practical management ofHEAD AND NECK INJURY
practical management ofHEAD AND NECK INJURY          Edited by Jeffrey V Rosenfeld Sydney   Edinburgh London   New York Ph...
To Joe, Lorraine, Deborah, Alexander, Hannah and Gabriella
Churchill Livingstone                     is an imprint of Elsevier                     Elsevier Australia. ACN 001 002 35...
ContentsForeword vii                                                      H. Eye injuries 92                              ...
vi   CONTENTS     10 Ward care of the head-injured                      20 Prediction of outcome and the prognosis        ...
PrefaceGlobally, it has been estimated that at least 10                practitioners who work in remote locations wheremil...
PREFACE     ixa similarly engaging way for each topic with an          trauma at all types of healthcare facilities and in...
AcknowledgmentsI owe a debt of gratitude to my own neurosurgical             I particularly wish to thank Associate Profes...
Contributors and reviewersCONTRIBUTORSRocco Armonda MD, COL, MC                                         Bruce Day MBBS, FR...
xii   CONTRIBUTORS AND REVIEWERS      Lucia M Li MA(Cantab), MBBChir                                John Olver MBBS, MD, F...
1Epidemiology                                                                                 Peter Bragge, Russell L Grue...
2   PRACTICAL TREATMENT OF HEAD AND NECK INJURY        The Glasgow Coma Scale (GCS)10 is a clinical           of the distr...
1 • Epidemiology   3  TABLE 1.2 Distribution of International Classification of Diseases 10th edition (ICD-10) codes of hea...
4   PRACTICAL TREATMENT OF HEAD AND NECK INJURY    deaths in children occur in low- and middle-income          PTA duratio...
1 • Epidemiology   5 TABLE 1.3 Direct and indirect cost estimates for TBI in Australia23                                  ...
6   PRACTICAL TREATMENT OF HEAD AND NECK INJURY    FIG 1.1 Road traffic fatality trends in three high-income countries (Aus...
1 • Epidemiology   7              FIG 1.2 Road traffic fatalities, adjusted for underreporting, 1990–2020.         (Reprodu...
8   PRACTICAL TREATMENT OF HEAD AND NECK INJURY     9. Rosenthal M, Griffith E, Bond M. Rehabilitation of the       26. Dep...
1 • Epidemiology    9    Foundation guidelines for the treatment of severe      45. Department of Infrastructure and Trans...
Practical Management of Head and Neck Injury - Rosenfeld - 9780729539562
Practical Management of Head and Neck Injury - Rosenfeld - 9780729539562
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Practical Management of Head and Neck Injury - Rosenfeld - 9780729539562


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A succinct, pictorial approach to managing patients with head and neck injuries. This authoritative medical textbook covers the head and neck patient's journey through various stages, including the pre-hospital setting, the emergency room and the intensive care unit. It incorporates all aspects of care at each stage.

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  1. 1. practical management ofHEAD AND NECK INJURY
  2. 2. practical management ofHEAD AND NECK INJURY Edited by Jeffrey V Rosenfeld Sydney Edinburgh London New York Philadelphia St Louis Toronto
  3. 3. To Joe, Lorraine, Deborah, Alexander, Hannah and Gabriella
  4. 4. Churchill Livingstone is an imprint of Elsevier Elsevier Australia. ACN 001 002 357 (a division of Reed International Books Australia Pty Ltd) Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067© 2012 Elsevier AustraliaThis publication is copyright. Except as expressly provided in the Copyright Act 1968 and the CopyrightAmendment (Digital Agenda) Act 2000, no part of this publication may be reproduced, stored in any retrievalsystem or transmitted by any means (including electronic, mechanical, microcopying, photocopying, recordingor otherwise) without prior written permission from the publisher.Every attempt has been made to trace and acknowledge copyright, but in some cases this may not have beenpossible. The publisher apologises for any accidental infringement and would welcome any information toredress the