Urgente Traumatice Neurochirurgicale
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URGENTE TRAUMATICE NEUROCHIRURGICALE
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• COMA TRAUMATICA
• TRAUMATISMELE CRANIO – CEREBRALE
• TRAUMATISMELE VERTEBRO - MEDULARE
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COMA TRAUMATICA
• DEFINITIE
• DIAGNOSTIC
• TRATAMENT
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COMA DIAGNOSTIC
CLINIC TOPOGRAFIC
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COMADIAGNOSTIC CLINIC
• STABILIREA STĂRII DE COMĂ
• PROFUNZIMEA STĂRII DE COMĂ
• MODUL DE INSTALARE
• EVOLUŢIA
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COMADIAGNOSTIC CLINIC
STABILIREA STĂRII DE COMĂ
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COMADIAGNOSTIC CLINIC
• GCS
• DeschidereaOchilor (4- 1)
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COMADIAGNOSTIC CLINIC
GCS
Răspunsul Motor (6 -1)
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COMADIAGNOSTIC CLINIC
GCS
RăspunsulVerbal (5 -1)
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COMAGLASGOW COMA SCALE
15 7 3
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COMADIAGNOSTIC CLINIC
• STABILIREA STĂRII DE COMĂ
• PROFUNZIMEA STĂRII DE COMĂ
• MODUL DE INSTALARE
• EVOLUŢIA
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COMADIAGNOSTIC CLINIC
PROFUNZIMEA STĂRII DE COMĂ
MODIFICĂRIOFTALMOLOGICE
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COMADIAGNOSTIC CLINIC
PROFUNZIMEA STĂRII DE COMĂ
MODIFICĂRI DE TONUS
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COMADIAGNOSTIC CLINIC
PROFUNZIMEASTĂRIIDE COMĂ
REFLEXE DETRUNCHICEREBRAL
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COMADIAGNOSTIC CLINIC
PROFUNZIMEASTĂRIIDE COMĂ
FUNCŢIIVEGETATIVE
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COMA TRAUMATICA
• Modificari pupilare• Modificari tonus
muscular• Reflexe trunchi cerebral• Functii vegetative
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COMA DIAGNOSTIC
CLINIC TOPOGRAFIC
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COMADIAGNOSTIC TOPOGRAFIC ŞI STADIALIZARE
MEZENCEFALIC I
MEDIO – PONTIN II
PONTIN INFERIOR III
BULBAR IV
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COMA
• STABILIREA STĂRII DE COMĂ
• PROFUNZIMEA STĂRII DE COMĂ
• MODUL DE INSTALARE
• EVOLUŢIA
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COMAMOD DE INSTALARE ŞI EVOLUŢIE
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COMA EXPLORARE PARACLINICĂ
TRAUMATISME
HIC
SEMNE DE FOCAR
MENINGISM
• CT
• PL
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COMA
TRAUMATICĂ NON - TRAUMATICĂ
neurologică metabolică
focale difuze
supratentoriale
subtentoriale
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COMA TRAUMATICĂ PRINCIPII TERAPEUTICE
TRATAMENT MEDICAL
• Prevenirea şi limitarea extensiei leziunilor cerebrale
• Tratarea corectă şi precoce a leziunilor extracraniene asociate
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COMA TRAUMATICĂ PRINCIPII TERAPEUTICE
PERFUZIA CEREBRALĂ(PIC, TA)
NORMOVOLEMIE
NORMOTENSIUNE
PROTECŢIE NEURONALĂ
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HIPERTENSIUNEA INTRACRANIANA POSTRAUMATICA
• Pozitia extremitatii cefalice
• Normovolemia • Sedare • DVE• Diuretice osmotice• Hiperventilation • Coma barbiturica
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MOARTEA CEREBRALĂ
Absenţa reflexelor de trunchi cerebral
Apnee AdinamieTemperatura Tensiunea arterială
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TRAUMATISMELE CRANIO - CEREBRALE
• LEZIUNI INITIALE
• LEZIUNI SECUNDARE
• LEZIUNI TARDIVE
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0 50 min
LEZIUNI INITIALE
Ore zile
LEZIUNI SECUNDARE
Luni ani
