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HEAD TRAUMA

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HEAD TRAUMA August, 22, 2002 Adam Oster PGY2 Dr. Mark Yarema HEAD TRAUMA Outline Epidemiology Biomechanics of HI Minor HI Canadian CT Head Rule future developments ... – PowerPoint PPT presentation

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Title: HEAD TRAUMA


1
HEAD TRAUMA
  • August, 22, 2002
  • Adam Oster PGY2
  • Dr. Mark Yarema

2
HEAD TRAUMA
  • Outline
  • Epidemiology
  • Biomechanics of HI
  • Minor HI
  • Canadian CT Head Rule
  • future developments
  • Severe HI
  • physiology
  • management issues and controversies
  • future developments
  • Pediatric HI

3
HEAD TRAUMA
  • Epidemiology
  • approx 1 000 000 HI evaluated in ED in N.A/yr
  • majority (80) are minor or minimal
  • majority of these can be discharged home safely
  • small percentage will deteriorate and require
    neurosurgery
  • early diagnosis of these NSx lesions is important
    and effects long short and long term outcome
  • 50 000 die before reaching the ED
  • leading cause of traumatic death in males lt25 y.o

4
HEAD TRUMABIOMECHANICS
  • Primary
  • Direct Injury
  • occurs at the moment of the injury
  • damage can occur directly beneath the area
    involved
  • , EDH, ICH, contusion
  • or occur remotely from propagation of energy
  • Indirect Injury
  • occurs when the cranial contents are set in
    motion within the skull
  • SDH, DAI, coup-contra-coup pattern, concussion.

5
HEAD TRUMABIOMECHANICS
  • Secondary Injury
  • Hypoxia
  • includes seizures
  • Hypotension
  • Decreased CPP
  • (CPPMAP-ICP)
  • Anemia
  • Systemic and Metabolic insults
  • Infection
  • areas of brain suffering irreversible primary
    injury are surrounded by a penumbra of tissue
    that is injured but potentially salvageable.

6
HEAD INJURY CLASSIFICATION
  • MINOR (80)
  • GCS 13-15
  • MODERATE (10)
  • GCS 9-13
  • SEVERE (10)
  • GCS 3-8

7
Anatomy
8
Anatomy
9
  • 30 yo woman fell from a ladder 45 minutes ago
    while painting her house, witnessed by her
    husband. No LOC. Previously healthy.
  • What else do you want to know?
  • O/E
  • eyes are open
  • converses but not sure why shes in the hospital
  • obeys commands
  • no focal deficits
  • GCS --
  • remainder of exam normal

10
Minor HI
  • CT scan?
  • What is her risk of a NSx lesion
  • A clinically important brain injury
  • death from this HI

11
Minor HI
  • GCS 13-15
  • amnesia, disorientation and confusion are common
  • no focal neurologic deficits
  • Controversy about including GCS 13 in minor HI
    since the rates of NSx lesions and sequelae are
    closer to moderate HI (GCS9-12) than minor (GCS
    14-15(
  • 3 will deteriorate
  • 1 have surgical lesions
  • lt0.5 will die

12
CT scan in Minor HI
  • An ongoing and evolving issue
  • scan everyone
  • scan no one
  • selective scanning
  • wide variation in inter-physician and teaching
    hospital scanning rates

13
History of the debate
  • Haydel, 2000
  • H/A
  • Vomiting
  • Agegt60
  • Drug or ETOH intoxication
  • Amnesia
  • Seizure
  • Trauma above the clavicles
  • Sens 100 (95-100) for CT abnormality
  • Sens. for NSx intervention 54-100 (N6)

14
Rosen 2002 High Risk
  • Focal neurologic
    findings
  • Asymmetric pupils
  • Skull fracture
  • Multiple trauma
  • Serious, painful,
    distracting injuries
  • External signs of
    trauma
  • Initial Glasgow
    Coma Scale score of 13
  • Loss of
    consciousness (gt2 min)
  • Posttraumatic
    confusion/amnesia (gt20 min)

