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

Traumatic Brain Injury: Specific Management Items of Note for the Emergency Physician. Edward P. Sloan, MD, MPH Associate Professor Dept of Emergency Medicine. University of Illinois College of Medicine Chicago, IL. Attending Physician Emergency Medicine. University of Illinois Hospital

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

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  1. Traumatic Brain Injury:Specific Management Items of Note for theEmergency Physician

  2. Edward P. Sloan, MD, MPHAssociate ProfessorDept of Emergency Medicine University of Illinois College of Medicine Chicago, IL

  3. Attending Physician Emergency Medicine University of Illinois Hospital Our Lady of the Resurrection Medical Center Chicago, IL

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

  5. 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

  6. Methodology Literature Search • www.guidelines.gov • Traumatic Brain Injury • 21 guidelines provided • Relevant US guides used

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

  8. Methodology Source Documents • Guidelines for Rx of Adults with TBI • J of Neurosurgical Sciences • Vol 44:1 March 2000 • Three articles • Initial assessment, medical, surgical Rx • Emergency Medicine Reports • December 3, and December 17, 2001

  9. 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

  10. GuidelinesItalian Recommendations • I: Initial Assessment • RSI: Thiopental (ketamine or midazolam) Sux or vecuronium • GCS: In comatose pts (eye=1, verbal=1,2) Motor component very important. Use best response from either side.

  11. 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 > 15 min • Decrease in O2 sat below 50% > 15 min

  12. GuidelinesItalian Recommendations • II: Medical Therapy • Inotropes once blood volume restored • To maintain MAP above 90 mm Hg • To achieve CPP > 70 mm Hg if ICP high • Not in lieu of ICP management

  13. GuidelinesItalian Recommendations • III: Surgical Therapy • Absolute: • Focal lesion, midline shift > 5 mm • Space occupying lesion > 25 cc • Relative: • ICP > 20 mm Hg or CPP < 70 mm Hg • Optimal medical ICP management • Case-specific criteria also

  14. 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

  15. 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

  16. 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

  17. 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

  18. Neurology GuidelinesConcussion in Sports • Grade 1: Transient sx for < 15 minutes • May return if sx resolve within 15 minutes • Grade 2: Transient sx for > 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

  19. 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

  20. Emergent Cranial DecompressionProcedure • 4 cm vertical incision • External auditory canal is key landmark • Three cm superior to zygoma • Two cm anterior to ear

  21. 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

  22. 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)

  23. 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

  24. Biconvex high-attenuation epidural hematoma R frontal

  25. Extends to level of lateral ventricle

  26. Extends to level of roof of orbit R

  27. No fx evident here

  28. Skull fx evident at R orbit

  29. Associated STS

  30. R Subdural hematoma frontal lobe CSF leakage

  31. R to L midline shift with subfalcine herniation

  32. R to L midline shift with R uncal herniation

  33. R base hyperdense subdural hematoma

  34. Extension to anterior interhemispheric fissure

  35. R lateral ventricle body swelling

  36. Swelling L parietal region, no fracture evident

  37. 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

  38. 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

  39. 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

  40. 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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