Assessment, Management and Decision Making in the Treatment of Polytrauma Patients with Head Injuries

1
Assessment, Management and Decision Making in the
Treatment of Polytrauma Patients with Head
Injuries

• Roman A. Hayda, MD
• Original Author
• March 2004 Revised July 2006, November 2010

2
Epidemiologic Aspects

• 80,000 survivors of head injury annually
• 125,000 children lt15yo head injured annually
• 40-60 of head injured patients have extremity
  injury
• 32,000-48,000 head injury survivors with
  orthopaedic injuries annually

3
Overview

• Pathophysiology
• Initial evaluation
• Prognosis
• Management of Head Injury
• Orthopaedic Issues
• Operative vs. nonoperative treatment
• Timing of surgery
• methods
• Fracture healing in head injury
• Associated injuries
• Complications

4
2nd hit
1st hit

• 1st hit Head
• mechanical insult to brain tissue
• blunt or penetrating

• 2nd hit Head
• release of inflammatory mediators
• Hypoxia
• Acidosis
• Coagulopathy

• 1st hit body
• mechanical insult
• chest, abdomen
• extremities

• 2nd hit body
• systemic inflammation
• SURGERY

5
Evaluation

• ATLSABCs
• History
• loss of consciousness
• Physical exam
• Glasgow Coma Scale
• Radiographic studies
• CT Scan

6
Evaluation

• Must exclude head injury by evaluation if
• history of loss of consciousness
• significant amnesia
• confusion, combativeness
• Cannot be simply attributed to drug or alcohol
  use
• neurologic deficits on exam of cranial nerves or
  extremities

7
Physical Exam

• Exam of head and cranial nerves for lateralizing
  signs
• dilated or sluggish pupil(s)
• Extremities
• unilateral weakness
• posturing
• decorticate (flexor)
• decerebrate (extensor)

8
Glasgow Coma Scale

• Eye opening 1-4
• Motor response 1-6
• Verbal response 1-5

9
Glasgow Coma Scale

• Eye opening
• Spontaneous 4
• To speech 3
• To pain 2
• None 1

10
Glasgow Coma Scale

• Motor response
• Obeys commands 6
• Purposeful response to pain 5
• Withdrawal to pain 4
• Flexion response to pain 3
• Extension response to pain 2
• None 1

11
Glasgow Coma Scale

• Verbal response
• Oriented 5
• Confused 4
• Inappropriate 3
• Incomprehensible 2
• None 1

12
Glasgow Coma Scale

• Sum scores (3-15)
• lt9 considered severe
• 9-12 moderate
• 13-15 mild
• ModifiersxT if intubated (Best score possible
  11T) xTP if intubated and paralyzed (Best
  score possible is 3TP)
• Done in the field but best in trauma bay
  following initial resuscitation
  
  
  

13
Radiographic Studies
Frontal Contusion

• CT scan
• required in ALL cases EXCEPT
• LOC is brief
• AND
• patient can be serially examined
• lesions
• focal--epidural, subdural hematoma,
• contusions
• diffuse--diffuse axonal injury
• Plain films
• useful only to detect skull fracture
  but in the trauma setting wastes time

14
Treatment

• Initial
• Intubation if unresponsive or combative to give
  controlled ventilation
• pharmacologic paralysis
• after neurologic exam is completed
• Blood pressure and O2 saturation monitoring
• keep systolic gt 90 mm Hg
• 100 O2 saturation

15
ICP Monitoring

• Indications
• severe head injury (GCS lt 9)
• abnormal head CT
• or
• Coma gt6 hrs
• Intracranial hematoma requiring evacuation
• Delayed neurologic deterioration from mild to
  moderate (GCSgt9) to severe (GCS lt 8)
• Requirement for prolonged ventilation
• Pulmonary injury, surgery etc.

16
ICU Management Goals

• O2 saturation 100
• Mean arterial pressure 90-110 mm Hg
• ICP lt 20 mm Hg
• Cerebral Perfusion Pressure (CPPMAP-ICP) gt70 mm
  Hg

17
ICU Adjuncts

• HCT 30-33
• PaCO2 352 mm Hg
• CVP 8-14 mm Hg
• avoid dextrose IV
• maintain euthermia or mild hypothermia

18
Factors Influencing Prognosis

• Age
• Younger pts have greatest potential for survival
  and recovery
• 61-75 mortality if over 65
• 90 mortality in elderly with ICP gt20 and coma
  for more than 3 days
• 100 mortality if GCS lt 5, uni- or bilateral
  dilated pupils, and age over 75

• Bottom line survival and recovery not
  predictable except in old pts
• Treat presuming recovery

19
Factors Influencing Prognosis

• Hypotension--50 increase in mortality with
  single episode of hypotension
• Hypoxia
• Delay in treatment
• prolonged transport
• surgical delay when lateralizing signs present