15
Rosen 2002 Low Risk
  • Currently asymptomatic
  • No other injuries
  • No focality on
    examination
  • Normal pupils
  • No change in
    consciousness
  • Intact
    orientation/memory
  • Initial Glasgow
    Coma Scale score of 14 or 15
  • Accurate history
  • Trivial mechanism

16
Signs and SymptomsCorrelation with IC Lesion
Emergency Medicine Clinics Of North America vol
17, no.1. Feb., 1999.
  • LOC
  • incidence of IC lesions range 1.3 to 17.2
  • GCS 15 and LOC
  • 6.1 to 9.4
  • IC lesion incidence rises with increasing with
    LOC duration
  • lt5mins 5.9
  • gt5mins 8.5
  • H/A, nausea and vomiting
  • about 2x as likely to occur in HI without IC
    lesion as in HI with IC lesion.
  • Seizure
  • no correlation with IC lesion incidence

17
Signs and SymptomsCorrelation with IC Lesion
Emergency Medicine Clinics Of North America vol
17, no.1. Feb., 1999.
  • GCS 15 Shackford et. al
  • IC lesion rate 14.8
  • 3.2 required crani.
  • GCS 15 Miller et. al.
  • IC lesion in 6.1
  • 0.2 required NSx.
  • Anisocoria
  • incidence of IC increased with extent.
  • gt1mm, 30 IC lesion
  • gt3mm, 43
  • Basal Skull
  • 53-90 IC lesion

18
Canadian CT Head Rule
  • 3121 patients multicentred, prospective cohort
    study
  • inclusion criteria
  • GCS 13-15
  • witnessed LOC, amnesia or disorientation
  • injured within the past 24hrs
  • Excluded lt16, no LOC/amnesia/disorientation,
    obvious depressed skull , penetrating skull
    inj., focal neuro deficit, Sz post-injury,
    pregnant, congenital or acquired bleeding
    disorder.

19
Canadian CT Head Rule
  • Primary outcome
  • need for neurosurgical intervention
  • intubation or death within 7d, craniotomy,
    elevation of skull, ICP monitoring.
  • Secondary outcomes
  • Clinically Important Brain Injury
  • an injury which would normally require admission
    and neuro follow-up
  • consensus of EPs, neurosurgeons and
    neuroradiologists
  • CIBI
  • Solitary contusion lt5mm
  • Localized SAH
  • SDHlt4mm
  • Isolated pneumocephaly
  • Closed and depressed skull, not through inner
    table

20
Canadian CT Head Rule
  • Study Design
  • Patients assessed for 22 standardized findings on
    Hx, PE and neurological exam.
  • CT scan at discretion of physician
  • Follow-up by phone at 14days for those who did
    not have a CT to determine the presence of CIBI.

21
Canadian CT Head Rule
  • Results
  • 1 (44) required neurosurgical intervention
  • 0.13 (4) died
  • 8 (254) CIBI
  • 4 (94) CUIBI
  • small SAH, contusions lt5mm
  • 67 had CT, 33 phone follow-up, 363 () lost to
    follow-up

22
Canadian CT Head Rule
  • 7 variables with good IO agreement and strong
    association with the outcome
  • Goal was highest sensitivity while still
    achieving greatest specificity
  • Stratifies patients into three groups
  • high risk for the primary outcomes measure or
  • medium risk for the secondary outcome
  • Low risk for either outcome

23
Canadian CT Head Rule
  • High risk (for neurological intervention)
  • GCS score lt15 at 2 hours after injury
  • Suspected open or depressed skull fracture
  • Any sign of basal skull fracture
  • hemotympanum, "raccoon" eyes, CSF otorrhea or
    rhinorrhea, Battle's sign)
  • Vomiting gt 2 episodes
  • Age gt 65 years
  • Sens 100 (92-100)
  • Spec. (67-70)

