Assessment, Management and Decision Making in the Treatment of Polytrauma Patients with Head Injuries PowerPoint PPT Presentation

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Title: Assessment, Management and Decision Making in the Treatment of Polytrauma Patients with Head Injuries


1
Assessment, Management and Decision Making in the
Treatment of Polytrauma Patients with Head
Injuries
  • Roman A. Hayda, MD
  • Created March 2004 Revised July 2006

2
Epidemiologic Aspects
  • 80,000 survivors of head injury annually
  • 125,000 children lt15yo head injured annually
  • 40-60 of head injured patients have extremity
    injury
  • 32,000-48,000 head injury survivors with
    orthopaedic injuries annually

3
Overview
  • Initial evaluation
  • Prognosis
  • Management of Head Injury
  • Orthopaedic Issues
  • Operative vs. nonoperative treatment
  • Timing of surgery
  • methods
  • Fracture healing in head injury
  • Associated injuries
  • Complications

4
Evaluation
  • ATLSABCs
  • History
  • loss of consciousness
  • Physical exam
  • Glasgow Coma Scale
  • Radiographic studies
  • CT Scan

5
Evaluation
  • Must exclude head injury by evaluation if
  • history of loss of consciousness
  • significant amnesia
  • confusion, combativeness
  • Cannot be simply attributed to drug or alcohol
    use
  • neurologic deficits on exam of cranial nerves or
    extremities

6
Physical Exam
  • Exam of head and cranial nerves for lateralizing
    signs
  • dilated or sluggish pupil(s)
  • Extremities
  • unilateral weakness
  • posturing
  • decorticate (flexor)
  • decerebrate (extensor)

7
Glasgow Coma Scale
  • Eye opening 1-4
  • Motor response 1-6
  • Verbal response 1-5

8
Glasgow Coma Scale
  • Eye opening
  • Spontaneous 4
  • To speech 3
  • To pain 2
  • None 1

9
Glasgow Coma Scale
  • Motor response
  • Obeys commands 6
  • Purposeful response to pain 5
  • Withdrawal to pain 4
  • Flexion response to pain 3
  • Extension response to pain 2
  • None 1

10
Glasgow Coma Scale
  • Verbal response
  • Oriented 5
  • Confused 4
  • Inappropriate 3
  • Incomprehensible 2
  • None 1

11
Glasgow Coma Scale
  • Sum scores (3-15)
  • lt9 considered severe
  • 9-12 moderate
  • 13-15 mild
  • ModifiersxT if intubated (Best score possible
    11T) xTP if intubated and paralyzed (Best
    score possible is 3TP)
  • Done in the field but best in trauma bay
    following initial resuscitation



12
Radiographic Studies
Frontal Contusion
  • CT scan
  • required in ALL cases EXCEPT
  • LOC is brief
  • AND
  • patient can be serially examined
  • lesions
  • focal--epidural, subdural hematoma,
  • contusions
  • diffuse--diffuse axonal injury
  • Plain films
  • useful only to detect skull fracture
    but in the trauma setting wastes time

13
Treatment
  • Initial
  • Intubation if unresponsive or combative to give
    controlled ventilation
  • pharmacologic paralysis
  • after neurologic exam is completed
  • Blood pressure and O2 saturation monitoring
  • keep systolic gt 90 mm Hg
  • 100 O2 saturation

14
ICP Monitoring
  • Indications
  • severe head injury (GCS lt 9)
  • abnormal head CT
  • or
  • normal CT and at least two of the following
  • age over 40
  • uni- or bilateral flexor or extensor posturing
  • history of systolic BP lt 90 mm Hg
  • when unable to follow serial neurologic exams
  • i.e. for operative or lengthy diagnostic
    procedures

15
ICU Management Goals
  • O2 saturation 100
  • Mean arterial pressure 90-110 mm Hg
  • ICP lt 20 mm Hg
  • Cerebral Perfusion Pressure (CPPMAP-ICP) gt70 mm
    Hg

16
ICU Adjuncts
  • HCT 30-33
  • PaCO2 352 mm Hg
  • CVP 8-14 mm Hg
  • avoid dextrose IV
  • maintain euthermia or mild hypothermia

17
Factors Influencing Prognosis
  • Age
  • Younger pts have greatest potential for survival
    and recovery
  • 61-75 mortality if over 65
  • 90 mortality in elderly with ICP gt20 and coma
    for more than 3 days
  • 100 mortality if GCS lt 5, uni- or bilateral
    dilated pupils, and age over 75
  • Bottom line survival and recovery not
    predictable except in old pts
  • Treat presuming recovery

18
Factors Influencing Prognosis
  • Hypotension--50 increase in mortality with
    single episode of hypotension
  • Hypoxia
  • Delay in treatment
  • prolonged transport
  • surgical delay when lateralizing signs present

