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Emergency Procedure and Patient Care-Lec-6 BY Asghar Director/Associate professor Riphah College of Rehabilitation Sciences(RCRS) Riphah International University Islamabad Head Injuries • • • • • • • • • • • • • Pathomechanics of brain injuries Types of pathology Classification of cerebral concussion Cerebral contusion Cerebral hematoma Second impact syndrome Initial on site assessment Sideline assessment Special tests for assessment of coordination Special tests for assessment of cognition Other tests Medications Wake ups and rest Pathomechanics of Brain Injuries • Cerebral concussion can be defined as any transient neurological dysfunction resulting from an applied force to the head. • A forceful blow to the resting movable head usually produces maximum brain injury beneath the point of cranial impact.This is known as a coup injury. • A moving head hitting against an unyielding object usually produces maximum brain injury opposite the site of cranial impact (countercoup injury) as the brain rebounds within the cranium. Pathomechanics of Brain Injuries • Three types of stresses can be generated by an applied force when considering injury to the brain: • Compressive: Compression involves a crushing force whereby the tissue cannot absorb any additional force or load. • Tensile : Tension involves pulling or stretching of tissue • Shearing: Shearing involves a force that moves across the parallel organization of the tissue Types of Pathology Traumatic brain injury (TBI), which can be classified into two types: focal and diffuse. Focal brain injuries are posttraumatic intracranial mass lesions that may include subdural hematomas, epidural hematomas, cerebral contusions, and intracerebral hemorrhages and hematomas. Focal Brain Injuries Signs and symptoms of these focal vascular emergencies can include: Loss of consciousness Cranial-nerve deficits Mental-status deterioration Worsening symptoms Diffuse Brain Injuries • Diffuse brain injuries can result in widespread or global disruption • • • • of neurological function and are not usually associated with macroscopically visible brain lesions except in the most severe cases. Most diffuse injuries involve an acceleration–deceleration motion, either within a linear plane or in a rotational direction, or both. In these cases, lesions are caused by the brain essentially being shaken within the skull. The brain is suspended within the skull in CSF and has several dural attachments to bony ridges that make up the inner contours of the skull. With a linear acceleration–deceleration mechanism (side to side or front to back), the brain experiences a sudden momentum change that can result in tissue damage. Classification of Cerebral Concussion • Concussion is caused by a direct blow to the head or elsewhere on the body, resulting in a sudden mechanical loading of the head that generates turbulent rotatory and other movements of the cerebral hemispheres. • Concussion is most often associated with normal results on conventional neuroimaging studies, such as magnetic resonance imaging (MRI) or computed tomography (CT) scan Mild Concussion • The mild concussion, which is the most frequently occurring (approximately 85%), is the most difficult head injury to recognize and diagnose. • The force of impact causes a transient aberration in the electrophysiology of the brain substance, creating an alteration in mental status. • Mild concussion involves no loss of consciousness, dizziness and tinnitus (ringing in the ears) may also occur, but there is rarely a gross loss of coordination that can be detected with a Romberg test. The clinician should never underestimate the presence of a headache, which presents to some degree in nearly all concussions. • The intensity and duration of the headache can be an indication of whether the injury is improving or worsening over time. Moderate Concussion • The moderate concussion is often associated with transient mental confusion, tinnitus, moderate dizziness, unsteadiness and prolonged posttraumatic amnesia (30 minutes). • A momentary loss of consciousness often results, lasting from several seconds up to 1 minute. • Blurred vision, dizziness, balance disturbances, and nausea may also be present. Severe Concussion • It is not difficult to recognize a severe concussion because these injuries present with signs and symptoms lasting significantly longer than those of mild and moderate concussions. • Most experts agree that a concussion resulting in prolonged loss of consciousness should be classified as a severe concussion. • Neuromuscular coordination is markedly compromised, with severe mental confusion, tinnitus, and dizziness. Cerebral Contusion • The brain substance may suffer a cerebral contusion (bruising) • when an object hits the skull or visa versa. The impact causes injured vessels to bleed internally, and there is a associated loss of consciousness. • A cerebral contusion may be associated with partial paralysis or hemiplegia, one-sided