24
Canadian CT Head Rule
  • Medium risk (for brain injury on CT)
  • Amnesia before impact gt30 minutes
  • Dangerous mechanism
  • pedestrian struck by motor vehicle, occupant
    ejected from motor vehicle, fall from height gt3
    feet or 5 stairs
  • Sens. 98.4 (96-99)
  • Spec. 49.6 (48-51)

25
Canadian CT Head Rule
  • Questions
  • Is the sensitivity high enough?
  • Will it reduce the frequency of scanning Mild HI
    patients

26
  • 35 y.o intoxicated male brought in by EMS.
    Witnessed fall from own height at an LRT station
    approx. 45 minutes ago.
  • Open eyes to shouting, sleeping but easily roused
    with pain, swearing, moves all 4 limbs
    vigorously. VSS.
  • Obvious scalp lacerations. Remainder of exam
    normal.
  • Image now or observe?

27
  • Same guy but youve been busy. Now injury was
    approx. 6hrs ago.
  • Opens eyes to shouting, swears, moves all four
    limbs spontaneously.
  • Now what?

28
  • 50 y.o woman with chronic a.fib.. Husband saw
    her fall from the first rung of a step ladder.
    She cannot remember what happened. Otherwise
    healthy.
  • GCS 15.
  • Disposition?

29
  • 16 yo boy fell while skateboarding. LOC approx 10
    secs. Now feels fine.
  • GCS 15, normal exam.
  • Disposition?

30
Concussion
  • A brief alteration in mental function after
    minor head trauma. (Rosen, 2002).
  • Absent cerebral autoregulation for days following
  • Advice on discharge?
  • Depends on extent of concussion

31
Concussion
  • Grade 1 confusion without amnesia, no LOC
  • Grade 2 confusion with amnesia, no LOC
  • Grade 3 LOC

32
Concussion Grade 1
  • Remove from sporting event immediately. Examine
    immediately and serially for development of
    amnesia and post-concussive symptoms at rest and
    with exertion.
  • Consider return to sport if amnesia does not
    appear and no symptoms appear for at least 20

33
Concussion Grade 2
  • Remove from event. Re-examine next day.
  • May return to practice only after 1 full week
    without symptoms.

34
Concussion Grade 3
  • Transport to hospital for evaluation. Admit and
    observe if concerns of clinically significant
    brain injury. If no concern, discharge with
    instructions to family for overnight observation.
  • May return to practice only after 2 full weeks
    without symptoms

35
  • 30 yo helmeted male mountain biking in Edworthy.
    Came off bike while travelling downhill. Struck
    side of head on tree. Brief LOC. Immediate neck
    pain. Friends helped him up and they walked him
    out to their car. Drove him to the ED.

36
  • GCS 15, PERL 3mm
  • No focal neurologic deficits.
  • Central c-spine tenderness.
  • Rest of exam wnl.

37
HI and Pediatrics
  • Important to separate the traumatic or accidental
    from the non-accidental.
  • Adult resuscitation principles apply, e.g
    avoiding hypoxia, hypotension, hyperthermia.
  • Challenge is predicting who is low risk enough to
    be observed and discharged home.

38
Pediatric HIGeneral Principles
  • The younger the child the lower your threshold
    should be for imaging
  • The greater the forces the lower your threshold
    should be
  • The more physical symptoms the lower your
    threshold should be
  • Consider intentional injury/neglect.
  • Can get hypovolemic hypotension

39
Pediatric HI Predictors for Intracerebral
Injury Trauma Reports, 2000.
  • Skull
  • better predictor than clinical symptoms
  • Sens. 60 to 100
  • Scalp hematoma (sens 80 to 100) and young age
    are predictors for SF
  • Altered mental status
  • Focal neurological findings
  • Scalp swelling,
  • HI without a clear history of trauma
  • In the lt6mo. May be asymptomatic
  • LOC and vomiting are not predictive.