Potentially controllable!!
19
Outcome
  • Glasgow Outcome Score
  • 1-dead
  • 2-vegetative
  • 3-cannot self care
  • 4-deficits but able to self care
  • 5-return to preinjury level of function

20
Outcome Prediction
  • Glasgow scale (post resuscitation) 44-66
    accuracy in determining ultimate outcome
  • 39 with an initial GCS of lt 5 made functional
    recovery
  • CT based scoring (Marshall Computed Tomographic
    score) only 71 accurate

21
Outcome Prediction
  • Serum markers (S-100B)
  • Accuracy of 83 (Woertgen, J Trauma, 1999)
  • Good sensitivity in moderate to severe injury
    even with extracranial injury (Savola, J Trauma,
    2004)
  • May be elevated in 29 fx pts without head injury
    (Unden, J Trauma, 2005)

Clinical utility not defined
22
Prognosis
  • Significant disability _at_ 1 yr
  • Disability even in mild injury
  • Glasgow cohort 742 pts with 71 follow-up
  • Rate of combined severe and moderate disability
    similar among groups (48, 45 and 48)
  • Age gt40, previous head injury, comorbidities
    increased disability
  • (Thornhill, BMJ, 2000)

Dead or vegetative Severe disability Moderate disability Good recovery
Mild (GCS 13-15) 8 20 28 45
Mod (GCS 9-12) 16 22 24 38
Severe (GCS lt9) 38 29 19 14
23
Prognosis of the SeverelyHead Injured Patient
  • Gordon (J Neurosurg Anes 95)
  • 1,294 pts with severe injury(GCS lt9) at 10 year
    follow-up
  • 55 good recovery
  • 19 significant disability
  • 7 vegetative
  • 19 mortality
  • Sakas (J Neurosurg 95)
  • 40 pts with fixed and dilated pupils
  • 55 younger than 20 years made independent
    functional recovery
  • 25 mild to moderate functional disability
  • 43 mortality

24
Orthopaedic Issues in the Head Injured Patient
  • Role in resuscitation
  • pelvic ring injury
  • open injuries
  • long bone fractures
  • Treatment methods and timing
  • Associated injuries
  • Complications

25
Initial Surgery in the Head Injured is Damage
Control Surgery
26
Damage Control Orthopaedics
  • Goal
  • Limit ongoing hemorrhage, hypotension, and
    release of inflammatory factors
  • Limit stress on injured brain
  • Initial surgery
  • lt1-2 hrs
  • limit surgical blood loss

27
Damage Control Orthopaedics
  • Methods
  • Initial focus on stabilization
  • External fixation
  • Limited debridement
  • Limited or no internal fixation or definitive
    care
  • Delayed definitive fixation (5-7 days)

28
Resuscitation Role of Orthopaedics
  • Goal limit ongoing hemorrhage and hypotension
  • pelvic ring injury--
  • external fixation reduced
  • mortality from 43 to 7
  • (Reimer, J Trauma, 93)
  • open injury--limit bleeding
  • long bone fracture--controversial

29
Long Bone Fracture in the Head Injured Patient
  • Early fixation (lt24 hours) well accepted in the
    polytrauma patient
  • In the head injured patient early fixation may be
    associated with
  • hypotension elevated ICP
  • blood loss/coagulopathy
  • hypoxia
  • Advocates of early and delayed treatment

30
Early Osteosynthesis
  • Hofman (J Trauma 91)
  • 58 patients with a GCS lt 7
  • lower mortality and higher GOS with operative
    treatment within 24 hours
  • Poole ( J Trauma 92)
  • 114 patients with head injury
  • delayed fixation did not protect the injured
    brain
  • McKee (J Trauma 97)
  • 46 head injured with femur fractures matched
    with 99 patients without fracture
  • no difference in neurologic outcome or mortality

31
Early Osteosynthesis
  • Bone (J Trauma 94)
  • in 22 patients (age lt50) with a GCS 4-5
  • 13.6 (early fixation) vs 51.3 (delayed
    fixation) mortality rates
  • Starr (J Orthop Trauma 98)
  • 32 pts with head injury
  • 14 early, 14 delayed, 4 nonoperative
  • delayed fixation associated with 45X greater
    pulmonary complications but did not affect
    neurologic complications

32
Early Osteosynthesis
  • Kalb (Surgery 98)
  • 123 patients, head AIS gt 2, 84 early, 39 late
    fixation
  • early group had increased fluid requirement but
    no other difference in mortality or complication
  • emphasized the role of appropriate monitoring
  • Scalea (J Trauma 99)
  • 171 patients, mean GCS 9, 147 early, 24 late
    fixation
  • early fixation no effect on length of stay,
    mortality, CNS complications