TARDIVECONTACT DIRECTE,FOCALE fracturi fracturi iradiate fracturi infundare plagi cranio-cerebr contuzie cerebr
ACCELERATIE/ INDIRECTE,DIFUZEDECELERATIE MULTIFOCALE
liniare contuzia
rotatorii comotia leziuni axonale difuze
HematoameEdem cerebralLeziuni mixte
compresiune angajare
Hidrocefalia Vasospasm PEIC
PIC
ISCHEMIE
INFECTII
HEMATOAME
HIDROCEFALIE
ATROFIE
GLIOSA CICATRICIALA
DEZECHILIBRE SISTEMICE
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TRAUMATISMELE CRANIO-CEREBRALE
MECANISM DE CONTACT
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TRAUMATISMELE CRANIO-CEREBRALEMORFOLOGIA TRAUMATISMULUI
• SCALP• CRANIU• EXTRADURAL• SUBDURAL• SUBARAHNOIDIAN • INTRACEREBRAL• INTRAVENTRICULAR
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SEVERITATEA TRAUMATISMULUI CRANIO- CEREBRAL
TCC MINOR
TCC MODERAT
TCC SEVER
GCS 14-15
GCS 9-13
GCS 3-8
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TCC MINOR GCS 14-15
Observaţie clinică 2h
CT dacă GCS <15 2h de la traumatism
Spitalizare dacă starea clinică nu se normalizează după 4h de la traumatism sau există modificări CT
Varsta > 65 ani sau se identifică coagulopatii, intoxicaţii exo/endogene, cazuri sociale
Dirijare către domiciliu dacă nu există modificări clinice la 4h de la traumatism, nu există factori de risc sau modificări CT
Scrisoare medicală către medicul de familie
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TCC MINOR riscuri minore
GCS 15 primele 2h de la traumatismAbsenta deficitelor neurologice focaleAbsenţa semnelor fracturilor craniene(mecanism direct,plagi
scalpate, semne ale fracturilor de bază de craniu)Pierderea stării de cunoştinţă <5 minAmnezia antero/retrogradă < 30minAbsenţa crizelor comitiale postraumaticeEpisod unic de vărsăturăCefalee discretăAbsenţa coagulopatiilorVarsta < 65 aniMecanism traumatic simpluAbsenţa semnelor de intoxicaţie exo/endogenă
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TCC MINOR riscuri majore
GCS <15 în primele 2h de la traumatism sau deteriorarea GCS cu 2 punctePrezenţa deficitelor neurologice focale (aspect pupile)Prezenţa semnelor fracturilor craniene(mecanism direct,plagi scalpate,
semne ale fracturilor de bază de craniu)Pierderea stării de cunoştinţă >5 minAmnezia antero/retrogradă >30minPrezenţa crizelor comitiale postraumaticeCel puţin 2 vărsăturiCefalee severă, persistentă, efect Cushing Prezenţa coagulopatiilorVarsta > 65 aniMecanism traumatic complexPrezenţa semnelor de intoxicaţie exo/endogenăPrezentarea tardivă sau revenirea Multitrauma
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TCC MINOR dirijare domiciliu
Stare de cunoştinţă nealteratăAbsenţa modificărilor cliniceCT normal/absenţa indicaţiei CTAnturaj apt pentru supravegherePosibilitate de revenire în caz de agravare
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TCC MODERATE GCS 9-13
Spitalizare Observaţie clinică periodicăSusţinerea funcţiilor vitale şi a celor neurologicePrevenirea leziunilor secundareCT în urgenţăConsult neurochirurgical în urgenţă dacă starea clinică
nu se ameliorează sau dacă există modificări CTIOT pentru oxigenoterapie şi ventilaţie adecvată
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TCC SEVERE GCS 3-8
Internarea în ATIIOTSusţinerea funcţiilor vitale şi a celor neurologicePrevenirea leziunilor secundare cerebrale(PaO2>60;SaO2>90;PaCO2 35-40;TA >90, cap procliv)CT în urgenţăConsult neurochirurgical în urgenţăMonitorizare PICAdministrarea de anticonvulsivante
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0 50 min
LEZIUNI INITIALE
Ore zile
LEZIUNI SECUNDARE
Luni ani
TARDIVECONTACT DIRECTE,FOCALE fracturi fracturi iradiate fracturi infundare plagi cranio-cerebr contuzie cerebr
ACCELERATIE/ INDIRECTE,DIFUZEDECELERATIE MULTIFOCALE
liniare contuzia
rotatorii comotia leziuni axonale difuze
HematoameEdem cerebralLeziuni mixte