40
Pediatric HIRisk Stratification lt 2 y.o
Pediatrics. Vol 17, no. 5. May, 2001
  • High Risk
  • Decreased LOC
  • Focal findings
  • Basal or any skull
  • Irritability
  • bulging fontanelle
  • LOCgt1min, post-injury SZ, worsening vomiting
  • Consensus guideline
  • Low Risk
  • Trivial (low energy) mechanism
  • Fall lt3feet
  • No signs/symptoms at gt2yrs post-injury
  • Age gt3mo
  • Require a period of observation for
    deterioration.

41
Pediatric HI Normal CT and Discharge
  • 3 studies
  • HI and Normal CT
  • Incidence of deterioration was 0
  • (95 CI 0-1.4)

42
CATCH CT Study
43
Rosen, 2002 Pediatric minor HI and Management
  • No LOC and Normal Exam
  • observe for up to 24hrs by a competent adult
  • LOC and normal exam
  • may consider observation by competent adult
  • CT if high risk mechanism or currently
    symptomatic (e.g vomiting, seizure)

44
  • 26 yo male, brought in by STARS from Canmore for
    CHI.
  • EMS on scene -- GCS 11, full spines
  • STARS called for transport to FMC
  • In ED
  • 90, 120/70, 16, 99 on 5L by np, 36.5
  • opens eyes to shouting his name, moaning, 4 limb
    spontaneous movement.

45
SEVERE HEAD INJURY
46
Head InjuryHistory
  • Key Historic Info
  • MVC
  • fall
  • height, landing position, assault weapon
  • LOC
  • amnesia
  • Sz (Hx of Sz)
  • vitals and GCS on scene and transport
  • AMPLE
  • current complaints
  • 26 yo previously healthy male. Unrestrained
    passenger in high-speed single vehicle rollover.
    No airbags.
  • ?LOC
  • No alcohol/drugs involved

47
Head Injury Physical Exam
  • Key Clinical Info
  • ABCs --high incidence of polytrauma
  • GCS
  • Head and neck
  • ?basal skull
  • pupils
  • size, reactivity, asymmetry
  • motor exam
  • symmetry, abnormal posturing, strength.
  • Cranial nerves
  • gag, corneal ref.
  • DTRs and pathologic reflexes
  • vitals
  • ?herniation syndromes
  • Approx 60 TBI will have a second system injury
  • 16 associated c-spine injury

48
Head InjuryGlasgow Coma Scale
  • GCS
  • developed for assessment at 6hrs post-injury
  • isolated HI and hemodynamically stable
  • use at lt6hrs is limited
  • hemodynamics, intubation, ETOH,
    sedation/paralysis
  • does not assess brainstem function

49
SEVERE HI
  • Prevention of secondary injury
  • 1 episode of hypotension (SBPlt90) increased
    mortality by 150.
  • Hypoxia (paO2lt60) also significantly increased
    mortality (but less than hypotension).
  • Combined hypotension and hypoxia more detrimental
    than either alone.
  • Chestnut, RA. Analysis of the role of Secondary
    Brain Injury in determining the outcome from
    severe head injury. J. Neurosurg 199072360.

50
  • 26 yo male, brought in by STARS from Canmore for
    CHI.
  • EMS on scene -- GCS 11, full spines
  • STARS called for transport to FMC
  • In ED
  • 90, 120/70, 16, 99 on 5L by np, 36.5
  • opens eyes to shouting his name, moaning, 4 limb
    spontaneous movement.
  • GCS
  • 12 (E3, V3, M6)
  • Hemodynamically stable
  • no focal complaints
  • Management
  • Airway and Breathing
  • BP
  • imaging
  • CT head nil acute
  • c-spine films normal
  • Disposition...

