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lucid interval and its importance in trauma and mental health
- 2. CASE SCENARIO • A 38 year old cricket player ,while fielding at forward short leg was hit on the temple by cricket ball hit by fellow batsman. He was not wearing helmet. He was found lying on the ground. But he was well enough to get up and after reassuring the fielders that he is okay, went back to dressing room unassisted. after sometime the player told his teammates that he felt unwell and was rushed to hospital.by the time he got there he had lost consciousness, and after he suffered convulsions ,he was operated on to remove a blood clot from left side of his brain, but there was no hope of recovery and he died after 3 days, when his life support was turned off.
- 3. ANATOMY BRAIN IS AN IMPORTANT ORGAN • Protective coverings of brain: 1. BONY COVERING OF THE CRANIUM 2. THREE MEMBRANOUS COVERING(MENINGES) 3. CEREBROSPINAL FLUID(CSF) - acts as a water cushion
- 6. DURAMATER • Thick, tough , outer covering of the brain • Consists of two layers:- Periosteal(outer) Meningeal(inner) • Dura partitions Falx cerebri Tentorium cerebelli Falx cerebelli Diaphragma sellae
- 7. • ARACHNOID:- thin, avascular, transparent membrane that loosely surrounds the brain without dipping into its sulcus. • PIAMATER:- thin, vascular membrane which closely invests the brain, dipping into various sulci and other irregularities of its surface
- 9. SPACES BETWEEN THE MENINGES • Epidural space- between duramater and skull bone. • Subdural space- between arachnoid and duramater • Subarachnoid space- between arachnoid and piamater
- 12. WHAT IS LUCID INTERVAL ?? lucid interval is the short period of consciousness between initial unconsciousness which occur immediately after accident and unconsciousness at later stage. • commonly seen in extradural hematoma
- 13. CEREBRAL BLOOD FLOW • Brain is dependent on continuous cerebral blood flow for oxygen and glucose delivery • CBF= 55mL/min for every 100 g of brain tissue. • CPP= MAP-ICP • CPP= 75-105mmHg • MAP= 90-110mmHg • ICP= 5-15mmHg • INCREASED ICP AND REDUCED CPP AND CBF PRODUCES DAMAGE TO THE BRAIN • 20 ml /min—ischemia and < 20ml/min cause infarction
- 14. THE MONRO KELLIE DOCTRINE
- 18. HERNIATION • there is rapid increase in ICP ,when there is exhaustion of the compensation mechanism • result in herniation of the brain tissue • the uncus of temporal lobe herniate over the tentorium cerebelli---- pupil abnormalities • cerebellar tonsilar herniation through foramen magnum— Cushing's triad– hypertension, bradycardia and irregular respiration
- 21. • Neurosurgical emergency • Caused due to rupture of an artery, vein or venous sinus, in association with a skull fracture. There is collection of blood in extra Dural space. • most commonly in temperoparietal region. • Examples- road traffic accidents, fall from height, close contact sports , coup and countercoup injury • transient loss of consciousness is typical, and the patient may then present in lucid interval with headache but without neurological deficit. • as the haematoma expands ,compensation is exhausted. • there is contra lateral hemiparesis, reduced consciousness level and ipsilateral pupillary dilatation
- 22. • classical presentation occurs in only one third cases. • Takes time to develop, usually presents within 24hrs • Dura is stripped from site of blow, slowly developing bleed • Mostly seen in young males... Rarely seen before 2 yrs and after 60 yrs
- 23. PATHOLOGY Injury Fracture of thin temporal bone Tear of vessels Bleeding gradual stripping of Dura from skull and collection of blood occurs in 6-12 hrs. extradural haematoma occurs increased ICP Coning of supratentorial contents through tentorial hiatus shift of midbrain towards opposite side injured by sharp edge of tentorial cerebelli Corticospinal tract gets injured before decussation on opposite side Hemiparesis, pupillary changes occur on the same side of hematoma KERNOHAN’S NOTCH EFFECT
- 24. CLINICAL FEATURES 1. Bruising of scalp 2. Skull fracture across the middle meningeal artery or large venous sinuses 3. Boggy swelling over the temporal region. 4. Severe and increasing headache- distortion of pain sensitive dura 5. Deterioration of conscious level – raised ICP 6. Dilatation of pupil- severe brain stem damage. Once both pupils dilate and gets fixed- decerebrate rigidity develops, followed by respiratory failure and death
- 25. INVESTIGATION • On CT , extra dural haematoma appear as a lentiform ( lens shaped or biconvex) hyper dense lesion between skull and brain, constrained by the adherence of Dura to the skull . • mass effect may be evident, with compression of surrounding brain and midline shift. • areas of mixed density suggest active bleeding. • a skull fracture is usually evident
- 27. IMPORTANCE OF LUCID INTERVAL???? • patient is asymptomatic in this period and appears fine • so it can be easily missed • lucid interval precede delayed deterioration due to expanding intracranial hematoma. • recognition of lucid interval is having a great impact on the survival of patient.