situation.This publication has been carefully reviewed and checked to ensure that the content is as accurate and currentas possible at time of publication. We would recommend, however, that the reader verify any procedures,treatments, drug dosages or legal content described in this book. Neither the author, the contributors, nor thepublisher assume any liability for injury and/or damage to persons or property arising from any error in oromission from this publication.National Library of Australia Cataloguing-in-Publication DataAuthor: Rosenfeld, Jeffrey.Title: Practical management of head and neck injury / Jeffrey Rosenfeld.ISBN: 9780729539562 (pbk.)Subjects: Head–Wounds and injuries–Treatment. Neck–Wounds and injuries–Treatment.Dewey Number: 617.51044Publisher: Luisa CecottiDevelopmental Editor: Neli BryantPublishing Services Manager: Helena KlijnProject Coordinator: Geraldine MintoEdited by Carol NatsisProofread by Forsyth Publishing ServicesCover and internal design by Darben DesignIndex by Cynthia SwansonTypeset by Toppan Best-set Premedia LimitedPrinted by ••
  5. 5. ContentsForeword vii H. Eye injuries 92 Anthony Hall, Jeffrey V RosenfeldPreface viiiAcknowledgments x 6 Injury to the spine and spinal cord 97Contributors and reviewers xi A. Spinal injury 97 Susan M Liew, Arvind Jain1 Epidemiology 1 B. Traumatic spinal cord injury 122 Russell L Gruen Jin W Tee, Jeffrey V Rosenfeld, Patrick Chan2 Anatomy of the head and neck 10 Tony Goldschlager, Jeffrey V Rosenfeld 7 Vascular injury 135 A. Blunt carotid and vertebral artery3 Pathophysiology of traumatic brain injuries 135 injury 39 Jeffrey V Rosenfeld, Jin W Tee Tony Goldschlager, Jeffrey V Rosenfeld B. Traumatic caroticocavernous fistula 140 Peter Hwang, Anoop Madan4 Pre-hospital management 56 Stephen Bernard C. Penetrating injury to the cervical carotid and vertebral arteries 147 Jeffrey V Rosenfeld, Jin W Tee5 Emergency department management 63 Jeffrey V Rosenfeld, Mark Fitzgerald, Alfredo Mori, David Morgan, Vince Cousins, Anthony Hall 8 Operative surgery 149 A. Initial treatment and assessment 63 A. Neurosurgery 149 Mark Fitzgerald, Alfredo Mori, Jeffrey V Rosenfeld Jeffrey V Rosenfeld B. Ear, nose and throat (ENT) surgery 175 B. Maxillofacial injuries 80 Vince Cousins David Morgan, Jeffrey V Rosenfeld C. Ocular injuries 179 C. Blunt injury of the neck 84 Anthony Hall Vince Cousins, Jeffrey V Rosenfeld D. Maxillofacial injuries 180 D. CSF rhinorrhoea 85 David Morgan Vince Cousins, Jeffrey V Rosenfeld E. Cervical spine injuries 193 E. Epistaxis 85 Susan M Liew, Arvind Jain Vince Cousins, Jeffrey V Rosenfeld F. Injuries to the ear 87 9 Intensive care management of Vince Cousins, Jeffrey V Rosenfeld head injury 211 G. Fractures of the temporal bone 88 Andrew Davies, D James Cooper, Vince Cousins, Jeffrey V Rosenfeld Jeffrey V Rosenfeld v
  6. 6. vi CONTENTS 10 Ward care of the head-injured 20 Prediction of outcome and the prognosis patient 222 of head injury 326 Peter Hwang, Jin W Tee, Antoinette David Lucia M Li, Mathew R Guilfoyle, Peter Hutchinson 11 Rehabilitation following traumatic brain injury 230 21 Prevention of head injury and the role of John Olver, Bianca Fedele trauma systems 353 Biswadev Mitra, Russell L Gruen 12 Head injury in children 241 Jeffrey V Rosenfeld, Simon Young Appendixes 361 A Glasgow Coma Scale 362 13 Head injury in the elderly 253 B Paediatric Glasgow Coma Scale 362 Peter Hwang, Jin W Tee, Jeffrey V Rosenfeld C Glasgow Outcome Score (Extended) 362 D Marshall CT Grading 362 14 Head injury in sport 262 Gavin A Davis, Michael Makdissi, Paul McCrory E Injury Severity Score 363 F American Spinal Injury Association (ASIA) 15 Penetrating head injury 280 Scale for Acute Spinal Cord Injury Assessment 364 Rocco Armonda, Randy S Bell, Jeffrey V Rosenfeld G Westmead Post-traumatic Amnesia (PTA) 16 Bleeding diathesis and Scale 366 anticoagulants 293 H Disability scales: short-form 12 (SF-12) 369 Peter Hwang, Mark Seifman, Jeffrey V Rosenfeld I Alfred Cervical Spine Clearance Protocol for Trauma Patients 371 17 Neurotrauma in pregnancy 302 J Post-traumatic amnesia screening and referral Jeffrey V Rosenfeld, Jin W Tee process 372 K Essential surgical instruments for emergency 18 Brain death 310 neurosurgery 374 Alvin Teo, Andrew Davies L Guidelines bibliography 374 (i) Evidence-based guidelines 374 19 Persistent vegetative and minimally (ii) Mild traumatic head injury guidelines 374 responsive states following head injury 316 Index 375 Bruce Day
