Case of the day

CEREBRAL HAEMORRHAGIC CONTUSIONS

25yrs/M after consuming alcohol crossed the road without looking and knocked down by speeding bike,H/o LOC and vomitting since then.GCS -10 upon arrival intubated and resuscitated in emergency NEUROSURGEON OPINION WAS DONE Chief Complaints RTA with head injury Vitals BP -120/80,HR -110,Spo2 -98%,RR -32 Physical Examination Multiple laceration wound stapled and dressed,GCS - M4V4E2,Pupils - B/l 4mm RTL Diagnosis DIAGNOSIS? Management PLAN?

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Multiple contusion with cerebral oedema , continue supportive treatment, cerebral decongestant, continue venti support , all blood workup , rule out associated injury , gcs , pulse rate monitoring , if still further raised icp feature , decompressive craniectomy should be plan

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Multiple haemorrhagic contusions right frontal and temporal region with perilesional cerebral oedema. Treatment- Prognosis is Good provided energetic Treatment is done 1.Decongestive therapy with mannitol 100 ml × 8 hourly 2.Inj Eptoin × 8 hourly 3.IV fluids- maintenance fluid 4.Inj Pantoprazole IV O.D 5.inj Cefriaxone 1 gm B.D - considering the lacerated wound for 5- 7 days 6.Keep a watch on ABG studies, vitals , urine output

Cerebral oedema EDH rt parietal region Rx inj manitol Inj lasix Inj dexamethasone Inj Ceftriaxozone Monitor vitals Keep oxygenation saturation

Thanx dr S I Godara
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Probably RT parietal extra dural haemorrhage IV line Inj.manitol IV dexona Inj. Phenytoin a mj meropenum TT under guidens neurosurgeon

No EDH
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Multiple confusions brain intubate reduce icp if necessary decompression craniectomy may reduce icp.explain bad prognosis

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Scalp edema noted. Rt frontotemporal region few calcified opacities seen. Possibly underlying axonal injury.

