TRAUMAWhat is meant by neurological trauma?Trauma refers to direct physical injury to the brain or spinal cord. These organs are extremely delicate, and hence are encased in the bony skull and vertebral column for their protection. A common cause of neurological trauma is automobile accidents. About 5% of all deaths in the United States are caused by brain injury resulting from trauma, and there are over six thousand new cases of spinal cord injury each year. Approximately 65% of all victims of acute spinal cord trauma are under 35 years of age. Men are affected by such trauma three to four times more often than women. Neurological trauma can be divided into two broad categories: » Head Injury » Spinal Cord Injury HEAD INJURYWhat are the classifications of head injury?Head injury is generally classified according to the extent to which the skull is damaged. Despite this classification scheme the prognosis of a head injury is more dependent on the severity of brain damage than on the degree to which the skull is injured. The most common symptom of a head injury is loss of consciousness. The longer the duration of unconsciousness the worse the outcome. In a closed head injury there is either no damage to the skull or there may be a linear or basilar skull fracture. Linear fractures account for 80% of all skull fractures and are managed conservatively. A basilar fracture occurs with more serious trauma. In severe cases continuous leakage of CSF out of the skull can occur. In a depressed fracture part of the fractured skull is depressed inwards and injures the portions of brain beneath it. In a compound fracture the scalp has been lacerated and directly communicates with the brain via the bony fragments of the skull. This type of fracture is associated with the worst prognosis and is often accompanied by severe brain damage. What neurological problems can result from head injury?Concussion In a concussion there is only a brief loss of consciousness, (i.e. less than one hour), and the prognosis is generally good. A concussion is often associated with a brief period of amnesia. If the loss of consciousness persists for a prolonged period of time, then it is assumed that there has been structural injury of brain tissue, and the patient is considered to be in coma. Therefore a concussion, in contrast to a coma, results from an interruption of the physiological functioning of the brain, and not structural brain injury. Cerebral edema refers to brain swelling due to an accumulation of water. This is often caused by an excessive movement of fluid into the brain tissue from the blood vessels supplying that tissue. Both this condition and an increase in the amount of CSF surrounding the brain (hydrocephalus) can lead to a dangerous increase in the pressure within the skull (known as the intracranial pressure or ICP). Critical brain swelling can develop hours or days after a serious head injury, and can be detected with an intracranial pressure monitor. Diffuse axonal injury (DAI) A patient may be in a persistent coma because of a widespread stretching or shearing of brain cell structures known as axons. Such generalized axonal damage is known as diffuse axonal injury. Contusion. This refers to bleeding within the brain as it scrapes across the inner surface of the skull. Large contusions result in blood clots within the brain (intracerebral hemorrhage). Epidural hematoma. This results when arterial blood enters the potential space between a membrane which covers the brain, the dura mater, and the inner surface of the skull. The result is a localized collection of blood on the outside of the brain. A large epidural hematoma can lead to death through increased intracranial pressure and herniation, which occurs when the brainstem is pushed down from above. Immediate surgery can be life-saving. Subdural hematoma. This results when venous blood enters the space between the dura mater and the arachnoid membrane. Elderly and alcoholic patients are particularly prone to subdural bleeding. Similar to epidural hematoma, a large subdural hematoma can be life threatening without surgery. Seizures. In instances of severe head injury convulsive seizures can develop as a result of the injury. Often these seizures will develop months or years after the actual injury.  Abnormalities related to head injury How is head injury treated in a neuro-ICU?Treatment of head injury is dependent on the severity of the injury. Head injury is thus divided into three categories: mild, moderate, or severe. In the case of severe head injury, treatment in an ICU is mandated. Although the brain damage occurring upon impact cannot be easily treated, much can be done to avoid subsequent brain damage. A neuro-ICU treats severe head injury in the following fashion:
How is increased intracranial pressure treated in a neuro-ICU?Once ICP is monitored, elevations can be detected and treated before serious brain damage occurs. Measures to reduce ICP include:
SPINAL CORD INJURYWhat are the different types of spinal cord injury?The most common cause (50%) of spinal injury is road accidents which include automobile accidents, motorcycle accidents, and injury to pedestrians. Among other common causes of spinal trauma are domestic and industrial accidents, as well as athletic injuries. Spinal cord injury can be generally divided into two types:
What are the complications of spinal cord injury?The most dangerous complication of spinal cord injury is impairment of respiration. The cervical spinal cord contains the cell bodies of nerve cells responsible for controlling the diaphragm. If these cell bodies are injured the diaphragm is not contracted during inspiration and breathing is impaired. Other potential complications of spinal cord injury may include: pneumonia and other infections, venous blood clots in the leg which can travel to the lung (pulmonary embolism), muscle wasting, incontinence, neuropathic pain, and loss of sexual function. What is the prognosis for spinal cord injury?About 40% of patients will die from a cervical spinal cord injury within 24 hours of the initial accident, depending on the level of the injury. Mortality rates are higher in patients with complete spinal cord transections. Overall, long-term survival and rehabilitation for survivors is directly related to the level and extent of the lesion, the age of patient, and the overall quality of medical and rehabilitation care. The most important factor overall is probably the severity of injury at the moment of impact. In some cases with incomplete spinal cord injury, patients can recover from almost complete paralysis to resume walking (e.g. New York Jet Dennis Byrd). Other people with more severe injury may not be as lucky, and may be dependent on a respirator for the rest of their life (e.g. the actor Christopher Reeve). How can spinal cord injury be treated in a neuro-ICU?The most important specific treatment for spinal cord injury is the administration of high doses of a steroid drug known as methylprednisolone. Research has shown that methylprednisolone is effective for the treatment of both complete and incomplete spinal cord injury. In order to be effective, however, it must be given as soon as possible, and at least within eight hours of the injury. ICU care of patients with spinal cord injury is primarily supportive and directed towards minimizing secondary complications. In some cases, the additional expertise of physicians and nurses in a neuro-ICU may be beneficial for managing breathing abnormalities or disturbances of the autonomic nervous system. Can anything be done if paralysis of the breathing muscles is permanent?Yes, in selected cases. If the cervical spine injury is above the C3,4,5 level and this area is not completely damaged, the nerves to the diaphragm may still be intact. In this case, a new device called a phrenic nerve pacemaker can be surgically implanted. This device directly stimulates the phrenic nerves which innervate the diaphragm, causing them to contract. If successful, this type of treatment can allow independence from a ventilator. ^top |
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