Head Injury in the ED: Stabilization and Medical Management

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Head Injury in the EDStabilization and Medical
Management

• AKA Oh crap, I start Neurosurg next week
• - Amy Gillis, PGY-2

www.anaesthesia.co.in anaesthesia.co.in_at_gmail.co
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Objectives

• Discuss moderate and severe blunt head injury
• Adult population (over 18)
• Epidemiology and importance
• Review relevant physiology and anatomy
• Review types of injury (1o , 2o, tSAH, SDH, EDH,
  Skull , ICH, Contusion, DAI)
• No specifics of clinical presentation
• Airway management
• B and C
• Treatment of elevated ICP
• Medical management and complications
• To survive Neurosurgery

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Why Bother?

• Most likely to result in long-term disability
• 3rd leading cause of injury admission in Canada
• In Alberta in 1997/98
• 227 deaths (51 in CHA)
• 17 of all injury deaths
• 2694 were admitted (324 in CHA)
• 11, 981 visited the ED (2024 in CHA)

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Why Bother?

• Minor head trauma (GCS 13-15) 80
• Moderate head trauma (GCS 9-12) 10 / 20
  mortality
• Severe head trauma (GCS lt/ 8) 10 / 40
  mortality
• Considerable variations in care remain
• We have the principle role in preventing
  secondary insults

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Important Physiology

• CBF CPP
• CPP MAP ICP
• MAP (SBP) 2(DBP)/3
• Normal ICP 0-10mmHg

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Important Physiology
Autoregulation
(2) CBF at 100 when MAP/CPP is 50-150 mmHg

• ability to maintain a constant CBF via
  constriction or dilation in response to MAP, O2,
  CO2, viscosity

(3) head injured patients lose autoregulatory
abilities
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Important Physiology

• Eucapnia allows normal CBF
• CO2 causes vasodilation and increased CBF
• CO2 causes vasoconstriction, ischemia,
  decreased
• CBF and ICP
• O2 causes vasodilation, increased ICP and
  vasogenic
• edema

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Types of Injury

• Primary
• The initial, irreversible mechanical injury
• lacerations
• intracerebral hemorrhage
• contusions
• avulsion

• Secondary
• Further insults that ultimately lead to
  ischemia
• hypotension
• hypoxia
• anemia
• seizures
• hyperglycemia
• hyperthermia

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Relevant Anatomy
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(1) Traumatic SAH

• Most common 30-40
• Blood within the CSF and
• subarachnoid (SA) space
• Tearing of small SA vessels
• Blood is related to GCS and outcome
• Blood often seen in the basilar
• cisterns, interhemispheric fissures
• and sulci
• Vasospasm very rare
• Surgical Case to case
• Prognosis Case to case

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(2) Acute Subdural Hematoma

• 30 of head injuries
• Forceful acceleration-deceleration injuries
• Blood between the dura and brain
• Arterial gt venous
• Hyperdense, crescent shaped, extend beyond
  suture lines
• Quick clinical course
• Surgical Consider assoc parenchymal injury,
  thickness (mm, cuts), ? basal cisterns, ?
  ventricular effacement, ? shift
• Prognosis 60-80 mortality

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(3) Epidural Hematoma

• 0.5-1 of head injuries
• Rare in kids lt 2 and adults gt 60
• Blood between the skull and dura
• Middle meningeal artery (MMA) gt dural sinuses,
  veins, line
• Classic LOC then lucid (30)
• Rapid symptomatology
• 80 associated with skull
• 40 have other intracranial badness
• Surgical Usually immediate, may observe
• Prognosis Very good

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(4) Skull Fracture

• Significant
• Overlying vaculature ? hematoma
• Depressed
• Basal Skull
• Open
• Intracranial Air

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(4) Skull Fracture

• Linear Skull Fracture
• Entire skull thickness
• Temporoparietal, frontal, occiptal
• Significant if they cross the middle meningeal
  groove or major venous dural sinuses and lead to
  EDH
• Usually 3mm wide widest at midportion,
  narrowest at ends
• Can be comminuted
• Surgical If cosmetic
• Prognosis Who cares

