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Assessment Of the Patient With Cranial Trauma

By Dr Guillermo Zamora


Every time we see a patient with this type of problem is very important to have a clear perception about of the expectations we may have with our patient. Homeopathy and surgical procedures can offer a window of hope. The following are some criteria of assessment that should be used.


1.-Initial assessment.
A-Airway, ventilation, circulation must be evaluated in all patients with impaired consciousness or if the trauma is therefore important. Head injuries can cause severe hypoventilation wich raises intracranial pressure. Systemic hypotension secondary brain injury caused by ischemia. Avoid nasal intubation in patients with facial fractures.

B-It should be performed cervical spine radiographs in all patients and immobilize the neck until we have ruled out the presence of fractures or dislocations at this level.

C. "In the history it should be recorded the chronology of all symptoms, especially loss of consciousness, the existence of a lucid period (which will make us to suspect a growing hematoma) and amnesia (which is related to the intensity the coup).

D. "In the general physical examination is necessary to ascertain whether the patient's vital constants are stable. It should be investigated if there are puncture wounds or other significant trauma.

E.-The neurological examination must evaluates the level of consciousness and the score on the Glasgow coma scale, focal deficits and signs of herniation, exploration has to be repeated at frequent intervals to document any progression that occurs in neurological deficits.

It is very important also assess if there is no bleeding through the nose or ears to rule out fracture of the skull base.


GLASGOW COMA SCALE
OPEN THE EYES:
spontaneously ....... 4 POINTS
Verbal Order ........ 3
Pain stimulus........ 2
No answer........... 1



MOTOR RESPONSE:
Obey orders .............................. 6
Localizes painful stimuli ................ 5
He/she retired from the painful stimulus…….…....4
Abnormal flexion limbs (decortication) ... ....….. 3
Abnormal extension limbs (decerebration )........ 2
No response………………............................. .. 1



VERBAL RESPONSE:
Oriented ......................................... 5
Confused ......................................... 4
Inappropriate words……................ 3
Incomprehensible sounds .............. 2
No response............................. 1


MODIFIED GLASGOW IN CHILDREN

Glasgow for children it is modified only in the step of “Verbal response”. The steps of “Open eyes” and “Motor response” must be considered as in the adult level as well.


• VERBAL RESPONSE:
Social Smile...................................... 5
Consoling cry ................................... 4
Irritated persistently……................... 3
Restless, agitated............................. 2
Quiet, silence ................................... 1



Treatment depends on the severity of brain injury


GRADE I: (mild)
• Temporary loss of state on alert, oriented, without neurological deficit, may have headache, nausea or vomiting.
GLASGOW 13-15 POINTS.


GRADE II .-(moderate)
• Transient loss of alertness, able to obey a simple command, may be alert but with focal neurological deficit like anisocoria, hemi paresis, aphasia, ETC. GLASGOW 9-12 POINTS


GRADE III .-(severe)
The patient has altered the state of consciousness LOC (Person-time-space) and he is not able to obey a simple command. He uses inappropriate language May have decerebrated posture.
GLASGOW <9

GRADE IV .-
• Brain Death
GLASGOW <6.

Although Glasgow Scale is not enough to establish if patient got Brain death, it must be completed with the following criteria:

Brain Death criteria (clinical and Radiographic):

1.-Unknown cause coma.

2.-Absolute security of non drug intoxication.

3.-Mydriatic pupils still without response.

4.-Absence of oculus-cephalic reflexes. (Turn the head 30 degrees, previous cleaning of auditory canal, later it is applied cold water into the conduct and is getting deviation ocular toward the side where is applied the water followed for quick nistagmus to opposite side.

5.-Absence of corneal reflex.

6.-Vestibular tests negative.

7.-Absence of respiratory automatism.

8.-No motor response.

9.-No myotatic reflex.

10.-The persistence of coma for minimum 6 hours.

11.-Lack of cerebral perfusion in carotid angiography.

12.-Lack of cerebral perfusion in computed tomography contrast.

13.-collapse of all Cisterns in the simple CT.

14.-EEG Isoectric.

Views: 38

Tags: cranial, head-injury, homeopathy, trauma

Comment by Dr Muhammed Rafeeque on February 3, 2010 at 11:26pm
Thanks for the information.

ABCD is the rule of thumb for giving first aid to a serious patient. A stands for airway, B for breathing, C for circulation and D stands for the doctors help.
Comment by Dr Guillermo Zamora on February 4, 2010 at 1:11pm
Yes Dr. Rafeeque...ATLS method is very important to assess these patients or with trauma.

Thank your for comments.
Comment by Dr Muhammed Rafeeque on February 5, 2010 at 11:57pm
The most important point to be considered before giving first-aid is: our intervention should not cause any risk to our health and the condition of the victim.

1, Electric shock: Before touching the victim, make sure that the electricity is disconnected.

2, Do not touch the blood with bear hands.

3, If the victim is a woman, call somebody to be present at the site, while giving the first aid.

4, Do not give mouth to mouth breathing to a case of poisoning.

5, Our first aid should not complicate the condition of the victim. i e. giving cardiac massage to a case of multiple fracture of ribs; rupture of organs like liver caused by rigorous chest compression; inducing vomiting in case of poisoning by volatile liquids like kerosene; complete obstruction of blood circulation due to tight and prolonged application of tourniquet; victim dying as a result of tetanus caused from the wound created at the site of snakebite to "drain out" the poison; emergency tracheostomy causing injury to the major blood vessels; giving alkali to a case of acid poisoning to "neutralize" the poison etc.
Comment by Debby Bruck on February 6, 2010 at 11:17am
Excellent tutorial by all. Precautions for health care worker also important.

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