51
PATHOPHYSIOLOGY
  • Normal brain
  • CBF is constant over a wide range of pressures
    (MAP 60-150)
  • will vary linearly outside this range
  • cerebral vessel diameter also varies linearly
    with paCO2 and inversely with pa O2
  • Cannot measure CBF so use surrogate
  • CPPMAP-ICP
  • MAPgt70mmHg
  • ICPlt20mmHg
  • what increases ICP
  • intra-axial mass
  • edema, CSF obstruction.

52
PATHOPHYSIOLOGY
  • Intracranial compensatory mechanisms can
    accommodate approx. 50cc to 100cc of increased
    volume.
  • Beyond this ICP (and CPP) will increase
    dramatically.
  • MAP transmitted directly to ICP.

53
  • 18 yo girl. Motorcross with family. Witnessed
    fall off bike while jumping.
  • LOC, no Sz.
  • GCS 8 on scene
  • hemodynamics normal
  • bagged by EMS to FMC
  • Triage
  • airway and breathing
  • BP
  • neuro exam

54
  • neuro
  • does not open eyes
  • Moaning and very agitated
  • moves all four limbs vigorously
  • withdraws from painful stimuli
  • GCS?
  • Pupils
  • Rt 4 Lt 2, reactive
  • motor exam
  • no posturing
  • brainstem function normal
  • reflexes
  • ?Babinski
  • toes downgoing
  • rectal tone normal

55
  • Whats your management plan?
  • Airway capture?
  • Indications for intubation
  • Imaging
  • Disposition

56
Indications for Intubation
  • Failure to protect
  • inability to oxygenate
  • inability to ventilate
  • anticipated clinical course
  • loose airway in near future
  • transport
  • DI

57
Challenges during the Intubation
  • CPPMAP-ICP
  • challenges during intubation
  • MAP
  • ICP
  • decreasing MAP
  • increasing ICP
  • RSRL
  • reflex inc. ICP due to laryngoscopy

58
RSI the chosen one
  • Preparation
  • pre-oxygenate
  • pre-treatment
  • L -- lidocaine
  • O -- opiates
  • A -- atropine
  • D -- defasciculator or low dose sux
  • paralysis with induction
  • etomidate is agent of choice thiopentol
  • protection/positioning
  • placement/proof

59
RSI
  • Pitfalls
  • paralysis in a patient with potential neurologic
    deficits requiring serial exams
  • monitoring for Sz

60
  • CT head read as normal
  • now what?
  • Serial exams
  • ?extubation and to NSx
  • remain intubated to ICU

61
  • 29 yo male, witnessed fall from a 2nd storey
    building with LOC. Brought in by EMS in full
    spinal precautions on O2.
  • On scene, hemodynamically stable.
  • GCS 9 (E2, V2, M5), PERL 3mm
  • stable throughout transport (20mins) to FMC

62
  • Triaged to resusc room
  • O2 and monitors applied
  • 80, 120/80, 20, 99
  • Rt pupil 5mm, sluggish to light
  • Lt pupil 3mm, reactive
  • GCS
  • no eye opening
  • moaning
  • withdraws to pain
  • Intubate
  • why?
  • what else?
  • Raise bed 30 deg.
  • Hyperventilate
  • pCO2 to 30-35
  • Mannitol
  • 1mg/kg
  • Seizure prophylaxis

63
Acute Deterioration Increasing ICP
  • Hyperventilation
  • mechanism
  • onset
  • duration
  • no response?
  • Role for prophylactic hyperventilation?
  • Hypocapnia pitfalls
  • reduced CBF can cause ischemia
  • temporary measure

64
Acute Deterioration Increasing ICP
  • Mannitol
  • mechanism
  • decreased blood viscosity
  • increases BP
  • reduces ICP through osmotic cerebral dehydration
  • lasts 90mins to 6hrs
  • use smaller doses and boluses
  • Mannitol pitfalls
  • causes BBB failure and will build up in cerebral
    tissue causing a reverse osmotic shift.