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(4) Skull Fracture

• Depressed Skull Fracture
• Predispose to significant IC injury
• Predispose to complications (sz, inf)
• Direct impact (hammer, bat)
• Parietal, temporal regions
• Caution on palpation
• Depression may be distal to laceration
• Swelling may mask
• 25 report LOC
• CT scan for history or exam findings
• Admit for observation
• Surgical Elevation if cosmetic, significantly
  below skull table
• Prognosis Very good

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(4) Skull Fracture

• Basal Skull Fracture
• 20 of head injuries
• 50 associated with IC injury
• Clinical Signs (50 of cases)
• Hemotympanum temporal bone bleed into middle
  ear
• Rhinorrhea/Otorrhea - causes a dural tear
  communication with SA space, paranasal sinuses
  and middle ear
• Battles sign disrupt bones of auricular area
• Racoon eyes orbital roof , blood stains
  periorbital fat, no swelling, well demarcated
• CN palsies compression/entrapment of CN of
  basal foramina, direct nerve damage
• Treatment No abx
• Surgical If gaping holes exist
• Prognosis Death if damage to internal carotid,
  sphenoid bone otherwise good

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(4) Skull Fracture

• Open ?Intracranial Air
• Scalp laceration overlies a
• If dura disrupted, communication exists to the
  brain
• Also includes through paranasal sinuses and
  middle ear
• Surgical Careful irrigation and
• debridement, otherwise nothing
• Prognosis Good

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(5) Intracerebral Hemorrhage

• Formed deep within the brain
• Caused by tensile and shearing forces brain vs.
  cranium
• Subsequent stretch and tear of deep arterioles
• Most often frontal and temporal
• gt 50 sustain LOC at impact
• Often causes increased ICP
• Surgical Usually none, evacuation if significant
  hematoma
• Prognosis 45 mortality if unconscious in ED

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(6) Contusion

• From parenchymal vessel damage
• Scattered petechial hemorrhage edema ?
  widespread ? further
• hemorrhage and swelling
• Problematic mass, compression, ischemia,
  necrosis, cavitation
• Often delayed in clinical presentation
• Surgical Usually none, evacuation if significant
  hematoma
• Prognosis Good to poor

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(7) Diffuse Axonal Injury

• 44 of primary lesions in severe head injury
• Cause of traumatic coma not caused by mass
  lesions or ischemic foci
• Shear and tensile forces with additional
  disruption of cortical physiology and
  microanatomy
• Severity determined by clinical course
• (1) Mild DAI Coma for 6-24 hours initial
  posturing mortality 15
• (2) Moderate DAI Most common coma gt 24 hours
  initial posturing amnesia cognitive deficits
  25 mortality
• (3) Severe DAI Prolonged coma demonstrate
  persistent brainstem and autonomic dysfxn
  vegetative state or death

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Stabilization and ManagementAirwayBreathing
and CirculationTreatment of Elevated ICPMedical
Management and Complications
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Airway

• Specific Indications for Intubation
• Optimize oxygenation and ventilation
• Declining LOC
• Unable to protect airway
• Risk to ICP from agitation, lack of
  cooperation
• To control the situation
• GCS lt/ 8
• GCS 9-12 may be more difficult and indications
  are unclear
• Must use clinical judgement, weigh risks and
  benefits

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Airway

• Rapid sequence intubation (RSI) is always
  required
• Your patient may have altered mental status, but
  they are not anesthetised
• Drugs chosen to optimize cerebral and cardiac
  hemodynamic parameters
• There is significant in ICP with airway
  stimulation (laryngoscopy and intubation)

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Airway

• (A) Pretreat
• Lidocaine 1.5-2 mg/kg IV
• Fentanyl 3-5 µ/kg IV
• Rocuronium 0.1mg/kg
• (B) Induction
• Thiopental 3-5 mg/kg IV
• Etomidate 0.3 mg/kg IV
• Propofol 0.5-1 mg/kg IV
• (C) Paralysis
• Succinylcholine 1.5 mg/kg

blunt SNS/airway response attenuate
SNS/maintain BP defasciculate decreases
ICP/maintains MAP / /minimal cardiac
effects decreases ICP/caution with
BP clinically insignificant effects on ICP
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B is for Breathing

