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Neurologic Trauma. Bryan E. Bledsoe, DO, FACEP. Neurologic Trauma. Neurologic Trauma. “Suppose you were an idiot. And suppose you were a member of Congress. But I repeat myself.” Mark Twain. Traumatic Brain Injury (TBI).

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neurologic trauma

Neurologic Trauma

Bryan E. Bledsoe, DO, FACEP

neurologic trauma3
Neurologic Trauma

“Suppose you were an idiot. And suppose you were a member of Congress.

But I repeat myself.”

Mark Twain

traumatic brain injury tbi
Traumatic Brain Injury (TBI)
  • Defined as a blow or jolt to the head or a penetrating head injury that disrupts the function of the brain.
statistics
Statistics
  • 1.4 million people sustain a TBI each year in the United States:
    • 50,000 die,
    • 235,000 are hospitalized,
    • 1.1 million are treated and released from the ED.
statistics6
Statistics
  • Causes:
    • Falls (28%)
    • MVCs (20%)
    • Struck by/against events (19%)
    • Assaults (11%)

 Blasts are the leading cause of TBI for active duty military personnel in war zones.

statistics7
Statistics
  • Males are about 1.5 times more likely to sustain a TBI as a female.
statistics8
Statistics
  • Highest risk for TBI:
    • 0-4 years
    • 15-19 years
  • African Americans have the highest death rate from TBI.
statistics9
Statistics
  • Estimated $60 billion lost from TBI (medical costs and lost productivity).*

* 2000

physiology
Physiology
  • Brain Metabolism:
    • Like all tissues, the brain requires a constant supply of oxygen and nutrients.
physiology23
Physiology
  • Brain accounts for 2% of total body mass.
  • Brain accounts for 15% of total metabolism in the body.
  • Brain metabolic rate 7.5 times the rate of other neurological tissues.
physiology24
Physiology
  • Almost all of the brain’s energy needs are supplied by glucose.
  • Provided by capillaries in the brain.
physiology25
Physiology
  • Insulin NOT needed for glucose delivery to brain tissues.
physiology26
Physiology
  • The brain is among the most oxygen dependent organs in the body.
  • The brain is not capable of much anaerobic metabolism.
    • Primarily due the high metabolic rate of the neurons.
physiology27
Physiology
  • Because of this, sudden cessation of blood flow to the brain can cause unconsciousness within 5-10 seconds.
physiology28
Physiology
  • Neuroglobin:
    • Intracellular hemeprotein.
    • Reversibly binds oxygen with an affinity greater than that of hemoglobin.
    • Increases oxygen availability to brain tissue and provides protection under hypoxic or ischemic conditions, potentially limiting brain damage.
physiology29
Physiology
  • Brain requires:
    • Oxygenation
    • Glucose
    • Perfusion
  • Any deficit in these results in immediate dysfunction.
intracranial pressure
Intracranial Pressure
  • The cranial vault is effectively a closed container.
  • Largest opening is the foramen magnum.
  • Limited room for brain swelling.
intracranial pressure31
Intracranial Pressure
  • There is always some pressure in the brain.
  • Referred to as intracranial pressure (ICP).
  • Normal ICP:
    • Children: 0-10 mm Hg
    • Adults: 0-15 mm Hg
intracranial pressure32
Intracranial Pressure
  • Volume of the cranial vault defined by the Monro-Kellie doctrine:

Intracranial Volume (fixed) =

Brain Volume + CSF Volume + Blood Volume + Mass Lesion Volume

intracranial pressure33
Intracranial Pressure
  • Normally:
    • Brain = 80% of cranial vault space
    • Blood = 10% of cranial vault space
    • CSF = 10% of cranial vault space

Space Available for Blood or MASS = 0%

intracranial pressure34
Intracranial Pressure
  • To perfuse the brain, the pressure of blood delivered to the brain MUST be greater than the intracranial pressure.

CPP = MAP - ICP

intracranial pressure35
Intracranial Pressure
  • Mean Arterial Pressure:

MAP  DP + 1/3 (SP–DP)

intracranial pressure36
Intracranial Pressure
  • Perfusion of the brain is driven by the CPP.

MAP - ICP = CPP

  • - 30 = 40

CPP of 60 is the critical minimum threshold.