  7. 7. PrefaceGlobally, it has been estimated that at least 10 practitioners who work in remote locations wheremillion people each year suffer a traumatic brain there is no neurosurgical service.injury (TBI) that results in death or hospitalisation, Why head and neck? A myriad of textbooks onand an estimated 57 million people worldwide have head injury have been published in the last twobeen hospitalised with one or more TBIs. Even in decades. Many are encyclopaedic, but mainly con-trauma systems with advanced pre-hospital and in- fined to the brain and skull. However, injuries to thehospital medical care, 50% of patients with severe brain and skull also frequently involve the face andTBI either die or survive with severe lifelong dis- sinuses, mouth, teeth and jaws, orbits, eyes, ears andability. Most of the severe disability survivors are neck, including the great vessels, spine, spinal cordyoung males who are never able to live indepen- and pharynx, larynx and trachea. A more holisticdently or return to employment. There are also many approach is required. The interplay between thechildren and elderly people who suffer TBI. Sport various specialties is highlighted and should encour-and leisure activities are an important cause of TBI age the multidisciplinary team approach to caringin young people. Penetrating brain injury sustained for these war zones and because of urban crime is also a Practical management of head and neck injurymajor problem worldwide. Acute spinal cord injury, captures the essence of the day-to-day managementfacial, ocular, auditory and cervical vascular injury of head and neck injury by following all aspectsfurther contribute to the overall injury burden. of care through the patient’s journey from the acci- The cost of severe TBI in Australia in economic dent scene all the way through to rehabilitation.terms has been independently calculated recently by Separate chapters are devoted to specialised topicsAccess Economics to be A$4.8 billion annually. This covering children, the elderly, pregnancy, coagula-does not describe the human cost. In the USA, the tion disorders, brain death, persistent vegetativeeconomic burden of TBI is estimated to be US$60 state, head injury in sport and penetrating headbillion annually. Imagine the cost to nations and injury. These are all pertinent problems that juniorfamilies where trauma systems and medical care are staff may encounter and with which they shouldnot well developed or resourced, and consider the have some familiarity. The management of head andincalculable worldwide economic burden of brain neck injury also depends on a sound understandingand spinal cord injury, particularly in low- and mid- of the essential anatomy, including CT images, asdle-income countries. These sobering statistics can well as the pathophysiology. The general issues ofbe improved through education of health providers, epidemiology, prognosis of TBI, prediction ofbetter trauma systems, high quality hospitals and outcome, head injury prevention and trauma systemsongoing basic and applied research. complete the coverage. The recent pertinent scien- Helping to save lives and improve the outcome tific evidence and discussion of many controversiesof those affected by head and neck trauma is the aim are also included.of this book. Practical management of head and We have assembled a group of authors who areneck injury is written for the broad audience of all experts in their respective specialties. Whilemedical students, junior doctors and doctors in many who write about the patient’s journey allspecialist training in emergency medicine, neuro- work together at the Alfred Hospital and Monashsurgery, trauma and general surgery, orthopaedics, University in Melbourne, Australia, other Australianotorhinolaryngology, ophthalmology, rehabilitation and international authorities are included.medicine, neurology and intensive care, and con- I make no apologies for not structuring the manytains sections written by experts in all of these spe- varied chapters the same way. I intentionally gavecialties. We believe it will also be of interest to the authors some latitude in how they presentedparamedics, nurses, physician assistants and allied their material and how many references were professionals. Many chapters will also inform Despite this, the authors have managed to write in viii