65
Acute Deterioration Increasing ICP
  • Off to the scanner

66
Acute Deterioration Increasing ICP
  • Needs a craniotomy stat
  • If delayed and no effect from hypocapnia and
    mannitol
  • next line
  • phenobarbitol
  • must be hemodynamically stable
  • dose
  • load 10mg/kg over 3hrs
  • then 1mg/kg/hr maintenance

67
Seizure Prophylaxis
  • Depressed skull
  • intubated and paralysed patient
  • Seizure at time of injury
  • History of seizures
  • penetrating HI
  • severe HI
  • EDH/SDH/ICH

68
Increasing ICP Controversies
  • Hypertonic saline (HTS)
  • science
  • improves CBF, MAP and CPP
  • studies to date (HTS of 1.6 to 23.4). Some add
    dextran.
  • RCTs
  • Shackford et al. 1.6 HTS vs LR underpowered and
    inconclusive
  • Simma et al. 1.6 HTS vs LR. HTS group had
    shorter ICU stays and fewer interventions

69
Increasing ICP Controversies
  • HTS
  • Case controlled
  • Khanna et al. 3 HTS vs conventional therapy in
    refractory ICP (peds)
  • effectively decreases ICP and safely tolerated.
  • ?outcomes measured
  • Retrospective
  • Quereshi, Annals of EM 2000. 2 or 5 HTS vs
    0.9. Did not lessen requirements for other
    interventions or decrease in-hosp. Mortality.
  • Take-home no harm, maybe effective, few RCTs
    (none against mannitol) and wide range of
    concentrations used.

70
Increasing ICP Controversies
  • Hypothermia
  • Niemann Annals of EM 2001
  • random assignment of 392 pts with CHI to
    hypothermia (33 deg.) vs normothermia within 6hrs
    post-injury for 48hrs.
  • No improvement in outcomes and trend to longer
    length of hospitalisation and higher rate of
    complications.

71
  • Hypertension
  • bradycardia
  • irregular respirations
  • the Cushing reflex

72
  • Dilated and sluggish Lt pupil
  • Rt sided Babinski
  • early Lt. uncal herniation

73
  • Dilated, non-reactive Rt pupil
  • Rt sided hemiparesis
  • Rt Babinski
  • late Rt uncal herniation (Kernohans notch
    phenomenon)

74
  • Bilaterally pinpoint pupils
  • bilateral decerebrate posturing
  • hyperventilation
  • central transtentorial herniation

75
  • Pinpoint pupils
  • flaccid quadriplegia
  • cerebellar tonsillar herniation

76
  • 35 yo woman. Restrained driver in a high-speed
    single vehicle collision. Passenger dead at
    scene. Patients airbag deployed and she remained
    the vehicle. Significant incursion of the light
    standard into the drivers side.
  • GCS 11 on scene and initial BP 90/60 but up to
    105/80 after 1L NS en route.
  • In ED GCS 8, no lateralizing signs
  • 110, 90/60.
  • Abdomen rigid, LUQ pain.

77
  • 17 yo male passenger in the back of a pickup.
    Thrown from vehicle. LOC on scene for 3 mins.
  • On scene eyes closed, moaning, moves left side
    more than right. Intubated. GCS?
  • In ED eyes closed, grunting, spontaneously moves
    left more than right . Lt pupil 5mm, sluggish, Rt
    pupil 2mm, reactive.
  • 110, 100/80, 100. Abdomen hard.
  • You give mannitol and hyperventilate.
  • What next?

78
  • Youre the STARS doc flying to Golden to pick-up
    an 18 yo CHI who is intubated and being
    hyperventilated for increasing ICP evidenced by a
    new Lt. sided blown pupil. His pupils became
    symmetric soon after. Mannitol was given.
  • When you get there the treating physician tells
    you his Lt. Pupil has blown again.
  • Emergency burr hole?

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