CPP of 40 is the critical minimum threshold for children < 8 years of age.

intracranial pressure37
Intracranial Pressure
  • Injury to brain tissue causes:
    • Swelling
    • Bleeding
    • Edema
  • All cause an increase in the size and mass of the brain.
intracranial pressure38
Intracranial Pressure
  • As the brain swells, it will eventually reach a critical volume where ICP increases to a point that perfusion is compromised.
brain injury
Brain Injury
  • Etiology of TBI:
    • Primary injury:
      • Damage to the brain from mechanical effects of trauma causing:
        • Ischemia
        • Anoxia/hypoxia
        • Shear injury
brain injury40
Brain Injury
  • Secondary Injury:
    • Results from a traumatic event and changes in the brain or in the brain vasculature.
      • Hypoxia
      • Hypotension ( cerebral blood flow)
      •  ICP
      • Hyperglycemia/Hypoglycemia
      • Metabolic disturbances
      • Seizures
brain injury41
Brain Injury
  • 12-24 hours post-injury:
    • Hypoperfusion and decrease in CBF.
    • Results from increases in distal microvascular resistance and intravascular clot formation.
brain injury42
Brain Injury
  • 1-5 days post injury:
    • Increased CBF > CMRO2.
      • Vascular engorgement
      • Swelling
      • Increased ICP
      • Induction of free radicals and oxidative stress.
brain injury43
Brain Injury
  • 5/6-14 days post injury:
    • CBF slows due to vasospasm
    • Brain vulnerable to changes in ICP.
brain injury44
Brain Injury
  • Secondary Injury:
    • Impaired autoregulation:
      • Autoregulation is the ability of the brain to maintain CBF in light of changes in BP and CPP.
    • Impaired autoregulation causes:
      •  O2 delivery to the brain and cerebral ischemia.
      • Cerebral metabolism altered due to loss of, or a decrease in, CBF.
      • Conversion from aerobic to anaerobic metabolism.
brain injury45
Brain Injury
  • Secondary Injury (extracranial causes):
    • Hypotension (SBP < 90 worsens outcomes)
    • Hypoxia (significantly associated with increased morbidity and mortality)
    • Hypocapnia:
      • Low CO2 causes vasoconstriction
      • 1 mm Hg decrease on CO2 = 3% decrease in CBF.
    • Anemia
    • Hyperthermia
brain injury47
Brain Injury
  • Compensatory mechanisms:
    • Brain shifts or is compressed.
    • Venous blood is shunted to heart.
    • CSP shunted to spinal SAS.
signs and symptoms
Signs and Symptoms
  • Early ( ICP):
    • Altered mental status
    • Agitation
    • Nausea and/or vomiting
    • Hemiparesis
signs and symptoms50
Signs and Symptoms
  • Late ( ICP):
    • Coma
    • Hemiplegia
    • Posturing
    • Cushing’s Triad:
      • Widening pulse pressure
      • Bradycardia
      • Respiratory abnormalities
brain herniation
Brain Herniation
  • Results when ICP increases beyond the capability of physiologic and limited physical compensation mechanisms.
brain herniation52
Brain Herniation
  • Major areas of brain herniation syndrome:
    • Subfalcial (a)
    • Uncal (b)
    • Central transtentorial (c)
    • External (d)
    • Cerebellotonsillar (e)
slide53
TBI
  • Mild (GCS = 14-15)
    • ~ 80% of patients
  • Moderate (GCS = 9-13)
    • ~ 10% of patients
  • Severe (GCS < 9)
    • ~ 10 of patients
trauma types
Trauma Types
  • Scalp Laceration:
    • Highly vascular
    • Can lead to massive blood loss
trauma types55
Trauma Types
  • Skull Fracture:
    • Classified by:
      • Location
      • Pattern
      • Open/closed
    • Up to 50% of patients with skull fracture will NOT have LOC or neurologic symptoms.
trauma types56
Trauma Types
  • Concussion:
    • Brief and temporary loss of neurologic function following head trauma.
    • May occur with or without LOC.
    • Symptoms:
      • Amnesia
        • Duration of amnesia predictive of injury severity.
      • Confusion
concussion
Concussion
  • Grade 1:
    • No LOC