33
Delayed Osteosynthesis
  • Reynolds (Annals of Surg 95)
  • Mortality 2/105 patients, both early rodding (lt24
    hrs)
  • one due to neurologic and the other pulmonary
    deterioration
  • Jaicks (J Trauma 97)
  • 33 patients with head AIS gt 2 19 early fixation
    14 late
  • early group required more fluid in 48 hrs (14 vs
    8.7 l) more intraoperative hypotension (16 vs
    7) lower discharge GCS (13.5 vs 15)

34
Delayed Osteosythesis
  • Townsend (J Trauma 98)
  • 61 patients with GCS lt 8
  • hypotension 8 X more likely if operated lt 2 hrs
    and 2 X more likely when operated within 24 hrs
  • no difference noted in GOS

35
Fracture Care
  • Ultimate neurologic outcome continues to be
    difficult to predict
  • Presume recovery
  • Avoid treatments that may compromise neurologic
    outcome
  • All interventions must strive to reduce
    musculoskeletal complications inherent in the
    head injured patient
  • Management decisions made in conjunction with
    trauma/neurosurgical team

36
Operative Fracture Care
  • Surgery is often optimal form of fracture
    treatment in the head injured polytrauma patient
  • Advantages
  • Alignment
  • Articular congruity
  • Early rehabilitation
  • Facilitated nursing
  • care

Galleazzi, ulna and olecranon fx with
compartment syndrome
37
Operative Fracture Care
  • Perform early surgery when appropriate
  • MUST minimize
  • hypotension
  • hypoxia
  • elevated ICP
  • Consider temporary methods
  • (external fixation)
  • Fixation must be adequate
  • Patient may be non compliant
  • accelerated healing cannot be relied upon

use appropriate monitors
38
Advances in Care of Head Injured
  • ICP monitoring
  • Evolution of anesthetic agents
  • Improvement in neuroanesthetic techniques
  • Allow for safer surgery in the head injured

39
Nonoperative Fracture Management
  • Treatment of choice when
  • nonoperative means best treat that particular
    fracture
  • operative risks outweigh potential benefits
  • Modalities
  • splint
  • brace
  • cast
  • traction
  • Caveat
  • device must be removed periodically to inspect
    underlying skin for decubiti

40
Bone Healing in the Head Injured Patient
  • Humoral osteogenic factors are released by the
    injured brain
  • Exuberant callus MAY be seen
  • Soft tissue ossification is common
  • Ultimate union rate of fractures is not
    significantly affected

41
Complications
  • Heterotopic Ossification
  • up to 89-100 incidence periarticular injury
    with head injury
  • Contractures
  • Malunion

Recurrent elbow dislocation secondary to
extensor posturing and heterotopic ossification
42
Heterotopic Ossification
  • Associated with ventilator dependency
  • Avoid periarticular procedures
  • Use approaches/techniques less associated with
    H.O.
  • Prophylaxis
  • XRT
  • Indocin
  • Excision

43
Contractures
  • Occurs due to spasticity/posturing
  • Effects
  • Inhibits restoration of function
  • Complicates nursing care
  • Predisposes to decubitus ulcers

44
Contractures
  • Treatment
  • Prevention
  • splinting/positioning
  • early physical and occupational therapy
  • Established
  • serial casting
  • manipulation
  • surgery
  • nerve blocks

45
Associated Injuries
  • Normal methods of clinical and radiologic
    assessment may not apply in the head injured
    patient
  • C spine injury
  • Occult fractures and injury

46
C Spine Injury
  • Incidence increases with increasing severity of
    head injury
  • Demetraiades, J
    Trauma, 00
  • Evaluation more difficult
  • Optimal protocol for evaluation and management
    controversial

C spine injury Incidence
GCS
47
C Spine Injury
  • Minimum requirement
  • Cervical collar
  • Plain films (3 views)
  • CT entire C spine
  • Adjuncts
  • MRI
  • Difficult in vent patient
  • May over call injury
  • Dynamic flexion extension radiographs in the
    obtunded patient
  • Safety and reliability not established

48
Occult Injuries
  • Fractures, dislocations and peripheral nerve
    injuries may be missed
  • Up to 11 of orthopaedic injuries may be missed
  • Peripheral nerve injuries are particularly common
    (as high as 34)
  • Occult fractures in children with head injury are
    also common (37-82)

49
Occult Injuries
  • Detailed physical exam with radiographs of any
    suspect area due to bruising, abrasion,
    deformity, loss of motion
  • Consider EMG for unexplained neurologic deficits
  • Bone scan advocated in children with severe head
    injury _at_ 72 hrs

50
Summary
  • Orthopaedic injuries are common in head injured
    polytrauma patients
  • Head injury outcome is difficult to predict
  • Management requires multidisciplinary approach
  • Operative management is safe and often improves
    functional outcome if secondary brain insults are
    avoided
  • Hypotension, hypoxia, increased ICP

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