  8. 8. PREFACE ixa similarly engaging way for each topic with an trauma at all types of healthcare facilities and in theappropriate weighting of literature review. There is full range of healthcare systems, including low-inevitable overlap between some of the chapters. income countries, where services are sparse andThis has been accepted to maintain the integrity of generalists do the best they can with limitedeach of these chapters and to reinforce important resources.concepts. It is my fervent hope that this textbook will help Jeffrey V Rosenfeldto improve the knowledge base and interdisciplinary Melbourneteam approach to the management of head and neck August 2011
  9. 9. AcknowledgmentsI owe a debt of gratitude to my own neurosurgical I particularly wish to thank Associate Professorteachers and mentors Mr JB Curtis, Mr D Brownbill Max Esser, Senior Orthopaedic Surgeon at theand Professor Andrew Kaye at the Royal Melbourne Alfred Hospital and Monash University for encour-Hospital, Mr CBT Adams and staff at the Radcliffe aging me to produce this book. He has co-authoredInfirmary in Oxford, Dr John Little MD and staff at Practical Fracture Treatment with Dr Ronaldthe Cleveland Clinic, Ohio, and many others too McRea, also published by Elsevier, which is argu-numerous to name. I wish to thank Professor Sir ably one of the definitive current textbooks on frac-Graham Teasdale, one of the world’s leading experts ture traumatic brain injury research and management, I am indebted to Elsevier for having confidencefor writing the Foreword. in the aim and conceptual design of this textbook. I thank the neurosurgery registrars at the Alfred The superb staff at Elsevier, Ms Neli Bryant, MsHospital, Dr Jin Wee Tee, Dr Tony Goldschlager as Sophie Kaliniecki and Ms Geraldine Minto, andwell as my neurosurgical colleagues at the Alfred, editor Ms Carol Natsis have been enthusiastic, gra-Clinical Associate Professor Peter Hwang and Mr cious and always very obliging in nurturing this textPatrick Chan, for their support and contribution to to its final form. I sincerely thank my personal assis-the book. I also thank my many Alfred colleagues tant, Ms Sylvia Oklobdzija, for all her tremendousand the other Australian and international contri- assistance.butors very much for sharing their tremendous Last but by no means least, no words can conveyknowledge and experience. I admire US military the deep appreciation I have for the tremendous loveneurosurgeons Dr Rocco Armonda MD and Dr and support I receive from my wife Debbie and myRandy Bell MD for the devotion they have shown family.and the expertise they have developed in improvingthe outcomes for victims of bomb blast and penetrat- Jeffrey V Rosenfelding brain injury. x
  10. 10. Contributors and reviewersCONTRIBUTORSRocco Armonda MD, COL, MC Bruce Day MBBS, FRACPAssistant Professor of Surgery, Uniformed Services Clinical Neurophysiologist, The Alfred Hospital,University of the Health Sciences Melbourne, VictoriaDirector, Cerebrovascular Surgery/Neurocritical Care,Bethesda, Maryland, USA Bianca Fedele BA(Hons) Research Assistant, Epworth Monash RehabilitationRandy S Bell MD, MC Medicine UnitNational Naval Medicine Center, Bethesda, Maryland, USA Mark Fitzgerald MBBS, FACEMStephen Bernard MBBS, MD, FACEM, FCICM Adjunct Clinical Associate Professor, Director of TraumaAssociate Professor, Intensive Care Physician, The Alfred Services, The Alfred Hospital, Melbourne, VictoriaHospital, Melbourne, VictoriaDirector of Intensive Care, Knox Private Hospital, Tony Goldschlager MBBS, DCH(London), PhD, FRACSMelbourne, Victoria Neurosurgical