Diffuse cerebral edema,inj mannitol and tb diamox 250 mg tds are sufficient

Multiple Contusions. Axial CT scans without contrast. Note the large areas of traumatic contusion, which consist of hemorrhage and surrounding edema, in the frontal lobes (left larger than right) and the right temporal lobe. Subarachnoid blood is also present, most easily seen over the tentorium posteriorly. A skull fracture is seen underlying the right temporal bone. The frontal and temporal lobe tips are common locations for cerebral contusions following head injury, wherein the brain continues to move forward, striking the inner skull, after the head has stopped moving. Contact is made first in the frontal and temporal tips. Surgical intervention should not be necessary in cases of contusions, unless the diagnosis of compartment syndrome is considered and confirmed. Other Treatment Multiple therapies that have become commonplace in the treatment of contusions exist. However, most therapies have not been proven to provide any benefit, and some may be damaging to the healing tissue. In a given situation, an injection of epinephrine (with lidocaine) may be considered in the acute phase of a contusion injury, along with ice and compression to help limit bleeding. Therapeutic ultrasound is a commonly used physical therapy modality that has been claimed to promote tissue repair by enhancing cell proliferation and protein synthesis during the healing of skin wounds, tendon injuries, and fractures. The theory is that of a micromassage effect. However, ultrasound can enhance both myogenic precursor cell and fibroblast proliferation. Prolonging the proliferation phase of fibroblasts during muscle regeneration can add to the amount of permanent scar-tissue production, which could outweigh the possible positive effects of ultrasound on satellite cell proliferation. Recent literature questions the utility of ultrasound and notes that some evidence reveals worsening recovery and outcome. Heat, whirlpool therapy, and electrotherapy, although pleasing to the patient, have not been shown to influence the rate of recovery from contusions. Recovery Phase Rehabilitation Program Physical Therapy In the second phase of muscle healing, known as the recovery or regeneration phase, the main feature is proliferation of reserve satellite cells and endomysial fibroblasts, followed by active protein synthesis. The main goal of this treatment phase is restoration of mobility and ROM. Early mobilization of the joint and muscle has been shown to dramatically reduce recovery time and increase tensile strength of the muscle. Early pain-free PROM establishes normal tissue planes, maintains uninjured muscle fiber excursion, and pumps excessive detritus from the soft tissue. The patient is ready to progress to the next level of therapy when ROM has been restored. Jackson and Feagin found that a patient is ready to move on to the next phase of treatment when 90° of knee flexion is achieved. Pain-free PROM of the knee with emphasis on flexion should be encouraged. Gentle isometric muscle exercises can be performed as tolerated. Weight bearing should be allowed as tolerated. Excessive passive stretching of a previously immobilized limb has been shown to produce myositis ossificans in animal models. This potential complication must be balanced against laboratory evidence showing that mobilization demonstrates faster healing times and increased vascularity of the affected tissue. Occupational Therapy Individualized education and instruction to adjust the athlete to ADL and routines with the injured limb may be needed to prevent reinjury, and working in conjunction with physical therapy to promote healing is advised. Medical Issues/Complications Reinjury is a significant factor in prolonging disability. A fine line exists between a sufficient amount of therapy and too much therapy. Pain tends to be an effective and adequate guide. Other Treatment (Injection, manipulation, etc.) Injection of medications into the contused tissue during the recovery phase, and any phase, has not been shown to be beneficial and may in fact be damaging to the tissues; this is especially true of corticosteroids. Maintenance Phase Rehabilitation Program Physical Therapy The third phase of muscle healing, known as maturation or remodeling, is characterized by a gradual recovery of the functional properties of the muscle, including the recovery of the tensile strength of its connective tissue component. The goal of this phase is to maintain the ROM while restoring full function to the muscle and joint. Progressive resistance exercises are encouraged until full strength and ROM are regained. Emphasis should be placed on regaining full ROM and restoring strength. Remember that therapy that is too aggressive and too early can result in reinjury caused by muscle strain. Occupational Therapy Reevaluation of the patient' s daily activities and increasing tolerance to normal use of the contused limb should be emphasized. Recreational Therapy Maintain agility by participation in noncontact sports such as squash, tennis, badminton, and swimming Medication Summary The physician needs to make every effort to relieve pain as completely and expeditiously as possible. Distinguishing the intensity of the pain can be difficult, because it tends to be subjective; therefore, treatment and therapy should be individualized. Objective parameters, such as tachycardia, are unreliable. Usually, minor trauma to the muscles is self-limited. An enormous selection of analgesics is available for use by the physician, but pharmacologic agents tend to fall into 2 general categories: nonnarcotic and narcotic analgesics. The physician also must consider the best route of delivery of the drug. Corticosteroids should not be used; they are catabolic, and they inhibit the healing process. These steroids promote overall negative nitrogen balance and loss of muscle. However, these agents continue to be used clinically to treat muscle contusion injuries and are injected into the site of injury to relieve the pain and to expedite a player's return to active status. This inhibition of the inflammatory response may have a sparing effect on the local muscle tissue and, perhaps, on the athlete as a whole in the short term; however, corticosteroids seem to cause an unwanted atrophy of both injured and uninjured muscles. Anabolic steroids may be proven useful in the treatment of contusion injuries