, with direction from the instructor, “All patients with suspicion of a brain injury.” The instructor can then reveal the statement in the 3-dimensional box. ©ACS

Indicações de Tomografia? Todos os pacientes com suspeita de lesão cerebral 6-26 Indications for CT Scan When this slide first appears on the screen, the instructor may ask the students what the indications are for obtaining a head CT scan. The students should respond, with direction from the instructor, “All patients with suspicion of a brain injury.” The instructor can then reveal the statement in the 3-dimensional box. ©ACS

Tratamento Clínico Manitol Usar se houver sinais de herniação tentorial Dose: 1,0 g / kg, EV, em bolo Consultar antes o neurocirurgião 6-27 Medical Management: Mannitol The instructor may use this slide to query the students about the use of Mannitol (indications, dose, etc). After a brief discussion the instructor may reveal the bulleted text items under Mannitol. The instructor should stress that a 20% Mannitol solution usually is used for IV boluses over a 5-minute period. Repeated doses of Mannitol should not be given to hypotensive patients because it is a potent diuretic and may cause hypovolemia. A brief discussion of other drugs can then ensue. Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click. ©ACS

Tratamento Clínico Outras medicações Anticonvulsivantes Sedação Drogas paralisantes (curarização) 6-28 Medical Management: Other Drugs Phenytoin is commonly given to brain-injured patients to prevent seizures during the 1st week after injury. This should be determined by the neurosurgeon caring for the patient. Sedatives and paralytics are used to control the combative, agitated patient. They sometimes reduce ICP in these patients and allow performance of the CT scan. Care must be used to prevent hypotension, and the user must realize that the clinical symptoms change after the administration of these agents. Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click. ©ACS

Tratamento Cirúrgico Lesões de Couro Cabeludo Local de possível sangramento intenso Compressão direta para parar o sangramento Eventualmente, fechamento temporário 6-29 Surgical Management: Scalp Injuries The instructor briefly reviews the management of scalp lacerations, while emphasizing that the scalp can be a source of major blood loss, especially in children. Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click. ©ACS

Tratamento Cirúrgico Lesão Intracraniana com Efeito de Massa Risco de vida, se rapidamente expansível Consultar imediatamente o neurocirurgião Hiperventilação / Manitol Craniotomia para controle do dano (“damage control”) : Transferir para neurocirurgião (áreas rurais / afastadas) 6-30 Surgical Management: Intracranial Mass Lesion The instructor may query the students about managing a patient with an expanding intracranial mass lesion in a remote or austere environment. The instructor can present a simple and brief case history. The students’ responses should include those on the slide. The instructor may then reveal the bulleted items on the slide, while emphasizing that patients with a severe brain injury and a rapidly expanding mass lesion should be transported rapidly to neurosurgical care. Transfer delays to stop the bleeding and stabilize the patient is appropriate. However, transfer delays for tests, eg, CT scans, must be avoided. An emergency craniotomy, performed by a nonneurosurgeon, is not recommended by the Committee on Trauma. In areas where neurosurgical care is not available, the Committee on Trauma recommends that the surgeons residing in the area should anticipate this need and obtain the proper training from a neurosurgeon before the situation arises. Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click. ©ACS

Diagnóstico de morte cerebral? Clínico Exames Subsidiários Glasgow = 3 Pupilas arreativas Ausência de reflexos de tronco cerebral Ausência de esforço ventilatório espontâneo EEG: Sem atividade Doppler ou estudo com radioisótopos: Sem fluxo PIC > PAM por pelo menos 1 hora Sem resposta cardíaca à atropina 6-31 How do I diagnose brain death? After asking this question of the students, the instructor asks for the clinical signs of brain death. The students elicit their responses and the instructor summarizes this component of the discussion by revealing the bulleted items under “Clinical” on the slide. The instructor then asks what ancillary studies might be performed to determine brain death. The students elicit their responses and the instructor then summarizes this component of the discussion by revealing the bulleted items under “Ancillary Studies” on the slide. The instructor may indicate that many people rely on the ancillary studies to diagnose brain death. The instructor should emphasize that certain reversible conditions can mimic brain death, eg, hypothermia and barbiturate coma. Physiologic parameters should be normalized. The instructor then reveals the last item on the slide, “Remember organ donation.” In trauma and nontrauma centers, doctors should be aware of the need for organ donation. Recognizing potential organ donors is important. The determination of brain death is appropriate in these situations. U.S. federal law requires that organ procurement agencies be notified of all patients with the diagnosis of or impending diagnosis of brain death. Lembrar da doação de órgãos ©ACS

? 6-32 Questions A click of the mouse causes the question mark to spiral onto the screen. ©ACS

Resumo: O que fazer? Manter PA > 90 mm Hg Manter PaCO2 próximo de 35 mm Hg Usar soluções isotônicas para manter a euvolemia Exame neurológico freqüente Uso liberal da tomografia Consultar precocemente o neurocirurgião 6-33 Summary: What should I do? The students should identify these main items of what to do for the brain-injured patient. After eliciting their responses, the instructor reveals each of the bulleted items in summary to the discussion, making any salient points not made by the students. Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click. ©ACS

Resumo: O que não fazer? Deixar o paciente ficar hipotenso Hiperventilar de forma exagerada Usar soluções intravenosas hipotônicas Usar drogas curarizantes de ação prolongada Curarizar antes de examinar completamente Depender apenas do exame clínico 6-34 Summary: What should I not do? The students should identify these main items of what to do for the brain-injured patient. After eliciting their responses, the instructor reveals each of the bulleted items in summary to the discussion, making any salient points not made by the students. Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click. ©ACS