Traumatic Brain Injury: Specific Management Items of Note for the Emergency Physician

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Traumatic Brain InjurySpecific Management Items
of Note for theEmergency Physician
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Edward P. Sloan, MD, MPHAssociate
ProfessorDept of Emergency Medicine

• University of Illinois College of Medicine
• Chicago, IL

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Attending Physician Emergency Medicine

• University of Illinois Hospital
• Our Lady of the Resurrection
• Medical Center
• Chicago, IL

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OverviewGlobal Objectives

• Understand disease state (TBI)
• Utilize best management strategies
• Have many options available
• Optimize patient outcome
• Maximize resource use
• Make our practice enjoyable

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OverviewSession Specifics

• Review Italian guidelines
• Discuss the EM Reports
• Examine the ACR head trauma criteria
• Summarize minor TBI practice parameters
• Detail trephination and antibiotic use
• Look at some head CTs
• Journal club articles

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Methodology Literature Search

• www.guidelines.gov
• Traumatic Brain Injury
• 21 guidelines provided
• Relevant US guides used

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Methodology Internet Sources

• www.guideline.gov/
• www.med.wayne.edu/diagRadiology/TF/
• www.brighamrad.harvard.edu/cases/
• www.ferne.org/
• www.google.com/

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Methodology Source Documents

• Guidelines for Rx of Adults with TBI
• J of Neurosurgical Sciences
• Vol 441 March 2000
• Three articles
• Initial assessment, medical, surgical Rx
• Emergency Medicine Reports
• December 3, and December 17, 2001

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Methodology Source Documents

• Roberts, Hedges Clinical Procedures in Emergency
  Medicine, 2nd Edition
• EM journal club articles
• make a point
• describe a clinical entity
• have medicolegal import

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GuidelinesItalian Recommendations

• I Initial Assessment
• RSI Thiopental (ketamine or midazolam) Sux or
  vecuronium
• GCS In comatose pts (eye1, verbal1,2) Motor
  component very important. Use best response
  from either side.

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GuidelinesItalian Recommendations

• I CT Indications
• Loss of two points on GCS
• Rise in ICP above 25 mm Hg
• Decrease in CPP below 70 mm Hg gt 15 min
• Decrease in O2 sat below 50 gt 15 min

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GuidelinesItalian Recommendations

• II Medical Therapy
• Inotropes once blood volume restored
• To maintain MAP above 90 mm Hg
• To achieve CPP gt 70 mm Hg if ICP high
• Not in lieu of ICP management

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GuidelinesItalian Recommendations

• III Surgical Therapy
• Absolute
• Focal lesion, midline shift gt 5 mm
• Space occupying lesion gt 25 cc
• Relative
• ICP gt 20 mm Hg or CPP lt 70 mm Hg
• Optimal medical ICP management
• Case-specific criteria also

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LiteratureEM Reports TBI, Subdural

• I Emergency Rx, Imaging
• Pathophysiology
• Neurologic exam
• CT indications
• MRI DAI, subcortical injury, brainstem
• Angiography Penetrating TBI, vascular
  occlusion, dissection, aneurysm

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LiteratureEM Reports TBI, Subdural

• II Emergency Rx of Severe TBI
• Severe TBI Rx, including ICP Rx
• Cranial decompression indications
• Monitoring indications
• Moderate TBI Rx, outcome
• Minor TBI, and post-concussion syndrome

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ACR GuidelinesAppropriateness Criteria

• Imaging in head trauma
• Classified by clinical condition
• Provides summary by imaging modality
• CT screening tool in mild TBI to determine who
  may benefit from observation
• Skull xrays calvarial fractures, penetrating
  injuries, and foreign bodies

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EAST GuidelinesMild TBI Management

• Transient neuro deficit, no acute pathology
• CT is gold standard
• Normal CT 0-3 deterioration (GCS 13-14)
• Neuropsychological testing at 1-2 months
• Most pts recover within one month
• Limited data on those who do not recover

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Neurology GuidelinesConcussion in Sports

• Grade 1 Transient sx for lt 15 minutes
• May return if sx resolve within 15 minutes
• Grade 2 Transient sx for gt 15 minutes
• No return to contest
• CT if sx persist
• Grade 3 Any LOC noted
• ED eval if sx persist or more than brief LOC

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Emergent Cranial DecompressionIndications

• Hippocrates utilized trephination
• To evacuate extradural hematomas
• To reverse signs of tentorial herniation
• Rapid, progressive neurologic deterioration
• Coma, fixed, dilated pupil, hemiplegia and
  presumed skull fx on side of pupil
• Likely intracranial hematoma on same side

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Emergent Cranial DecompressionProcedure

• 4 cm vertical incision
• External auditory canal is key landmark
• Three cm superior to zygoma
• Two cm anterior to ear

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Emergent Cranial DecompressionProcedure