compresiune angajare
Hidrocefalia Vasospasm PEIC
PIC
ISCHEMIE
INFECTII
HEMATOAME
HIDROCEFALIE
ATROFIE
GLIOSA CICATRICIALA
DEZECHILIBRE SISTEMICE
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COMOTIA CEREBRALA
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CONTUZIA CEREBRALA
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CONTUZIA CEREBRALA
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LEZIUNI AXONALE DIFUZE
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PRINCIPII TERAPEUTICE
• TA, Hb• Corectarea tulburarilor ventilatorii• PIC • Reevaluarea CT la 48 h• Prevenirea crizelor comitiale• Utilizarea solutiilor saline• Starea generala pacient
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PLAGILE CRANIO - CEREBRALE
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PLAGILE CRANIO - CEREBRALE
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PLAGILE CRANIO - CEREBRALE
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• Sportiv , 29 ani
• Traumatism cranian impact temporal drept
• Fara pierderea starii de cunostinta
• Cefalee
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HEMATOMUL EXTRADURAL
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HEMATOMUL EXTRADURAL
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HEMATOMUL EXTRADURAL
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HEMATOMUL EXTRADURAL
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HEMATOMUL SUBDURAL ACUT
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HEMATOMUL SUBDURAL ACUT
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TRAUMATISMELE CRANIO-CEREBRALELEZIUNI CRANIENE
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TRAUMATISMELE CRANIO-CEREBRALEFRACTURILE CRANIENE LA COPII
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TRAUMATISMELE CRANIO-CEREBRALEFRACTURILE CRANIENE
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FRACTURILE CU DENIVELARE
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FRACTURILE OSULUI TEMPORAL
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TABLOU CLINIC FRACTURI TEMPORALE
• Marca traumatica
• Otoragie
• Perforatia timpanala/hemotimpan
• Fistula de LCR
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FRACTURI STANCA TEMPORALA TABLOU CLINIC
• Marca traumatica
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FRACTURI STANCA TEMPORALA TABLOU CLINIC
• Otoragia
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FRACTURI STANCA TEMPORALA TABLOU CLINIC
• Perforatia timpanala/hemotimpan
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FRACTURI STANCA TEMPORALA TABLOU CLINIC
• Fistula LCR
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TABLOU CLINIC FRACTURI TEMPORALEcomplicatii
• Paralizia nerv facial• Diminuarea /pierderea auzului• Vertij • Greturi• Varsaturi
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Paralizia nerv facial
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FRACTURA LONGITUDINALA A OSULUI TEMPORAL
• Impact temporal• Traiect de fractura anterior,
extralabirintic
• Singerare la nivel CAE• Diminuarea auzului(conducere)• Paralizie de nerv facial• Fistula de LCR• Vertje
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FRACTURA TRANSVERSALA A OSULUI TEMPORAL
• Impact frontal si occipital• Traiect de fractura posterior
translabirintic
• Pierderea auzului(neurosenzorial)• Paralizia de nerv facial• Vertije sever• Nistagmus intens
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FRACTURILE OSULUI TEMPORALdiagnostic
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FISTULA LCR
• Diagnostic direct
• Diagnostic imagistic
• Tratament conservator
• Tratament chirurgical
• Complicatii(meningita, pneumatocelul)
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FRACTURILE OSULUI TEMPORAL
