颅脑损伤(英文版)说课讲解课件.ppt

1、“Boy,do I have an Excedrin headache!”managing the head injured patientLeaugeay Webre BS,CCEMT-P,NREMT-PScenario While descending Mt Hood in Oregon,Bob tumbled head over heels,and came to a stop dangling off a precipice by his Telemark ski at 11,000 ft.On arrival the ski patrol paramedics Bobs breath

2、ing was sonorous and shallow,and he had a GCS of 3-4.The only obvious injuries were to his head.His BP was 87/55,HR 100 and RR 16 How should the paramedics treat this patient?Should he be intubated?Should he be fluid resuscitated?Common major trauma4 million people experience head trauma annually Se

3、vere head injury is most frequent cause of trauma death GSW to cranium:75-80%mortalityAt Risk population Males 15-24 Infants Young Children ElderlyIntroduction to Head,Facial,&Neck InjuriesTIME IS CRITICAL Intracranial Hemorrhage Progressing Edema Increased ICP Cerebral Hypoxia Permanent DamageSever

4、ity is difficult to recognize Subtle signs Improve differential diagnosis Improves survivabilityIntroduction to Head,Facial,&Neck InjuriesScalp Strong Flexible mass of Skin Fascia Muscular Tissue Highly Vascular Hair provides Insulation Structures Beneath Galea Aponeurotica Between scalp and skull F

5、ibrous connective sheath Subaponeurotica(Areolar)Tissue Permits venous blood flow from the dural sinuses to the venous vessels of scalp Emissary Veins:Potential route for InfectionAnatomy&Physiology of the HeadParietalSuture LineFrontalTemporalOrbitsMaxillaeMandibleTemporal Mandibular JointOcciptalN

6、asal BonesZygomatic ArchSphenoidForamen Magnum(Hole in Base)Brain Occupies 80%of cranium Comprised of 3 Major Structures Cerebrum Cerebellum Brainstem High metabolic rate Receives 15%of cardiac output Consumes 20%of bodys oxygen Requires constant circulation IF Blood supply stops Unconscious within

7、10 seconds Death in 4-6 minutesAnatomy&Physiology of the Head Cerebral Perfusion Pressure Pressure within cranium(ICP)resists blood flow and good perfusion to the CNS Pressure usually less than 10 mmHg Mean Arterial Pressure(MAP)Must be at least 50 mmHg to ensure adequate perfusion MAP=DBP+1/3 Pulse

8、 Pressure Cerebral Perfusion Pressure(CPP)Pressure moving blood through the cranium CPP=MAP-ICPAnatomy&Physiology of the Head Calculating MAP(mean arterial pressure)DBP+1/3 PP PP(pulse pressure)=SBP-DBP SBP+2(DBP)3 Calculating CPP(cerebral perfusion pressure)MAP ICP ICP normally 90 systolic CPP=MAP-

9、ICP Most important to keep MAP=/70 Hypotension in the face of cerebral edema results in decreased CPP(cerebral perfusion pressure)MAP(2)DBP+SBP 3 Normal(70-100)Hypoxia Defined as SpO2 90 Preferably Map 70 mm HG Fluid of choice LR or NS Glucose causes fluid to be pulled into cells resulting in cerebr

10、al edemaMonitor Continuously monitor VS for Sx of rising ICP Changes in breathing patterns Increasing BP Decreasing HR Unequal pupils PosturingPosition Elevated HOB Midline head placement Assists with venous drainage from the head which decreases ICPHyperthermia Causes an increase in ICP and should

11、be regulated Head injured patients often suffer from increased body temperatures and should be monitored Acetaminophen and other cooling techniques may be used Do not induce hypothermia which may lead to shivering which results in increased ICPSeizures In the event of seizures treatment should be in

12、itiated immediately due to resultant hypoxia and increased ICP Treatment may include the use of Valium and Cerebyx Valium does not terminate abnormal electrical discharge as fosphenytoin does Patients may need to be in an induced barbiturate comaTreatment in Herniation Hyperventilate to EtCo2 of no

13、95%Medications:Diuretics Mannitol(osmotrol)MOA Large glucose molecule Does not leave blood stream Osmotic Diuretic Effective in drawing fluid from brain Contraindication Hypovolemia&Hypotension CHF Dose 1gm/kg CAUTION Forms crystals at low temperatures Reconstitute with rewarming&gentle agitation US

14、E IN-LINE filter&PREFLUSH lineMedications:Diuretics Furosemide(Lasix)MOA Loop Diuretic Inhibits reabsorption of Na+in Kidneys Increased secretion of water and electrolytes Na+,Cl,Mg+,Ca+.Venous dilation&Reduces cardiac preload May be given in combination with Mannitol Not effective in reducing cereb

15、ral edema Contraindication Pregnancy:fetal abnormalities Dose Slow IVP or IM over 1-2 minutes 0.5-1 mg/kg:Commonly 40 or 80 mgMedications:ParalyticsSuccinylcholine(Anectine)MOA Depolarizing Medication Causes Fasciculations Onset&Duration Onset:30-60 seconds Duration:2-3 minutes Precaution Paralyzes

16、ALL muscles including those of respiration Increases intraoccular eye pressure Contraindication Penetrating eye injury&Digitalis Dose 1-1.5 mg/kg IV Consider administration of defasiculating dose of paralytic Use with lidocaine 1mg/kg in head injured patientsMedications:ParalyticsPancuronium(Pavulon

17、)MOA Non-depolarizing agent Does not affect LOC Onset&Duration Onset:3-5 min Duration:30-60 min Dose Must premed with sedative 0.04-0.1 mg/kgVecuronium(Norcuron)MOA Non-depolarizing agent Does not affect LOC Onset&Duration Onset:70 or SBP 90 Orally intubate patients with GCS 8 Hyperventilate only herniating injuries to EtCO2 to 30mmHG