HEAD TRAUMA

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HEAD TRAUMA

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

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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

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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

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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.

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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.

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HEAD INJURY CLASSIFICATION

• MINOR (80)
• GCS 13-15
• MODERATE (10)
• GCS 9-13
• SEVERE (10)
• GCS 3-8

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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

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Minor HI

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

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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

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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

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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)

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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)

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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

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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

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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

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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.

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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

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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.

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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

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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

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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)

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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)

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Canadian CT Head Rule

• Questions
• Is the sensitivity high enough?
• Will it reduce the frequency of scanning Mild HI
  patients

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• 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?

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

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• 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?

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

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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

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Concussion

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

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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

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Concussion Grade 2

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

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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

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• 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.

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

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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.

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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

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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.

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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.

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Pediatric HI Normal CT and Discharge

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

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CATCH CT Study
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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)

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• 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.

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SEVERE HEAD INJURY
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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

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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

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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

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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.

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• 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...

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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.

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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.

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• 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

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• 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

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

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Indications for Intubation

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

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Challenges during the Intubation

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

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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

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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

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• 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

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• 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

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Acute Deterioration Increasing ICP

• Hyperventilation
• mechanism
• onset
• duration
• no response?
• Role for prophylactic hyperventilation?

• Hypocapnia pitfalls
• reduced CBF can cause ischemia
• temporary measure

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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.

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Acute Deterioration Increasing ICP

• Off to the scanner

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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

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Seizure Prophylaxis

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

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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

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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.

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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.

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• Hypertension
• bradycardia
• irregular respirations
• the Cushing reflex

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

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

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

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• 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.

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• 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?

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• 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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