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    Head Injury: Anthony G. Hillier, D.O. St. John West Shore Emergency Medicine Resident

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    1. Hyperventilation to a PaCO2 of less than 30 mm Hg is not recommended for managing increased intracranial pressure in head injured patients. 2. Post-concussive symptoms are common after traumatic brain injury and preventing secondary brain injury through careful management is critical. Traumatic brain injury also places a large economic burden on society. 3. The ring sign is not specific for detecting cerebrospinal fluid when blood is mixed with other fluids on filter paper according to an experimental study.

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    Head Injury: Anthony G. Hillier, D.O. St. John West Shore Emergency Medicine Resident

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    sgod34
    77 views45 pages
    1. Hyperventilation to a PaCO2 of less than 30 mm Hg is not recommended for managing increased intracranial pressure in head injured patients. 2. Post-concussive symptoms are common after traumatic brain injury and preventing secondary brain injury through careful management is critical. Traumatic brain injury also places a large economic burden on society. 3. The ring sign is not specific for detecting cerebrospinal fluid when blood is mixed with other fluids on filter paper according to an experimental study.

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    Head Trauma

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    1. Hyperventilation to a PaCO2 of less than 30 mm Hg is not recommended for managing increased intracranial pressure in head injured patients. 2. Post-concussive symptoms are common after traumatic brain injury and preventing secondary brain injury through careful management is critical. Traumatic brain injury also places a large economic burden on society. 3. The ring sign is not specific for detecting cerebrospinal fluid when blood is mixed with other fluids on filter paper according to an experimental study.

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    77 views45 pages

    Head Injury: Anthony G. Hillier, D.O. St. John West Shore Emergency Medicine Resident

    Uploaded by

    sgod34
    1. Hyperventilation to a PaCO2 of less than 30 mm Hg is not recommended for managing increased intracranial pressure in head injured patients. 2. Post-concussive symptoms are common after traumatic brain injury and preventing secondary brain injury through careful management is critical. Traumatic brain injury also places a large economic burden on society. 3. The ring sign is not specific for detecting cerebrospinal fluid when blood is mixed with other fluids on filter paper according to an experimental study.

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    Head Injury

    Anthony G. Hillier, D.O. St. John West Shore Emergency Medicine Resident

    Head Injury-Epidemiology
    1.5 million Non-fatal TBIs 370,000 Hospitalizations 80,000 cases of neurological sequela 52,000 Die from TBIs 4 billion annually for cost of treatment Peak incidence:
    Males age 15-24 years

    Causes of TBI
    Young: GSW Old: Falls

    Head Injury-Anatomy
    Scalp Blood supply Calvaria Brain
    Occupies 80% of calvarium

    Head Injury-Pathophysiology
    Primary injury
    Irreversible cellular injury as a direct result of the injury Prevent the event

    Secondary injury
    Damage to cells that are not initially injured Occurs hours to weeks after injury Prevent hypoxia and ischemia

    Head Injury-Normal Physiology


    Brain consumes 20% of total O2 Receives 15% of Cardiac Output Brain tissue perfusion CPP versus CBF
    CPP=MAP-ICP
    MAP=(SBP-DBP/3) + DBP
    ICP=IVM

    Autoregulation
    50-150 mm Hg

    ICP

    Head Injury-Initial Evaluation and Management


    Prevent Secondary Brain Injury
    Hypoxemia Hypotension Anemia
    Hyperglycemia Evacuation of mass

    Airway control with cervical spine immobilization


    Orotracheal Rapid Sequence Intubation
    Goal is to RSI to blunt rise in ICP and maintain adequate MAP Pretreatment-Lidocaine 1.5 mg/kg, Vecuronium 0.01 mg/kg Induction-Etomidate 0.3 mg/kg, Fentanyl 3-5 mcg/kg, Thiopental 3-5 mg/kg, Propofol 1-4 mg/kg Paralysis-Succinylcholine 1.5 mg/kg

    Head Injury-Initial Evaluation and Management


    Circulation
    Maintain MAP at 90 mm Hg Aggressive fluid resuscitation
    Does not increase ICP

