Head Trauma

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Head Trauma

• Dr. Roberts

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Epidemiology

• 1.1 million annual ED visits
• Highest lt 5 yo gt85 yo
• 80 minor head trauma (GCS 14-15)
• 10 moderate (GCS 9-13) 10 severe (8 below)
• 200,000 deaths, most under 25 yo 40 firearm
  related 34 MVC

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Anatomy

• Brain covered in multiple layers 1. dura 2.
  arahnoid 3. pia
• Subarchnoid space contains 150cc CSF 500 cc made
  each day
• Normal CSF pressures 5-15 mmHg
• Scalp 1. skin 2. subcutaneous, 3. galea, 4.
  areolar 5. pericranium
• rich blood supply

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What is the goal when treating TBI

• To prevent secondary injury caused by ischemia
  and hypoxia
• Primary injury occurs as a direct result of the
  force of the injury and cannot be reversed

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MS How do you calculate CPP

• CPPMAP-ICP
• MAP represent blood flow into the brain
• ICP represents blood flow out of the brain,
  normal lt15
• Autoregulation is functional with CPP 50-150.
• Normally under control of Pco2, BP, pH
• When autoregulation is lost due to increased ICP,
  CBF follows a linear pressure relationship to CPP

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Pathopphysiology

• Two main mechanisms of injury
• Primary initial mechanical trauma (irreversible)
• Secondary hypotension hypoxia anemia (our job)
• Cushings ReflexHypertension bradycardia
  respiratory irregularity (mostly kids)
• Cerebral herniation 4 Types
• Central Transtentorial-expanding lesion at
  frontal or occipital poles AMS, pinpoint pupils,
  bi-muscle weakness
• Cerebellotonsillar-cerebellar tonsils herniate
  through foramen magnum due to cerebellar mass
  Pinpoint pupils, quadriplegia and
  cardiorespiratory collapse
• Upward Transtentorial-expanding posterior fossa
  lesion pinpoint pupils, absence of vertical eye
  movements
• Uncal-most common, usually due to hematoma, 3rd
  nerve compression (anisocoria, ptosis, sluggish
  pupil, CN III defects)

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Types of herniation

1. Upward Transtentorial
2. Central Transtentorial
3. Uncal
4. Cerebellotonsillar

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Initial ED Evaluation Tx

• History
• High Risk prolonged amnesia, anticoagulation,
  coagulopathy, progressive vomiting, post injury
  seizure
• Physical Exam-Neuro Exam (GCS)
• High Risk focal neuro findings, distracting
  injury, signs of skull fracture, large
  extracranial hematoma, intoxication
• ABCs (consider lidocaine if RSI)
• Maintain PO2 MAP
• Watch for cushings
• CT if GCS lt 14, high risk Hx or Exam

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What agents can be used during RSI to prevent
increases in ICP

• Pre-induction
• Lidocaine
• Defasciculating dose of succs, vec
• Induction
• Barbituates (thiopental)
• Propofol, etomidate?
• NMB
• Succs-shortest acting, allowing for monitoring of
  neurologic changes and repeat exams

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Further ED Management

• Indications for Seizure Prophylaxis
• Depressed skull fracture
• Paralyzed Intubated patient
• Seizure at time of injury
• Seizure in ED
• Penetrating brain injury
• GCS lt9
• Acute Subdural/Epidural hematoma
• Intracranial hemorrhage
• Prior history of seizure

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How are TBI classified

• Based on GCS
• Mild-GCS 14-15
• Low risk-GCS 15 without LOC, amnesia, vomiting,
  diffuse headache, no CT
• Mod risk-GCS 15 plus one of the above, CT or
  skull x-rays if no CT avail (if xray move into
  high risk)
• High risk-GCS 14 or 15, skull fx, and/or
  neurologic deficit coagulopathy, drug or etoh
  use, previous NS procedure, epilepsy, gt60 yr old
  regardless of clinical presentation, CT
• Mod-GCS 9-13, admit for monitoring, intubate, NS
  consult, 50 long term disability
• Severe-GCS lt9, mortality 40, usually within 48hr

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Glasgow Coma Scale

• EYES
• - Opens Eyes spontaneously
  4
• - Opens eyes when told to do so
  3
• - Opens eyes after painful stimuli
  2
• - No response 1

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Glasgow Coma Scale

• VERBAL
• Speaks and makes sense (oriented) 5
• - Speaks but is confused (disoriented) 4
• - Speaks but makes no sense 3
• - Makes only sounds 2
• - No speech 1

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Glasgow Coma Scale

• MOTOR
• - Obeys verbal commands to move 6
• To painful stimulus
• - Localizes pain 5
• - Flexion-withdrawl from pain 4
• - Abnormal flexion (decorticate rigidity) 3
• - Extension (decerebrate rigidity) 2
• - No response to pain 1

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Which is worse decerebrate or decorticate
posturing

• Decerebrate
• arm extension, internal rotation wrist and
  finger flexion, leg extension with internal
  rotation
• Lesion below the midbrain
• Decorticate
• UE flexion and LE extension
• Injury above midbrain
• Better outcome

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Fig255-3.


                                                                                                                                                                                                                                                                                                        
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Fig. 255-5.
                                                                                                                                                                                          
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Specific Head Injuries

• Scalp Lac direct pressure, lido with epi,
  explore wound, suture/staples

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Skull Fractures

• Linear simple comminuted fx irrigate, suture,
  antibiotics per neuro surg consult
• Basilar

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What are signs of increasing ICP

• Uni or B/L dilated pupils, hemiparesis, motor
  posturing, progressive neurologic deterioration

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Specific Injuries

• Cerebral Contusion

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Subarachnoid Hemorrhage

• Disruption of small subarachnoid vessels
• Only detected 33 on initial CT
• Most common abnormality on Head CT
• Show signs of photophobia headache
• Marks significant increase morbidity/mortality in
  severe head injury

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Subdural Hematoma

• Blood clot between dura and brain
• Seen in acceleration-deceleration injuries
• Common in alcoholic elderly
• Rupture of superficial bridging vessels
• Acute-symptoms in 1st 24 hrs (lucid interval)
• Subacute-symptoms between 24 hrs-2 wks
• Chronic-symptoms after 2 wks

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Epidural Hematoma

• Collection of blood between skull dura due to
  blunt trauma causing rupture of middle meningeal
  artery
• May have a lucent period following immediate LOC
• Due to arterial bleeding, herniation occurs
  quickly

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Concussion

• Temporary brief interruption of neurologic
  function after minor trauma
• Symptoms-headache, confusion, amnesia
• Should not return to play until resolution of
  symptoms for 1 week

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Pediatric Head Trauma

• lt2yo consider abuse
• Higher mortality in children
• lt3months asymptomatic, no scalp hematoma then no
  CT
• 3months-2yrs scalp hematoma present then skull
  films, if fracture CT
• gt2yrs CT if high risk PE or history

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Penetrating Head Injuries

• ABCs
• Antibiotics Td proph
• CT Neurosurgery