Geriatric Trauma:

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Geriatric Trauma Traumatic Brain Injury
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Objectives TBI

• State the difference between primary
  secondary brain injury.
• Identify specific assessment treatment
  priorities for a patient with TBI
• Describe significant GCS pupil exam findings
  indicative of TBI.

Geriatric Trauma
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Elderly Brain A P

• 10 brain mass relatively large subdural
  space
• Bridging vessels are stretched fragile
• Normal changes of aging in other organ systems
  impact the elder patients response to brain
  trauma.

PHTLS Prehospital Trauma Life Support Sixth
Edition. Mosby 2007. p392.
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Definition
Traumatic Brain Injury (TBI) is blunt or
penetrating force resulting in skull and/or
brain injury which disrupts brain function.
http//www.cdc.gov/ncipc/tbi/TBI.htm

Geriatric Trauma
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Leading Causes of TBI 2002-2006
http//www.cdc.gov/TraumaticBrainInjury/causes.htm
l Geriatric Trauma
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TBI Consequences
CDC estimates 5.3 million Americans currently
need long-term or lifelong help to perform
activities of daily living as a result of TBI.
http//www.cdc.gov/ncipc/factsheets/tbi.htm
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Two types of TBI

• Primary Brain Injury
  direct trauma to the brain occurs _at_ time of
  energy transfer
• Secondary Brain Injury occurs minutes to
  hours after energy transfer

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Meningeal Layers Hemorrhage
Sites
Brain Trauma Foundation. Prehospital Management
of Traumatic Brain Injury
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Primary TBI Blunt
Intracranial Hematomas

• Epidural Hematoma

Epidural Hematoma
Subdural Hematoma
Intracerbral Hematoma
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Secondary Brain Injury

• Hypoxia airway or breathing compromise
• Hypotension circulatory compromise
• Brain stem herniation cerebral edema
• ALL have profound negative impact
  on patient outcome
• ALL are potentially preventable
  with early, aggressive management of
  A-B-Cs oxygenation

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Indicators of Poor Prognosis

• GCS lt 9
• Hypoxia
• Hypotension
• Coagulopathy
• Fixed dilated pupils

Wutzke , Jared. Penetrating Brain Injuries.
Downloaded from http//www.ohsu.edu/radiology/med/
neuro/pbi.ppt.
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Assessment Treatment Focus identify
primary brain injuries limit secondary
brain injury impact.
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Negative patient outcomes Hypoxia
Hypotension
Patent Airway Oxygenation
essential to limit secondary brain injury
Guidelines for the Management of Severe Traumatic
Brain Injury. J Neurotrauma. 2007 Vol 24, Supp
1.
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Airway Assessment

• Maintain c-spine
• Airway patency need for adjuncts
• Reassess every 5 minutes as needed

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Breathing Assessment

• Assess rate, depth, quality, O2 sat.,
  effectiveness of respirations every 5 minutes
  as needed.

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Circulation Assessment

• Assess pulse, B/P and bleeding control every
  five minutes and as needed
• Critical threshold SBP 90 mmHg
• Stable B/P critical to positive patient outcome
• 
  Geriatric Trauma

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Disability Assessment

• Level of consciousness
• Glasgow Coma Scale (GCS)
• Pupil response
• 
  
• 
  

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Disability Glasgow Coma Scale
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Disability GCS Components

• Eye Opening responds to command
• Open your eyes
• Verbal response responds to command
• Tell me the month the year
• Motor Response responds to command
• Show me 2 fingers.
• 
  Geriatric
  Trauma

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Disability GCS

• Motor Function exam definitions
• Localizes upper extremity crosses midline in
  purposeful attempt to locate remove painful
  stimulus
• Withdraws patient attempts to move upper
  extremity away from painful stimulus

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Disability Pupil Assessment
Brain Trauma Foundation. Prehospital Management
of Traumatic Brain Injury
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Disability Herniation Indicators

2. Cushings Triad LATE indicator

• Abnormal Pupils
• Unresponsive pt. with bilateral fixed dilated
  OR asymmetric pupils
• abnormal extension OR flaccid motor response to
  painful stimulus

Brain Trauma Foundation. Prehospital Management
of Traumatic Brain Injury
Geriatric Trauma
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Initial Assessment REMEMBER!

• Re-assess patient with SEVERE TBI every 5
  minutes
• Re-assess other patients as needed
• Indicates deteriorating pt. condition
• Pupil changes
• Decline of 2 or more points in GCS score

Brain Trauma Foundation. Prehospital Management
of Traumatic Brain Injury
Geriatric Trauma
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GCS 9-3 Severe TBI
Interventions Airway

• Protect c-spine during airway maneuvers
• Establish/protect airway
• Use best adjunct (scope of practice/pt. need)
• suction
• OPA/NPA
• Endotracheal tube
• Combitube, King tube, LMA
• Consider RSI

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Intervention Breathing

• Oxygen _at_ 15 lpm/nbm
• Assist respirations as/if needed
• BVM
• Maintain seal
• Ventilatory rate of 10-12 bpm
• Hyperventilate ONLY in the face of herniation
• Maintain O2 saturation gt 90

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Intervention Circulation

• Goal maintain SBP above 90 mmHg
• Control external bleeding
• Fluid resuscitation
• Isotonic IV fluid titrate to prevent or
  promptly correct hypotension
• Caution over hydration
• 1 episode of SBP lt 90 mmHg DOUBLES patient
  mortality

Chesnut RM, Marshall LF, Klauber MR, et al. The
role of secondary brain injury in determining
outcome from severe head injury. J Trauma
199334216-222.
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Anticoagulation and TBI

• Early CT head scan ALL at-risk patients
• Goal rapid reversal of anticoagulation
• Fresh Frozen Plasma (FFP)
• Vitamin K
• Other possibilities

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Transfer and Communication

• Appropriate trauma centers
• Transportation options
• Patient needs
• Level of care available/needed
• Weather/travel conditions/distance

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Other Considerations

• Blood glucose level
• Sedation, analgesics, paralytics
• medical direction, local protocols,
  neurosurgeon consultation
• Use short acting medications
• Mannitol ?
• Lidocaine ?

Brain Trauma Foundation. Prehospital Management
of Traumatic Brain Injury
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Summary 9 90 90

• To improve long term outcomes
• Assess, manage re-assess AB-Cs
• STRONGLY consider intubation when GCS lt 9
• Maintain O2 saturation gt 90
• Maintain systolic blood pressure gt 90 mmHg
• Assess for anti-coagulation
• CT head scan, treat, transfer emergently
• Ensure patient receives appropriate level of care
  in the shortest possible time.
• 
  Geriatric Trauma

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Questions?