    Vasopressors if crystalloids inadequate Transfuse if hypotensive and Hct <30 Hypertension-Assume Cushing Reflex
    If ICP is normal, gradually reduce MAP no more than 30%

    Spectrum of Traumatic Brain Injury


    Mild TBI
    GCS 14-15 80% of all TBI Low Risk
    GCS 15 and no LOC, amnesia, vomiting or diffuse HA Less than 0.1% risk of hematoma requiring evacuation

    Medium Risk
    GCS 15 and LOC, amnesia, vomiting or Diffuse HA 1-3% risk of hematoma requiring evacuation CT should be done in medium risk mild TBI

    Spectrum of Traumatic Brain Injury


    Mild TBI
    High Risk
    GCS 14-15 Neurologic deficits Up to 10% risk of hematoma requiring evacuation Anyone with coagulopathy, drug/alcohol consumption, epilepsy, age >60 and previous neurosurgery

    Disposition
    No CT indicated or negative CT with GCS 15-Home GCS 14 and negative CT-Observation admit

    Spectrum of Traumatic Brain Injury


    Moderate TBI
    GCS 9-13 10% of all TBI <20% mortality 50% morbidity 40% positive CT 8% NS intervention <10 make moderate recovery

    Severe TBI
    GCS <9 10% of all TBI 40% mortality

    Intracerebral Pressure
    Normal <15 mm Hg ICP >20-25 mm Hg
    Increases morbidity and mortality

    ICP monitoring rarely available in the ED Must use physical findings


    Neurologic deterioration Unilaterally dilated pupil Hemiparesis Posturing

    Increased ICP-Management
    Hypertonic Saline
    Improves CPP and brain tissue O2 levels Decreased ICP by 35% (8-10 mm HG) CPP increased by 14% MAP remained stable Greatest benefit in those with higher ICP and lower CPP Repeated doses were not associated with rebound, hypovolemia or HTN 30 mL of 23.4% over 15 minutes
    A. Defillo, Hennepin County Medical Center

    Increased ICP-Management
    Mannitol
    Osmotic agent Effects ICP, CBF, CPP and brain metabolism Free radical scavenger Reduces ICP within 30 minutes, last 6-8 hours Volume expansion, reduces hypotension Dosage
    0.25-1 gm/kg bolus

    Increased ICP-Management
    Hyperventilation
    Not recommended as prophylactic intervention Never lower than 25 mm Hg Reduces ICP by vasoconstriction, may lead to cerebral ischemia Used as a last resort measure Maintain PaCO2 at 30-35 mm Hg

    Increased ICP-Management
    Barbiturate Coma
    Not indicated in the ED Lowers ICP, cerebral metabolic O2 demand

    Anticonvulsants
    Reduce occurrence of post-traumatic seizures No improvement in long-term outcome

    ICP Monitoring
    Should be performed on TBI with GCS <9 Increased ICP may be managed by drainage

    Specific Head Injuries


    Scalp Lacerations
    May lead to massive blood loss Small galeal lacerations may be left alone

    Skull Fracture
    Linear and simple comminuted skull fractures
    Exploration of wound Prophylactic antibiotics are controversial Occipital fractures have a high incidence of other injury If depressed beyond outer table-requires NS repair

    Specific Head Injuries


    Skull Fractures
    Basilar Fracture
    Most common-petrous portion of temporal bone, the EAC and TM Dural tear
    CSF otorrhea CSF rhinorrhea Battle Sign Raccoon Sign Hemotympanum Vertigo Hearing loss Seventh nerve palsy

    CSF testing
    Ring sign, glucose or CSF transferrin

    Should be started on prophylactic antibiotics


    Ceftriaxone 1-2 gm

    The Ring Sign


    Ann Emerg Med. 1993 Apr;22(4):718-20. The 'ring sign': is it a reliable indicator for cerebral spinal fluid? Dula DJ, Fales W. Department of Emergency Medicine, Geisinger Medical Center, Danville, Pennsylvania. STUDY OBJECTIVE: To study the development of a ring sign when blood is mixed with various fluids. METHODS: One drop of blood and one drop of either spinal fluid, saline, tap water, or rhinorrhea fluid were placed simultaneously on filter paper, and the specimens were examined after ten minutes for the development of a ring. A variety of filter paper agents were used, including standard laboratory filter paper, paper towels, coffee filters, and bed linens. RESULTS: All fluids, when mixed with blood, gave rise to a ring sign; blood alone did not. The type of filter paper did not affect the development of a ring. CONCLUSION: In this experimental setting, the ring or halo sign is reliable for detecting cerebrospinal fluids but is not exclusive for cerebrospinal fluid.