Potentially controllable!!
20
Outcome

• Glasgow Outcome Score
• 1-dead
• 2-vegetative
• 3-cannot self care
• 4-deficits but able to self care
• 5-return to preinjury level of function

21
Outcome Prediction

• Glasgow scale (post resuscitation) 44-66
  accuracy in determining ultimate outcome
• 39 with an initial GCS of lt 5 made functional
  recovery
• CT based scoring (Marshall Computed Tomographic
  score) only 71 accurate

22
Outcome Prediction

• Serum markers (S-100B)
• Accuracy of 83 (Woertgen, J Trauma, 1999)
• Good sensitivity in moderate to severe injury
  even with extracranial injury (Savola, J Trauma,
  2004)
• May be elevated in 29 fx pts without head injury
  (Unden, J Trauma, 2005)

Clinical utility not defined
23
Prognosis

• Significant disability _at_ 1 yr
• Disability even in mild injury
• Glasgow cohort 742 pts with 71 follow-up
• Rate of combined severe and moderate disability
  similar among groups (48, 45 and 48)
• Age gt40, previous head injury, comorbidities
  increased disability
• (Thornhill, BMJ, 2000)

Dead or vegetative Severe disability Moderate disability Good recovery
Mild (GCS 13-15) 8 20 28 45
Mod (GCS 9-12) 16 22 24 38
Severe (GCS lt9) 38 29 19 14
24
Prognosis of the SeverelyHead Injured Patient

• Gordon (J Neurosurg Anes 95)
• 1,294 pts with severe injury(GCS lt9) at 10 year
  follow-up
• 55 good recovery
• 19 significant disability
• 7 vegetative
• 19 mortality
• Sakas (J Neurosurg 95)
• 40 pts with fixed and dilated pupils
• 55 younger than 20 years made independent
  functional recovery
• 25 mild to moderate functional disability
• 43 mortality

25
Orthopaedic Issues in the Head Injured Patient

• Role in resuscitation
• pelvic ring injury
• open injuries
• long bone fractures
• Treatment methods and timing
• Associated injuries
• Complications

26
Initial Surgery in the Head Injured is Damage
Control Surgery
27
Damage Control Orthopaedics

• Goal
• Limit ongoing hemorrhage, hypotension, and
  release of inflammatory factors
• Limit stress on injured brain
• Initial surgery
• lt1-2 hrs
• limit surgical blood loss

28
Damage Control Orthopaedics

• Methods
• Initial focus on stabilization
• External fixation
• Limited debridement
• Limited or no internal fixation or definitive
  care
• Delayed definitive fixation (5-7 days)

29
Resuscitation Role of Orthopaedics

• Goal limit ongoing hemorrhage and hypotension
• pelvic ring injury--
• external fixation reduced
• mortality from 43 to 7
• (Reimer, J Trauma, 93)
• open injury--limit bleeding
• long bone fracture--controversial

30
Long Bone Fracture in the Head Injured Patient

• Early fixation (lt24 hours) well accepted in the
  polytrauma patient
• In the head injured patient early fixation may be
  associated with
• hypotension elevated ICP
• blood loss/coagulopathy
• hypoxia
• Advocates of early and delayed treatment

31
Early Osteosynthesis

• Hofman (J Trauma 91)
• 58 patients with a GCS lt 7
• lower mortality and higher GOS with operative
  treatment within 24 hours
• Poole ( J Trauma 92)
• 114 patients with head injury
• delayed fixation did not protect the injured
  brain
• McKee (J Trauma 97)
• 46 head injured with femur fractures matched
  with 99 patients without fracture
• no difference in neurologic outcome or mortality

32
Early Osteosynthesis

• Bone (J Trauma 94)
• in 22 patients (age lt50) with a GCS 4-5
• 13.6 (early fixation) vs 51.3 (delayed
  fixation) mortality rates
• Starr (J Orthop Trauma 98)
• 32 pts with head injury
• 14 early, 14 delayed, 4 nonoperative
• delayed fixation associated with 45X greater
  pulmonary complications but did not affect
  neurologic complications

33
Early Osteosynthesis

• Kalb (Surgery 98)
• 123 patients, head AIS gt 2, 84 early, 39 late
  fixation
• early group had increased fluid requirement but
  no other difference in mortality or complication
• emphasized the role of appropriate monitoring
• Scalea (J Trauma 99)
• 171 patients, mean GCS 9, 147 early, 24 late
  fixation
• early fixation no effect on length of stay,
  mortality, CNS complications

34
Delayed Osteosynthesis

• Reynolds (Annals of Surg 95)
• Mortality 2/105 patients, both early rodding (lt24
  hrs)
• one due to neurologic and the other pulmonary
  deterioration
• Jaicks (J Trauma 97)
• 33 patients with head AIS gt 2 19 early fixation
  14 late
• early group required more fluid in 48 hrs (14 vs
  8.7 l) more intraoperative hypotension (16 vs
  7) lower discharge GCS (13.5 vs 15)