    • Confusion without amnesia
    • Treatment:
      • Remove from event and examine immediately and every 5 minutes for the development of amnesia.
        • If asymptomatic > 20 minutes, can return to game.
      • 2 Grade 1 concussions:
        • No sports for the day
      • 3 or more Grade 1 concussions:
        • Out for season and no contact sports for 3 months
concussion58
Concussion
  • Grade 2:
    • No LOC
    • Confusion and amnesia
    • Treatment:
      • Remove from event for the day.
      • Refer for exam the next day.
        • May return in 1 week if asymptomatic with rest/exertion.
      • 2 Grade 2 concussions:
        • No play for 1 season
      • 3 Grade 2 concussions:
        • Season terminated.
concussion59
Concussion
  • Grade 3:
    • LOC
    • Treatment:
      • Transport to ED for evaluation
      • Return to sport in 1 month if asymptomatic for a 2-week period.
      • 2 Grade 3 concussions:
        • Season terminated.
trauma types60
Trauma Types
  • Cerebral contusion:
    • Most frequent type of TBI
    • Most common in:
      • Subfrontal cortex
      • Frontal lobe
      • Temporal lobe
      • Occipital (less common)
    • Often associated with SAH.
trauma types63
Trauma Types
  • Subarachnoid hemorrhage:
    • Disruption of subarachnoid vessels.
    • 1/3 of all patients with moderate to severe TBI have traumatic SAH.
trauma types64
Trauma Types
  • Epidural hematoma:
    • Collection of blood between the dura and the skull.
    • Arterial bleed.
    • Incidence:
      • 0.5-1.0% of all head-injured patients.
      • <10% of head-injured patients who are comatose.
    • Almost all associated with skull fracture.
    • 80% will progress to uncal herniation.
epidural hematoma66
Epidural Hematoma
  • Signs and Symptoms:
    • Classis syndrome (<20% of cases):
      • Immediate LOC.
      • Patient awakens and has a “lucid interval.”
      • Loses consciousness as hematoma expands.
    • Most commonly:
      • Most patients either never lose consciousness or never regain consciousness.
trauma types67
Trauma Types
  • Subdural hematoma:
    • Collection of blood between the dura and the SAM.
    • Venous bleed.
    • Associated with sudden acceleration and/or deceleration.
    • Tears bridging veins.
subdural hematoma69
Subdural Hematoma
  • Usually more brain parenchymal injury than epidurals.
  • Classified as:
    • Acute (< 3 days)
    • Subacute (3-14 days)
    • Chronic (> 14 days)
trauma types70
Trauma Types
  • Diffuse Axonal Injury (DAI):
    • Interruption of axonal fibers in the white matter and brain stem.
    • Shearing forces (usually deceleration) cause injury.
      • Adults: MVCs
      • Babies: “Shaken baby” syndrome
    • Injury occurs immediately and is usually irreversible.
trauma types72
Trauma Types
  • Intracerebral Hemorrhage:
    • Usually caused by shearing forces.
    • Severity depends upon location and size.
    • Secondary injury common.
trauma types73
Trauma Types
  • Penetrating Injury:
    • Severity of injury related to:
      • Kinetic energy of injury
      • Location of injury
    • Infection a common complication.
trauma types74
Trauma Types
  • Probably mortal.
tbi signs and symptoms
TBI Signs and Symptoms
  • Anxiety/nervousness
  • Behavioral changes:
    • Disinhibition
    • Impulsiveness
    • Inappropriate laughter
    • Irritability
  • Diplopia
  • Depression
  • Trouble concentrating
  • Aphasia
  • Dysphagia
  • Dizziness
  • Headache
  • Uncoordination of movements
  • Lightheadedness
  • Ataxia
  • Amnesia
tbi signs and symptoms76
TBI Signs and Symptoms
  • Muscle stiffness/spasm
  • Seizures
  • Sleep disorders
  • Slurred or slowed speech
  • Tingling
  • Numbness
  • Pain
  • Vertigo
  • Localized weakness
  • Nausea
  • Vomiting
  • Body temperature changes
  • Coma
  • Posturing
  • Pupillary abnormality
tbi signs and symptoms77
TBI Signs and Symptoms