- 28. INITIAL MANAGEMENT ADVANCED TRAUMA LIFE SUPPORT(ATLS) PRIMARY SURVEY
- 29. NEUROLOGICAL ASSESSMENT • Level of consciousness. • Glasgow coma scale • Pupillary reaction • Pulse • Temperature • Blood pressure • Respiratory rate
- 30. • Reflexes • Limb movements- normal/mild weakness/severe weakness/ spastic flexion/ extension/ no response • History • rule out other causes of altered consciousness • physical examination
- 31. GLASGOW COMA SCALE- CONSCIOUS LEVEL Spontaneous 4 To verbal command 3 To Painful stimulus 2 Do not open 1 Eyes open
- 32. Normal oriented conversation 5 Confused 4 Inappropriate / words only 3 Sounds only 2 No sounds 1 Intubated patient T Best verbal response
- 33. Obeys command 6 Localises to pain 5 Withdrawal or flexion 4 Abnormal flexion 3 Extension 2 No motor response 1 Total score 3-15 Best motor
- 34. HEAD INJURY CLASSIFICATION Minor GCS 15 with no loss of consciousness Mild GCS 14 or 15 with loss of consciousness Moderate GCS 9-13 Severe GCS 3-8
- 35. NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE(NICE) • DISCHARGE CRITERIA IN MINOR AND MILD HEAD INJURY • GCS 15/15 with no focal deficits • normal CT brain if indicated • patient not under influence of alcohol or drugs • responsible adult accompanied
- 36. • verbal and written head injury advice: seek medical attention if: persistent worsening of condition persistent vomiting drowsiness visual disturbance limb weakness or numbness
- 37. NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE(NICE) CT SCAN GUIDELINES
- 38. • CRITERIA FOT CT-SCAN IN HEAD INJURY within 1 hour • GCS<13 AT ANY POINT • GCS <15 at 2hrs • Focal neurological deficit • Suspected open , depressed or basal skull fracture • More than one episode of vomiting • Any patient with a mild head injury over the age 65yrs or with coagulopathy • Dangerous mechanism of injury or retrograde amnesia >30 min warrants CT within 8hrs
- 39. DRUGS • Sedation is avoided • Analgesics and anticonvulsants- phenobarbitone or phenytoin • Diuretics to reduce cerebral edema-either mannitol 20% 200ml IV 8th hourly or furosemide 40mg 8th hourly • Antibiotics- penicillin, ampicillin, to prevent meningitis
- 40. • IMMEDIATE SURGICAL INTERVENTION IS A MUST TO SAVE LIFE OF THE PATIENT • Craniotomy is done and cranial flaps are raised. • Dura is fixed using- Hitch Stitches • Antibiotics and anticonvulsants are given postoperatively • Recovery is good after surgery
- 43. COMPLICATIONS EARLY • Brain stem injury- due to coning • Compression over cerebellum and medulla • CSF rhinorrhea • CSF ottorrhoea • Meningitis LATE • Chronic subdural hematoma • post-traumatic epilepsy • Post traumatic amnesia • Post traumatic hydrocephalous • Post traumatic headache
- 44. LUCID INTERVAL IN FORENSIC MEDICINE this is a period occurring in the case of mental illness during which there is complete cessation of the symptoms of mental illness, so, that person can judge his acts normally this is the temporary period of resolution of symptoms in a mentally ill person
- 45. MEDICO LEGAL IMPORTANCE 1) in lucid interval ,a person can judge his acts 2) during this period a person is held responsible for his criminal act 3) a person can make valid will 4) can give evidence 5) a person can make contract
- 46. RAMAN LAMBA • Raman lamba was an Indian cricketer, mainly a batsman. He died in 23 February 1998 , after slipping into coma due to internal hemorrhage three days after being hit on the temple by ball while fielding in Bangladesh's league cricket. Sources reveal that lamba was not wearing a helmet. Although he was fine initially, his conditioned worsened later , was hospitalized , operated for the clot but could not be saved
- 49. Thanku!! No head injury is too slight to neglect, not too severe to be despaired of -Hippocrates