• Drill a hole, enlarge with a Burr
• Careful as the inner table is perforated
• Epidural clotted, unless bleeding persists
• Middle meningeal artery is deep to clot
• Be prepared to replace blood loss
• Bilateral fixed pupils, or no clot, repeat on
  contra-lateral side

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Prophylactic AntibioticsSkull Fx, Penetrating TBI

• Sanford, ePocrates no recommendations
• EM study guide ask neurosurgeon
• Prophylaxis controversial
• Skull fracture and fever
• Pneumococcus within 72 hours
• Staph aureus and gram negs after 72 hours
• Vancomycin, 3rd gen ceph (ceftazadime)

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Radiology CasesSearching for Teaching Files

• Google Radiology Teaching Files
• Many universities post files
• Two examples of content
• Easy to use in the E.D.
• Radiology of Emergency Medicine

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Biconvex high-attenuation epidural hematoma R
frontal
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Extends to level of lateral ventricle
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Extends to level of roof of orbit R
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No fx evident here
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Skull fx evident at R orbit
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Associated STS
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R Subdural hematoma frontal lobe CSF leakage
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R to L midline shift with subfalcine herniation
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R to L midline shift with R uncal herniation
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R base hyperdense subdural hematoma
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Extension to anterior interhemispheric fissure
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R lateral ventricle body swelling
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Swelling L parietal region, no fracture evident
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Radiology CasesHow to Obtain Images

• Get the image on the screen
• Hit the print screen button
• Go to PowerPoint
• Edit Office Clipboard
• Double click on R to paste
• Resize to fit, add text box as needed

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Journal Club ArticlesBTF Guidelines

• Basis for lecture on TBI Rx
• Explains guideline development
• Guides acute ED therapies
• Brain Trauma Foundation J Neurotrauma, 1996 13
  643-645
• Brain Trauma Foundation J Neurotrauma, 1996
  13 653-659

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Journal Club ArticlesSkull X-ray Indications

• Multi-disciplinary study
• Provided key recommendations
• Changed clinical practice
• Skull xrays occult penetrating trauma
• Masters SJ N Engl J Med, 1987 316 84-91
• The Selection of Patients for X-Ray Examinations
  Skull
• X-Ray Examination for Trauma

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Journal Club ArticlesHypertonic Saline in TBI

• J Trauma literature review
• Proven mechanism for benefit
• Conflicting clinical data
• Restores MAP without edema, inc ICP
• Doyle JA J Trauma, 2001 50 367-383

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Journal Club ArticlesPEG-SOD in TBI

• JAMA article
• SOD oxygen radical scavenger
• EM physicians involved
• No benefit, control group did well
• Young B JAMA, 1996 276(7) 538-543

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Journal Club ArticlesCT in Mild TBI

• J Trauma article
• Is CT of all mild TBI pts cost-effective?
• CT is cost effective, no need to admit
• Normal CT and neuro exam home
• Shackford SR J Trauma, 1992 33(3) 385-394

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Journal Club ArticlesCT in TBI Hypotension

• Annals EM article
• CT prior to laparotomy?
• If stable after initial resus, OK to CT
• Average delay of 68 minutes
• Winchell RJ Ann Emerg Med, 1995 25(6) 737-742

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Journal Club ArticlesEtOH and Minor TBI

• Acad EM article
• CT in intoxicated minor TBI pts?
• 8 Positive CT, 2 craniotomy rate
• May need to CT with mild TBI and EtOH
• Cook LS Acad Emerg Med, 1994 1(3) 227-234

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Journal Club ArticlesPts Who Talk Deteriorate

• Annals EM article
• Can speak and then coma within 48 hrs
• 75 intracranial hematoma rate
• Deterioration bad prognosis
• Need to achieve early decompression
• Rockswold GL Ann Emerg Med, 1993 22(6)1004-100

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ConclusionsTBI Rx in the ED

• GCS motor key in coma
• RSI with Thiopental/sux
• Clear CT, surgery indications
• Inotrope, PRN if volume OK
• MRI, angio less needed

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ConclusionsTBI Rx in the ED

• CT is best screening tool
• Mild TBI 1 month recovery
• Concussion LOC is key
• Trephination epidural Rx
• Drill on side of blown pupil
• Anbx prophylaxis unclear

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ConclusionsTBI Journal Club

• BTF guidelines key
• Skull xray penetrating trauma
• HTN saline unclear
• CT even if hypotension prior
• EtOH CT liberally
• Talk deteriorate evacuate

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ConclusionsInternet Medical Information

• Guidelines.gov
• Google radiology teaching file
• PrintScreen, paste to PowerPoint
• FERNE.org

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RecommendationsTBI Rx in the ED

• Liberal CT use
• Follow guidelines
• Surf the web
• Maximize patient outcome
• edsloan_at_uic.edu
• [phone]