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FRACTURILE OSULUI TEMPORALtratament
• Corticoterapie
• Decompresiunea nervului facial
• Ligatura ACC
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FRACTURILE ETAJULUI ANTERIOR
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Fracturile etajului anterior
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Fracturile etajului anterior
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Fracturile etajului anterior
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Fracturile etajului anterior
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Fracturile etajului anterior
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0 50 min
LEZIUNI INITIALE
Ore zile
LEZIUNI SECUNDARE
Luni ani
TARDIVECONTACT DIRECTE,FOCALE fracturi fracturi iradiate fracturi infundare plagi cranio-cerebr contuzie cerebr
ACCELERATIE/ INDIRECTE,DIFUZEDECELERATIE MULTIFOCALE
liniare contuzia
rotatorii comotia leziuni axonale difuze
HematoameEdem cerebralLeziuni mixte
compresiune angajare
Hidrocefalia Vasospasm PEIC
PIC
ISCHEMIE
INFECTII
HEMATOAME
HIDROCEFALIE
ATROFIE
GLIOSA CICATRICIALA
DEZECHILIBRE SISTEMICE
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HEMATOMUL SUBDURAL CRONIC
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TRAUMATISMELE
VERTEBRO - MEDULARE
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TRAUMATISMELE VERTEBRO - MEDULARE
• Repere anatomice
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TRAUMATISMELE VERTEBRO - MEDULARE
• Repere anatomice
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TRAUMATISMELE VERTEBRO - MEDULARE
• Noţiuni de biomecanică
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TRAUMATISMELE VERTEBRO – MEDULAREMECANISME DE PRODUCERE
FLEXIA
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TRAUMATISMELE VERTEBRO – MEDULAREMECANISME DE PRODUCERE
EXTENSIA
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STABILITATEA RAHIDIANA
• LEZIUNI STABILE• LEZIUNI INSTABILE
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TRAUMATISMELE VERTEBRO-MEDULARECLASIFICARE
• DESCRIPTIVĂ
• CLINICĂ
• TERAPEUTICĂ
• deschise • închise
• mielice • amielice
• stabile• instabile
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EXAMENUL NEUROLOGIC
NIVELUL MEDULAR INTERESAREA MEDULARA
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SCALA FRANKELFRANKEL DEFICIT NEUROLOGIC
A DEFICIT NEUROLOGIC COMPLET SUB NIVELUL LEZIONAL
B DEFICIT MOTOR COMPLET, FUNCTIE SENZITIVA REZIDUALA
C ABSENTA DEFICIT SENZITIV, FUNCTIE MOTORIE REZIDUALA, NEFUNCTIONALA
D PREZENTA FUNCTIEI MOTORII SI SENZITIVE SUB NIVELUL LEZIONAL
E ABSENTA DEFICITULUI NEUROLOGIC
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TRAUMATISMELE VERETEBRO – MEDULARE CERVICALE
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Traumatismele vertebro-medulare cervicale
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RADIOGRAFIA STANDARD
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TRAUMATISMELE VERTEBRO-MEDULAREconduită terapeutică segment cervical
STABILIZARE
REDUCERE
OSTEOSINTEZA
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TRAUMATISMELE VERTEBRO-MEDULARE CERVICALEtratament ortopedic
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TRAUMATISMELE VERTEBRO-MEDULAREtratament chirurgical
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TRAUMATISMELE VERTEBRO-MEDULARE TORACO-LOMBARE
• COMPRESIUNE
• DISTRACTIE
• ROTATIE
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EXAMEN NEUROLOGIC
• MOTOR• SENZITIV• REFLEXE• SFINCTERE• TULBURARI NEUROVEGETATIVE
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TRATAMENT ORTOPEDIC
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TRATAMENT CHIRURGICAL
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