SIGNS AND SYMPTOMS

IN TBI

ARE EXTREMELY VARIABLE

assessment treatment
Assessment/Treatment
  • Airway (with c-spine control)
  • Breathing
  • Circulation
  • Disability
  • Exposure
assessment treatment79
Assessment/Treatment
  • Palpate skull, facial bones and neck
  • Assess rate, depth and quality of respirations.
    • Consider tachypnea at the following rates a sign of deterioration:
      • Infant: 40 breaths per minute
      • Child: 30 breaths per minute
      • Adult: 20 breaths per minute
assessment treatment80
Assessment/Treatment
  • Assess pupils carefully:
    • Pupil size
    • Symmetry
    • Reactivity to light
assessment treatment81
Assessment/Treatment
  • Pupillary assessment:
    • Bilateral symmetry (asymmetric pupils differ more than 1 mm).
    • Reactivity to light (a fixed pupil shows <1mm change in response to bright light).
    • Dilation (greater than or equal to 4mm diameter in adults)
assessment treatment82
Assessment/Treatment
  • Single fixed and dilated pupil:
    • 45% poor outcome
  • Bilateral fixed and dilated pupils:
    • 82% poor outcome
assessment treatment83
Assessment/Treatment
  • Mid-position fixed and dilated pupil:
    • Suggests brain stem herniation.
    • Indicative of mass on same side.
    • Treat hypoxia and hypotension, if present.
    • Treat increased ICP per practice parameters.
assessment treatment84
Assessment/Treatment
  • Indications of herniation:
    • Unilateral or bilateral dilated, nonreactive pupils.
    • Asymmetric pupils.
    • Decerebrate posturing.
    • No motor response to painful stimuli.
assessment treatment85
Assessment/Treatment
  • Monitor SpO2 and ETCO2.
    • Maintain SpO2 > 90%
    • Maintain ETCO2 between 35-37 mm Hg
  • Initiate IV line with saline:
    • Maintain adult systolic BP > 90 mm Hg
    • Pediatric values are lower.
  • Utilize Glasgow Coma Scale
assessment treatment88
Assessment/Treatment
  • Assess blood glucose level.
treat airway
Treat Airway
  • Protect C-spine alignment, consider facial trauma.
  • Airway support per scope of practice.
  • Intubate severe TBI patients.
  • Correct hypoxia.
when to intubate
When to Intubate
  • GCS < 9 (severe TBI).
  • All patients with respiratory failure of apnea.
treat breathing
Treat Breathing
  • Oxygenation.
    • Administer supplemental oxygen by non-rebreather or BVM as appropriate.
  • Ventilation.
    • Assess rate, depth, quality, to determine the effectiveness of respirations.
    • As necessary, assist ventilations with BVM and supplemental O2.
treat breathing92
Treat Breathing

Adult normal

Ventilation rate

=

10-12 per minute

hyperventilation
Hyperventilation?
  • Hyperventilation:
    • Rapid  PaCO2
    • Cerebral vasoconstriction
    • Decreased CBF
    •  ICP
  • But, hyperventilation can  CBF to the point of ischemia.
  • Monitor ETCO2!
hyperventilation94
Hyperventilation?
  • Potential harm in patients without evidence of brain herniation.
  • Short-term measure used in specific TBI patients (herniation) until definitive diagnostic or therapeutic can be provided.
hyperventilation95
Hyperventilation?
  • Rates:
    • Ages 9-Adult: 20 breaths per minute:
      • (ETCO2 ~ 35 mm Hg).
    • Ages 1-8 years: 30 breaths per minute:
      • (ETCO2 ~ 32-35 mm Hg).
    • Ages < 1 year: 40 breaths per minute:
      • (ETCO2 ~ 32-35 mm Hg).
fluids
Fluids
  • Fluids to maintain SBP> 90 mm Hg.
    • Normal saline
    • Hypertonic saline?
brain targeted therapies
Brain-Targeted Therapies
  • Glucose for hypoglycemia
  • Sedatives for agitation
  • Analgesics for pain
  • Paralytics for ET intubation
  • Controversial:
    • Mannitol
    • Lidocaine
    • Hypertonic Saline
destinations
Destinations
  • Mild (GCS 14-15): Emergency Department
  • Moderate (GCS 9-13): Trauma Center
  • Severe (GCS < 9): Trauma Center with severe TBI management capabilities.
take home messages
Take Home Messages
  • Clinical practice should be evidence-based.
  • Do early and repeated neurological assessments.
  • Identify patients with severe TBI (GCS < 9).
take home messages100
Take Home Messages
  • Avoid hypoxia, keep SpO2 > 90%.
  • Avoid hypotension, keep SBP > 90 mm Hg.
  • Hyperventilate only for clinical signs of herniation.
  • Triage and transport TBI to appropriate facilities based on severity.
the future
The Future
  • Therapies to protect against secondary injury:
    • Hypothermia.
    • Sedative-induced coma.
    • Metabolic therapies.
    • Antioxidant therapies.