because of the effects they have on nitrogen and protein balance and on stimulation of cell synthesis; however, research currently is limited. Many sporting governing bodies also control the use of anabolic steroids in their athletes, making the use of these agents controversial. Nonnarcotic Analgesics Class Summary Pain accompanying minor acute soft-tissue injuries may be relieved by a short course of nonnarcotic analgesics with acetaminophen. Acetaminophen (Tylenol, Feverall, Aspirin Free Anacin) View full drug information Ordinarily, the most commonly ingested pain reliever. Also marketed in combination with other drugs to provide analgesia. Advantages include availability, cost, and relatively high safety profile. The onset of relief is usually within 20-30 min. Extended release preparations do not appear to offer major benefits (other than dosing convenience) and may increase the incidence of toxicity. For children, acetaminophen is available as drops (80 mg/0.8 mL), elixirs (160 mg/5 mL), tablets (80 mg, 160 mg, 325 mg), and suppositories (125 mg, 325 mg). Nonsteroidal Anti-inflammatory Drugs (NSAIDs) Class Summary Controversial data exist on NSAIDs. By suppressing the initial inflammatory reaction, the NSAID permits improved performance in early time periods but appears to suppress the stimulus that may be needed for cellular remodeling in longer time periods. NSAIDs also may increase the amount of bleeding within the tissue. Currently, there is a lack of compelling evidence for either argument. Although acetaminophen is typically listed with NSAIDs, this agent lacks anti-inflammatory properties and is used for its antipyretic and analgesic effects. A number of NSAIDs are available for use. NSAIDs share a common mechanism of action, inhibiting the production of pain-mediating prostaglandins. Generally, NSAIDs provide a comparable degree of pain and inflammatory relief, but they differ in dosing schedule. The 5 categories of marketed NSAIDs are acetic acid derivatives, fenamates, oxicams, propionic acid derivatives, and related compounds. Numerous NSAIDs are obtainable over the counter (OTC). Choosing an NSAID to prescribe can be difficult because few data exist that compare these agents, and individual responses are inconsistent. With a lack of evidence that one NSAID proves to be clearly superior, base prescribing decisions on personal experience, safety profiles, cost, and convenience. Indomethacin (Indocin) View full drug information Rapidly absorbed; metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation; inhibits prostaglandin synthesis. Ketorolac (Toradol) View full drug information Has become the choice of parenteral pain medications dispensed in the ED. Frequently overlooked is the fact that this medication is an NSAID, carrying all its attendant risks, and it is almost 20 times the cost of morphine (and 140 times the cost of ibuprofen). Few data supporting its superiority over other analgesics exist. Ibuprofen (Motrin, Advil, Nuprin) View full drug information This prevalently used NSAID, also available OTC, is a derivative of the propionic class of NSAIDs and is considered the safest of the NSAIDs. Available as tablets of 200 mg, 400 mg, 600 mg, and 800 mg. Pediatric dosage forms are available as both a tablet and oral suspension (20 mg/mL). Advise taking ibuprofen with food or milk, if possible. Prescribe with caution in children with flulike illnesses. Narcotic Analgesics Class Summary Patients complaining of inadequate pain relief from NSAIDs may benefit from short-term supplementation with an opioid compound. A wide array of products is available. Orally (PO), hydrocodone (eg, Lortab, Lorcet, Vicodin, Anexsia), a schedule III narcotic, and oxycodone (eg, Roxicet, Percodan, Tylox), a schedule II substance, usually provide additional pain relief. Codeine-containing products (schedule III drugs) are not as reliable for alleviating pain. Although the relative potency for oxycodone and hydrocodone is approximately 0.33 (compared with parenteral morphine), that for oral codeine is 0.05. Mixed agonist-antagonist oral agents, such as butorphanol, nalbuphine, and pentazocine, offer no real advantages to opioid agents; yet, they cause a higher incidence of adverse effects. Common side effects include constipation, nausea, respiratory depression, sedation, and urinary retention. Generally, the approved dosage of hydrocodone is 5-10 mg, combined with 500-750 mg of acetaminophen and taken PO every 6 hours as needed (q6h prn). Oxycodone analgesic preparations typically combine 2.5-5 mg of oxycodone with 325 mg of acetaminophen. They are dosed as 1-2 tablets PO q4h prn for moderate to severe pain. Acetaminophen with codeine (Tylenol #3) contains 30 mg of codeine with 325 mg of acetaminophen. Usually, 1-2 pills q4h prn is recommended. Elixirs containing hydrocodone (Hycodan) are convenient for children older than 6 years who have moderate to severe pain and who are unable to swallow pills. One teaspoon (5 mL) of Hycodan contains 5 mg of hydrocodone; the dose usually is 1.25-2.5 mg q4h, depending on the child's size and the severity of pain. The elixir of Tylenol with codeine for children contains 120 mg of acetaminophen and 12 mg/5 mL of codeine in an alcohol base (7%). Generally, orally administered drugs impart a slower onset of action. For patients in severe pain or for those patients who must take nothing by mouth (NPO), parenteral agents may be necessary. Although the intramuscular (IM) route may be more convenient for the staff, the intravenous (IV) route offers a number of advantages. Narcotics given IV provide a rapid and predictable onset of action and are easier to titrate. Morphine and meperidine are the most commonly used parenteral narcotic agents. Hydrocodone and acetaminophen (Vicodin, Lorcet, Lortab, Anexsia) View full drug information A drug combination indicated for the relief of moderate to severe pain. Oxycodone and acetaminophen (Percocet, Tylox, Roxicet) View full drug information Drug combination indicated for the relief of moderate to severe pain. Acetaminophen and codeine (Tylenol #3) View full drug information A drug combination indicated for the treatment of mild to moderate pain.

TBI ? Haematoma? Follow all the protocols of Head Injury for 48 hrs,BP& Pulse monitor 2 hrly, Mannitol drips & Dexamethasone inj as per wt of the pt. Neurosurgeon's opinion shd be taken.

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