The Central Nervous System Upload 9.10 Central Nervous System Notes 1.
Central Nervous System Trauma
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Central Nervous System Trauma
Estrada Bernard, MD
Division of Neurosurgery
UNC Chapel
Central Nervous System Trauma
U.S fatalities >150,000/yr SCI >10,000/yr Disabled (prev) >200,000
Central Nervous System Trauma –Incidence (San Diego)
Head Inj
All
Head Inj
Mod/Sever
Spinal
1978 295 40
1981 180 44
1992 150 33 4.2
1997 144 34 4
Central Nervous System Trauma
Assume spinal injury Maintain alignment Watch for spinal shock
Head Injury
Primary Secondary
Secondary Head Injury
Elevated ICP Hypotension Hypoxemia/Hypercapnia Ischemia Seizures
Central Nervous System Trauma – Acute Evaluation
Primary survey (ABC) Initial neurological exam Post resuscitation exam
Central Nervous System Trauma – Airway Mgmt
Avoid hypoxia Avoid hypercarbia Avoid aspiration
Central Nervous System Trauma - Resuscitation
Goals BP > 90 mm Hg PaO2 > 60 mm Hg
Central Nervous System Trauma – Acute Mgmt
??? Sedation ??? Neuromuscular blockade ??? Mannitol ??? Hyperventilation
Cranial Nerve Injury
Olfactory
Optic
Abducens
Facial
Vestibulocochlear
Central Nervous System Trauma - Pathophysiology
Mediators Mechanical Neuroexcitation Free radical production
Skull Fractures
Types Risk factors
Skull Fractures
Linear 62% of severe HI
Depressed Simple Compound
Basilar csf fistula
Head Injury Mechanisms
Contact Skull deformation
Local - skull fx, EDH, coup Remote - vault, basilar fxs
Shock wave Contrecoup ICH
Head Injury Mechanisms
Acceleration Surface strain
SDH Contrecoup
Deep strain Concussion Dai
Focal Injury
Hematoma Extradural Subdural Intracerebral
Contusions Coup Contrecoup
Diffuse Injury
Concussion Diffuse axonal injury
Mild Moderate Severe
Central Nervous System Trauma – Clinical Trials
Cholinergic agents Corticosteroids Barbiturates Neuroexcitatory antagonists Free radical scavengers Calcium channel antagonists Hypothermia
Central Nervous System Trauma – Elevated ICP Rx
Progressive neurologic deterioration Transtentorial herniation
Steroids for Spinal Cord Injury
8 hour therapeutic window Methylprednisolone 30 mg/kg bolus 5.4 mg/kg/hr infusion over 23 hours
Cervical Spine Injuries
Atlanto-occipital dislocation Odontoid fractures Hangman’s fracture Jefferson’s fracture
Burst fractures Hyperflexion-anterior subluxation Facet dislocations Hyperextension injuries
Cervical Spine Injuries
Central Nervous System Trauma
Prevention is better than cure