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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 Severe HI physiology management issues and controversies future developments Pediatric HI. HEAD TRAUMA.

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Head trauma

HEAD TRAUMA

August, 22, 2002

Adam Oster PGY2

Dr. Mark Yarema


Head trauma1

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


Head trauma2

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 <25 y.o


Head truma biomechanics

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.

HEAD TRUMA:BIOMECHANICS


Head truma biomechanics1

Secondary Injury

Hypoxia

includes seizures

Hypotension

Decreased CPP

(CPP=MAP-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.

HEAD TRUMA:BIOMECHANICS


Head injury classification

HEAD INJURY CLASSIFICATION

  • MINOR (80%)

    • GCS 13-15

  • MODERATE (10%)

    • GCS 9-13

  • SEVERE (10%)

    • GCS 3-8


Anatomy

Anatomy


Anatomy1

Anatomy


Head trauma

  • 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 she’s in the hospital

    • obeys commands

    • no focal deficits

      • GCS --

  • remainder of exam normal


Minor hi

Minor HI

  • CT scan?

  • What is her risk of a NSx lesion

  • A “clinically important” brain injury

  • death from this HI


Minor hi1

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

<0.5% will die

Minor HI


Ct scan in minor hi

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


History of the debate

History of the debate

  • Haydel, 2000

    • H/A

    • Vomiting

    • Age>60

    • Drug or ETOH intoxication

    • Amnesia

    • Seizure

    • Trauma above the clavicles

  • Sens 100% (95%-100%) for CT abnormality

  • Sens. for NSx intervention 54%-100% (N=6)


Rosen 2002 high risk

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 (>2 min)

Posttraumatic confusion/amnesia (>20 min)

Progressively worsening headache

Vomiting

Posttraumatic seizure

History of bleeding disorder/anticoagulation

Recent ingestion of intoxicants

Unreliable/unknown history of injury

Suspected child abuse

Age >60 yr, <2 yr


Rosen 2002 low risk

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

Injury >24 hr ago

Reliable home observers


Head trauma

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

<5mins 5.9%

>5mins 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

Signs and Symptoms:Correlation with IC Lesion Emergency Medicine Clinics Of North America vol 17, no.1. Feb., 1999.


Head trauma

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.

>1mm, 30% IC lesion

>3mm, 43%

Basal Skull #

53%-90% IC lesion

Signs and Symptoms:Correlation with IC Lesion Emergency Medicine Clinics Of North America vol 17, no.1. Feb., 1999.


Canadian ct head rule

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; <16, no LOC/amnesia/disorientation, obvious depressed skull #, penetrating skull inj., focal neuro deficit, Sz post-injury, pregnant, congenital or acquired bleeding disorder.


Canadian ct head rule1

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 <5mm

Localized SAH

SDH<4mm

Isolated pneumocephaly

Closed and depressed skull#, not through inner table

Canadian CT Head Rule


Canadian ct head rule2

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.


Canadian ct head rule3

Canadian CT Head Rule

  • Results

    • 1% (44) required neurosurgical intervention

    • 0.13% (4) died

    • 8% (254) CIBI

    • 4% (94) CUIBI

      • small SAH, contusions <5mm

    • 67% had CT, 33% phone follow-up, 363 (%) lost to follow-up


Canadian ct head rule4

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


Canadian ct head rule5

Canadian CT Head Rule

  • High risk (for neurological intervention)

    • GCS score <15 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 > 2 episodes

    • Age > 65 years

  • Sens 100% (92%-100%)

  • Spec. (67%-70%)


Canadian ct head rule6

Canadian CT Head Rule

  • Medium risk (for brain injury on CT)

    • Amnesia before impact >30 minutes

    • Dangerous mechanism

      • pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from height >3 feet or 5 stairs

  • Sens. 98.4% (96%-99%)

  • Spec. 49.6% (48%-51%)


Canadian ct head rule7

Canadian CT Head Rule

  • Questions

    • Is the sensitivity high enough?

    • Will it reduce the frequency of scanning Mild HI patients


Head trauma

  • 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?


Head trauma

  • Same guy but you’ve been busy. Now injury was approx. 6hrs ago.

    • Opens eyes to shouting, swears, moves all four limbs spontaneously.

    • Now what?


Head trauma

  • 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?


Head trauma

  • 16 yo boy fell while skateboarding. LOC approx 10 secs. Now feels fine.

    • GCS 15, normal exam.

    • Disposition?


Concussion

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


Concussion1

Concussion

  • Grade 1 = confusion without amnesia, no LOC

  • Grade 2 = confusion with amnesia, no LOC

  • Grade 3 = LOC


Concussion grade 1

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


Concussion grade 2

Concussion: Grade 2

  • Remove from event. Re-examine next day.

  • May return to practice only after 1 full week without symptoms.


Concussion grade 3

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


Head trauma

  • 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.


Head trauma

  • GCS 15, PERL 3mm

  • No focal neurologic deficits.