pupil dilation, or altered vital signs and may last for a prolonged period. • Progressive swelling (edema) may further compromise brain tissue not injured in the original trauma. Cerebral Hematoma • The skull fits the brain like a custom-made helmet, leaving little room for space-occupying lesions like blood clots. • Blood clots, or cerebral hematomas, are of two types, epidural and subdural, depending on whether they are outside or inside the dura mater. • Each of these can cause an increase in intracranial pressure and shifting of the cerebral hemispheres away from the hematoma. • The development of the hematoma may lead to deteriorating neurological signs and symptoms typically related to the intracranial pressure. Epidural Hematoma • An epidural hematoma most commonly results from a severe blow to the head that typically produces a skull fracture in the temporoparietal region. • These are usually isolated injuries involving acceleration– deceleration of the head, with the skull sustaining the major impact forces and absorbing the resultant kinetic energy. • The epidural hematoma involves an accumulation of blood between the dura mater and the inner surface of the skull as a result of an arterial bleed—most often from the middle meningeal artery. • These are typically fast-developing hematomas leading to a deteriorating neurological status within 10 minutes to 2 hrs Subdural Hematoma • The mechanism of the subdural hematoma is more complex. • The force of a blow to the skull thrusts the brain against the point of impact. As a result, the subdural vessels stretch and tear, leading to the development of a hematoma in the subdural space. • Bleeding into the subdural space is typically venous in origin; the resultant hematoma will therefore accumulate over a longer period of time compared to an epidural hematoma. • This pathology has been divided into acute subdural hematoma, which presents in 48 to 72 hours after injury, and chronic subdural hematoma, which occurs in a later time frame with more variable clinical manifestations. • As bleeding produces low pressure with slow clot formation, symptoms may not become evident until hours or days (acute) or even weeks later (chronic), when the clot may absorb fluid and expand. Intracerebral Contusion and Hemorrhage • A cerebral contusion is a heterogeneous zone of brain damage that consists of hemorrhage, cerebral infarction, necrosis, and edema. • Cerebral contusion is a frequent sequela of head injury and is often considered the most common traumatic lesion of the brain visualized using imaging studies. • Typically, these are a result of an inward deformation of the skull at the impact site Second Impact Syndrome(SIS) • SIS occurs when a person who has sustained an initial head trauma, most often a concussion, sustains a second injury before symptoms associated with the first have totally resolved. Often, the first injury was unreported or unrecognized. • SIS usually occurs within 1 week of the initial injury and involves rapid brain swelling and herniation as a result of the brain losing autoregulation of its blood supply. • Brain stem failure develops in 2 to 5 minutes, causing rapidly dilating pupils, loss of eye movement, respiratory failure, and eventually coma. On-Site Assessment Primary Survey: Rule out life-threatening condition History Mental confusion Check respirations (breathing) Check cardiac status Secondary Survey History: Mental confusion, Loss of consciousness, Amnesia Observation: Monitor eyes,Deformities, abnormal facial expressions, speech patterns, respirations, extremity movement Palpation :Skull and cervical spine abnormalities Pulse and blood pressure (if deteriorating) Cranial Nerves: Function and Assessment • Nerve Name • I -Olfactory Sense of smell Identify odor II -Optic Vision Check for blurred or double vision III- Oculomotor Control size of pupil, some eye motions Check pupil reactivity; check upward and downward eye motion IV -Trochlear Some eye motions Check lateral eye motion V-Trigeminal Jaw muscles Check ability to keep mouth closed VI- Abducens Some eye motions Check lateral and medial eye motion VII- Facial Some facial muscles Check ability to squeeze eyes closed tightly or “big smile” VIII-Vestibulocochlear Hearing; balance Check for loss of hearing on one side; balance testing IX- Glossopharyngeal Gag reflex Check ability to swallow X-Vagus Controls voice muscles Check ability to say “ahhh” XI- Accessory Innervate trapezius muscles Check resisted shoulder shrug XII- Hypoglossal Motor function of tongue Check ability to stick out tongue • • • • • • • • • • • • • • Function Assessment Six testing conditions for the Balance Error Scoring System (BESS). Double-leg stance on firm surface Single-leg stance on firm surface Tandem on firm surface. Double-leg stance on foam surface Single-leg stance on foam surface Tandem on foam surface Physical Therapy Management • Pain management • Positioning • Balance • Coordination • Muscle strength • ROM • Endurance • Gait training