35
Delayed Osteosythesis

• Townsend (J Trauma 98)
• 61 patients with GCS lt 8
• hypotension 8 X more likely if operated lt 2 hrs
  and 2 X more likely when operated within 24 hrs
• no difference noted in GOS

36
Advances in Care of Head Injured

• ICP monitoring
• Evolution of anesthetic agents
• Improvement in neuroanesthetic techniques
• Allow for safer surgery in the head injured

37
Fracture Care

• Ultimate neurologic outcome continues to be
  difficult to predict
• Presume recovery
• Avoid treatments that may compromise neurologic
  outcome
• All interventions must strive to reduce
  musculoskeletal complications inherent in the
  head injured patient
• Management decisions made in conjunction with
  trauma/neurosurgical team

38
Algorithm for Fracture care in Head injured

• Severe Head injury (GCSlt9) or unstable pt
• DAMAGE CONTROL SURGERY
• Convert to definitive at 5 days
• Mild head injury (GCS 13-15) stable pt
• Consider EARLY TOTAL CARE
• Intermediate head injury
• Determined by pt stability complexity of surgery

39
Operative Fracture Care

• Surgery is often optimal form of fracture
  treatment in the head injured polytrauma patient
• Advantages
• Alignment
• Articular congruity
• Early rehabilitation
• Facilitated nursing
• care

Galleazzi, ulna and olecranon fx with
compartment syndrome
40
Operative Fracture Care

• Perform early surgery when appropriate
• MUST minimize
• hypotension
• hypoxia
• elevated ICP
• Consider temporary methods
• (external fixation)
• Fixation must be adequate
• Patient may be non compliant
• accelerated healing cannot be relied upon

use appropriate monitors
41
Nonoperative Fracture Management

• Treatment of choice when
• nonoperative means best treat that particular
  fracture
• operative risks outweigh potential benefits
• Modalities
• splint
• brace
• cast
• traction
• Caveat
• device must be removed periodically to inspect
  underlying skin for decubiti

42
Bone Healing in the Head Injured Patient

• Humoral osteogenic factors are released by the
  injured brain
• Exuberant callus MAY be seen
• Soft tissue ossification is common
• Ultimate union rate of fractures
  inconsistently affected

43
Fracture Healing with Head Injury

• Cadosch, JBJS-A, 2009
• Case matched series of 17 pts with avg GCS 5.6,
  treated with IM nail
• Union 2X faster 37-50gt callus serum induced
  osteoblast proliferation
• Boes, JBJS-A, 2006
• Experimental model of 43 rats with IM nailed
  femur fx /- head injury
• More fx stiffness in head injury cohort
• Serum of head injured rats promoted stem cell
  proliferation

44
Complications

• Heterotopic Ossification
• up to 89-100 incidence periarticular injury
  with head injury
• Contractures
• Malunion

Recurrent elbow dislocation secondary to
extensor posturing and heterotopic ossification
45
Heterotopic Ossification

• Associated with ventilator dependency
• Use approaches/techniques less associated with
  H.O.
• Prophylaxis
• XRT
• Indocin
• Excision

46
Contractures

• Occurs due to spasticity/posturing
• Effects
• Inhibits restoration of function
• Complicates nursing care
• Predisposes to decubitus ulcers

47
Contractures

• Treatment
• Prevention
• splinting/positioning
• early physical and occupational therapy
• Established
• serial casting
• manipulation
• surgery
• nerve blocks

48
Associated Injuries

• Normal methods of clinical and radiologic
  assessment may not apply in the head injured
  patient
• C spine injury
• Occult fractures and injury

49
C Spine Injury

• Incidence increases with increasing severity of
  head injury
• Demetraiades, J
  Trauma, 00
• Evaluation more difficult
• Optimal protocol for evaluation and management
  controversial

C spine injury Incidence
GCS
50
C Spine Injury

• Minimum requirement
• Cervical collar
• CT entire C spine with reconstructions
• Adjuncts
• MRI
• Difficult in vent patient
• May over call injury
• Dynamic flexion extension radiographs in the
  obtunded patient
• Safety and reliability not established

51
Occult Injuries

• Fractures, dislocations and peripheral nerve
  injuries may be missed
• Up to 11 of orthopaedic injuries may be missed
• Peripheral nerve injuries are particularly common
  (as high as 34)
• Occult fractures in children with head injury are
  also common (37-82)

52
Occult Injuries

• Detailed physical exam with radiographs of any
  suspect area due to bruising, abrasion,
  deformity, loss of motion
• Consider EMG for unexplained neurologic deficits
• Bone scan advocated in children with severe head
  injury _at_ 72 hrs

53
Summary

• Orthopaedic injuries are common in head injured
  polytrauma patients
• Head injury outcome is difficult to predict
• Management requires multidisciplinary approach
• Operative management is safe and often improves
  functional outcome if secondary brain insults are
  avoided
• Hypotension, hypoxia, increased ICP

54

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