  • Central c-spine tenderness.

  • Rest of exam wnl.


Hi and pediatrics

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.


Pediatric hi general principles

Pediatric HI:General 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


Pediatric hi predictors for intracerebral injury trauma reports 2000

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 <6mo. May be asymptomatic

  • LOC and vomiting are not predictive.


Pediatric hi risk stratification 2 y o pediatrics vol 17 no 5 may 2001

High Risk

Decreased LOC

Focal findings

Basal or any skull #

Irritability

bulging fontanelle

*LOC>1min, post-injury SZ, worsening vomiting

*Consensus guideline

Low Risk

Trivial (low energy) mechanism

Fall <3feet

No signs/symptoms at >2yrs post-injury

Age >3mo

Require a period of observation for deterioration.

Pediatric HI:Risk Stratification < 2 y.o Pediatrics. Vol 17, no. 5. May, 2001


Pediatric hi normal ct and discharge

Pediatric HI: Normal CT and Discharge

  • 3 studies

    • HI and Normal CT

    • Incidence of deterioration was 0

      • (95% CI 0-1.4%)


Catch ct study

CATCH CT Study


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…)

Rosen, 2002: Pediatric minor HI and Management


Head trauma

  • 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.


Severe head injury

SEVERE HEAD INJURY


Head injury history

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

Head Injury:History


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

Head Injury: Physical Exam


Head injury glasgow coma scale

Head Injury:Glasgow Coma Scale

  • *GCS

    • developed for assessment at 6hrs post-injury

    • isolated HI and hemodynamically stable

    • use at <6hrs is limited

      • hemodynamics, intubation, ETOH, sedation/paralysis

    • does not assess brainstem function


Severe hi

SEVERE HI

  • Prevention of secondary injury

    • 1 episode of hypotension (SBP<90) increased mortality by 150%.

    • Hypoxia (paO2<60) 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 1990;72:360.


Head trauma

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...


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

CPP=MAP-ICP

MAP>70mmHg

ICP<20mmHg

what increases ICP

intra-axial mass

edema, CSF obstruction.

PATHOPHYSIOLOGY


Pathophysiology1

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.

PATHOPHYSIOLOGY


Head trauma

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


Head trauma

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


Head trauma

  • What’s your management plan?

    • Airway capture?

      • Indications for intubation

    • Imaging

    • Disposition


Indications for intubation

Indications for Intubation

  • Failure to protect

  • inability to oxygenate

  • inability to ventilate

  • anticipated clinical course

    • loose airway in near future

    • transport

    • DI


Challenges during the intubation

Challenges during the Intubation

  • CPP=MAP-ICP

    • challenges during intubation

      • MAP

      • ICP

    • decreasing MAP

    • increasing ICP

      • RSRL

      • reflex inc. ICP due to laryngoscopy


Rsi the chosen one

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


  • Head trauma

    RSI

    • Pitfalls

      • paralysis in a patient with potential neurologic deficits requiring serial exams

      • monitoring for Sz


    Head trauma

    • CT head read as normal

    • now what?

      • Serial exams

      • ?extubation and to NSx

      • remain intubated to ICU


    Head trauma

    • 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


    Head trauma

    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


    Acute deterioration increasing icp

    Hyperventilation

    mechanism

    onset

    duration

    no response?

    Role for prophylactic hyperventilation?

    Hypocapnia pitfalls

    reduced CBF can cause ischemia

    temporary measure

    Acute Deterioration: Increasing ICP


    Acute deterioration increasing icp1

    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.

    Acute Deterioration: Increasing ICP


    Acute deterioration increasing icp2

    Acute Deterioration: Increasing ICP

    • Off to the scanner


    Acute deterioration increasing icp3

    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


    Seizure prophylaxis

    Seizure Prophylaxis

    • Depressed skull #

    • intubated and paralysed patient

    • Seizure at time of injury

    • History of seizures

    • penetrating HI

    • severe HI

    • EDH/SDH/ICH


    Increasing icp controversies

    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


    Increasing icp controversies1

    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.


  • Increasing icp controversies2

    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.


    Head trauma

    • Hypertension

    • bradycardia

    • irregular respirations

    • the Cushing reflex


    Head trauma

    • Dilated and sluggish Lt pupil

    • Rt sided Babinski

    • early Lt. uncal herniation


    Head trauma

    • Dilated, non-reactive Rt pupil

    • Rt sided hemiparesis

    • Rt Babinski

    • late Rt uncal herniation (Kernohan’s notch phenomenon)


    Head trauma

    • Bilaterally pinpoint pupils

    • bilateral decerebrate posturing

    • hyperventilation

    • central transtentorial herniation


    Head trauma

    • Pinpoint pupils

    • flaccid quadriplegia

    • cerebellar tonsillar herniation


    Head trauma

    • 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.


    Head trauma

    • 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 mannitoland hyperventilate.

      • What next?


    Head trauma

    • You’re 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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