    Specific Head Injuries


    Brain Herniation
    Four Types
    Uncal Transtentorial Central Transtentorial Cerebellotonsillar Upward Posterior Fossa

    Case 1

    Specific Head Injuries


    Traumatic Subarachnoid Hemorrhage
    Most common CT finding in moderate to severe TBI If isolated head injury, may present with headache, photophobia and meningismus Early tSAH development triples mortality Size of bleed and outcome Timing of CT Nimodipine reduces death and disability by 55%

    Case 2

    Specific Head Injuries


    Epidural Hematoma
    Occurs in 0.5% of all head injuries Blunt trauma to temporoparietal region Eighty percent with associated skull fracture May occur with venous sinus tears Classic presentation only 30% of the time

    Specific Head Injuries


    Subdural Hematoma
    Sudden acceleration-deceleration injury with tearing of bridging veins Common in elderly and alcoholics Classified as acute, subacute or chronic
    Acute <2 weeks Chronic >2 weeks

    Specific Head Injuries


    Diffuse Axonal Injury
    Disruption of axons in white matter and brainstem Injury occurs immediately and is irreversible Seen after MVC or shaken baby syndrome Usually have persistent vegetative state CT usually normal MRI with multiple, diffuse abnormalities

    Specific Head Injuries


    Penetrating Injury
    Gunshot Wounds
    Injury due to direct brain injury and cavitary effects GCS predicts prognosis
    GCS >8 and reactive pupils = 25% mortality GCS <5 = nears 100% mortality

    Stab wounds

    Complications-Long Term Sequela


    Seizure Disorder
    2% Early post-traumatic incidence Increased to 30% in children, alcoholics and with intracranial hematoma
    Prophylactic antiepileptics reduce early occurrence Use not supported by the literature

    Concussion
    - Brief LOC
    - Dizziness - Photophobia - Vertigo - Nausea - Headache - Vomiting - Cognitive/Memory dysfunction

    Complications-Long Term Sequela


    Concussion
    Up to 80% may have symptoms at 3 months 15% may have symptoms at 1 year Persistence of these symptoms is termed Postconcussive Syndrome 85-90% recover after 1 year Risk factors:
    - Female - Litigation - Low socioeconomic status

    Complications-Long Term Sequela


    Infection
    Skull fracture CSF leak Intubation History of Fracture
    Fever Signs of meningitis
    3rd generation cephalosporin Vancomycin

    ICU Treatment
    Prophylactic antibiotics

    Questions?

    Lecture Questions
    1. Which of the following modalities is not recommended for head injured patients with elevated ICP?
    a. b. c. d. e. Hypertonic saline Hyperventilation to CO2 of <30 mm Hg Mannitol ICP monitoring Barbiturate coma

    2. Which of the following are true regarding TBI?


    a. Post-concussive symptoms are common b. It is expensive to society c. Preventing secondary brain injury is critical in the management d. All of the above are correct

    3. Epidural hematomas are associated with all of the following except:


    a. b. c. d. e. Trauma to the temporoparietal region Extremes of age Have classic presentation only 30% of the time Damage to the middle meningeal artery Damage to a venous sinus

    4. Traumatic subarachnoid hemorrhage has all the following features except:


    a. Has a higher mortality than an equal aneurysmal SAH b. Mortality is reduced with nimodipine c. Surgical drainage is usually unnecessary d. Most common CT finding in TBI e. Size of bleed is unrelated to mortality

    5. Concerning basilar skull fractures which of the following is not true?


    a. The ring sign is both sensitive and specific for CSF otorrhea/rhinorrhea b. The only physical exam finding may be a hemotympanum c. Battle and Raccoon signs are usually not initially present in the ED d. Most commonly occurs in the temporal bone
    b, d, b, e, a

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