• Cerebral O2 delivery is threatened by loss of
  autoregulation
• Hypoxemia causes a significant increase in
  mortality
• PO2 lt 60 mmHg causes ICP
• Want 100 O2
• Prophylactic hyperventilation is bad
• Ventilate to CO2 of 35-45 mmHg

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C is for Circulation

• BP lt 90 mmHg led to 150 increase in mortality
• Recommendations
• CPP gt 70 mmHg
• MAP gt/ 90 mmHg
• SBP 120 140 mmHg
• Assumes ICP threshold of 20 mmHg
• Crystalloid to restore intravascular volume
• Prevent anemia transfuse to a HCT of 30-33
• Consider pressors only as a temporizing measure
• Art line, CVP, foley

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Increased ICP

• General signs of ICP include H/A,
  dizziness, LOC, nausea, vomiting, focal weakness
  or paresthesias or other focal neuro signs
• In this population, more significant, ominous
  signs include
• Acute change in mental status
• Cushing Reflex
• Asymmetrical pupils
• Contralateral paralysis
• ICP is well above 20 mmHg

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Treatment of Increased ICP

• 1). Elevated HOB to 30o
• 2). Align neck (allows maximum jugular venous
  outflow)
• 3). Hyperventilation to CO2 of 28-35 mmHg
  brief
• intervention
• 4). Mannitol (0.75-1g/kg IV) reduces cerebral
  volume
• Use in active herniation
• Contraindicated in shock
• 5). Lasix
• 6). Boyds Burr Holes

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Medical Management and Complications

• Seizure Prophylaxis
• Only for those with a witnessed seizure (on
  scene or in the ED)
• Phenytoin loaded at 18mg/kg
• Hyperglycemia
• Worsens outcomes
• Hyperthermia
• Increases O2 demand hypothermia considered an
  effective means of managing ICP

• Medical complications
• 1) DIC present in 90 of severe head injury
• 2) Neurogenic pulmonary edema ? ARDS
• 3) ECG changes present in 50 of patients SVT,
  ST depression, large upright or deeply inverted t
  waves, prolonged QT and U waves

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References

• Bulger EM et al Management of severe head
  injury Institutional variations in care and
  effect on outcome. Critical Care Medicine 30(8)
  1870-1876, 2002
• Chesnut R The management of severe traumatic
  brain injury. Emergency Medicine Clinics of North
  America 15(3) 581-605, 1997
• Craen RA, Gelb AW The anesthetic management of
  neurosurgical emergencies. 39(5) R29-R34, 1992
• Garner AA, Schoettker P Efficacy of
  pre-hospital interventions for the management of
  severe blunt head injury. 33(4) 329-337, 2002
• Goh KYC, Ahuja A, Walkden SB, Poon WS Is
  routine computed tomographic (CT) scanning
  necessary in suspected basal skull fractures?
  28(5) 353-357, 1997

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References

• Kramer DA, Richman M, Schnieder SM Traumatic
  brain injury State-of-the-art protocols for
  evaluation, management, and resuscitation.
  Emergency Medicine Reports www.emronline.com,
  1998
• Kraus JJ, Metzler MD, Coplin WM Critical care
  issues in stroke and subarachnoid hemorrhage.
  Neurological Research 24(S1) S47-S57, 2002
• Marik P, Chen K, Varon J, Fromm R, Sternbach GL
  Management of increased intracranial pressure A
  review for clinicians. The Journal of Emergency
  Medicine 17(4) 711-719, 1999
• Paterakis K et al Outcome of patients with
  diffuse axonal injury The significance and
  prognostic value of MRI in the acute phase. The
  Journal of Trauma 49(6) 1071-1075, 2000

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References

• Rosen Section II System Injuries Head
  287-314
• Samii M, Tatagiba M Skull base trauma
  Diagnosis and management. Neurological Research
  24 147-156, 2002
• Stieg PE, Kase CS Intracranial hemorrhage
  Diagnosis and emergency management. Neurologic
  Clinics 16(2) 373-390, 1998
• Tintinalli Chapter 247 Head Injury

www.anaesthesia.co.in anaesthesia.co.in_at_gmail.co
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