Registrar, The Alfred Hospital, Melbourne and Monash Medical Centre, Clayton VictoriaPatrick Chan MBBS(Melb), MD(Melb), FRACSNeurosurgeon, The Alfred Hospital, Melbourne, Victoria Russell L Gruen MBBS, PhD, FRACS Director, National Trauma Research Institute,D James Cooper BMBS, MD, FRACP, FCICM Melbourne, VictoriaProfessor of Intensive Care Medicine, Monash University, Surgeon and Head of Trauma Quality Assurance,Melbourne, Victoria The Alfred Hospital, Melbourne, VictoriaDirector of the ANZIC Research Centre, Monash Professor of Surgery and Public Health, MonashUniversity, Melbourne, Victoria University. Melbourne, VictoriaDeputy Director of ICU, The Alfred Hospital, Melbourne,Victoria Mathew R Guilfoyle BSc, MBBCh, MRCSHead of Intensive Care Unit (ICU) Research, The Alfred Academic Clinical Fellow, Addenbrooke’s Hospital,Hospital, Melbourne, Victoria Cambridge, UKVincent Cousins BMedSci(Hons), MBBS(Hons), FRACS Anthony Hall MD, FRANZCOAdjunct Clinical Associate Professor, Ear Nose and Throat Adjunct Clinical Associate Professor, Head of Unit,Surgeon, Head of Unit, Otolaryngology 2, The Alfred Department of Ophthalmology, The Alfred Hospital,Hospital, Melbourne, Victoria Melbourne, VictoriaAntoinette David RN, GradCert(Neurosciences) Peter Hutchinson BSc(Hons), MBBS, PhD,Clinical Support and Development Nurse, Neurosurgery FRCS(Surg Neurol)and Neurotrauma, The Alfred Hospital, Melbourne, Reader and Honorary Consultant Neurosurgeon,Victoria Addenbrooke’s Hospital, Cambridge, UKAndrew Davies MBBS, FRACP, FCICM Peter Hwang MBBS, FRACS, FRCS(Edin), FRCS(Glag),Adjunct Clinical Associate Professor, Intensive Care Unit, FCSS, FAMSThe Alfred Hospital, Melbourne, Victoria Neurosurgeon, The Alfred Hospital, Melbourne, VictoriaAdjunct Associate Professor, Department of Epidemiology Adjunct Clinical Associate Professor, Central Clinicaland Preventative Medicine, Monash University School, Monash University, The Alfred HospitalGavin A Davis MBBS, FRACS (Neurosurgery) Arvind Jain MBBS, MS(Ortho)Associate Professor, Neurosurgery, Department of Orthopaedic Principal Fellow, The Alfred Hospital,Neurosurgery, Cabrini Hospital, Malvern, Victoria and Melbourne, VictoriaDepartment of Neurosurgery, Austin Hospital, Heidelberg,Victoria xi
  11. 11. xii CONTRIBUTORS AND REVIEWERS Lucia M Li MA(Cantab), MBBChir John Olver MBBS, MD, FAFRM(RACP) Academic Foundation Doctor in Neurosurgery, Victor Smorgon Chair of Rehabilitation Medicine, Monash Addenbrooke’s Hospital, Cambridge, UK University, Melbourne, Victoria Director Rehabilitation, Epworth Healthcare, Melbourne, Susan M Liew MBBS(Hons), FRACS(Orth) Victoria Adjunct Clinical Associate Professor, Orthopaedic & Spine Surgeon, Director of Orthopaedic Surgery, The Alfred Jeffrey V Rosenfeld AM MBBS(Melb), MD(Monash), Hospital, Melbourne, Victoria MS(Melb), FRACS, FRCS(Edin), FACS, FRCS(Glasg) Adjunct Clinical Associate Professor, Monash University, Hon, FCNST Hon, FRCST Hon, FACTM, MRACMA, The Alfred Hospital, Melbourne, Victoria RAAMC Professor and Head, Division of Clinical Sciences and Paul McCrory MBBD, PhD, FRACP, FACSP, FFSEM, Department of Surgery, Central Clinical School, Monash FACSM, GradDipEpidStats University, The Alfred Hospital, Melbourne,Victoria Associate Professor, Centre for Health, Exercise and Sports Director, Department of Neurosurgery, The Alfred Medicine & The Brain Research Institute, University of Hospital, Melbourne, Victoria Melbourne, Victoria Major General and Surgeon General, Australian Defence Force—Reserves Anoop Madan MBBS, FRANZCR Interventional Neuroradiologist, Department of Radiology, Marc Seifman MBBS, BMedSc The Alfred Hospital, Melbourne, Victoria Surgical Registrar, The Alfred Hospital, Melbourne, Adjunct Lecturer, Monash University, Melbourne, Victoria Victoria Michael Makdissi BSc(Hon) MBBS PhD FACSP Jin W Tee MBBS, BMedSc Research Fellow, Centre for Health, Exercise and Sports Neurosurgery Registrar, The Alfred Hospital, Medicine & the Brain Research Institute, University of Melbourne, Victoria Melbourne, Victoria Neurotrauma Research Fellow, The Alfred Hospital, Melbourne, Victoria Biswadev Mitra MBBS(Melb), MHSM, MAAFP, FACEM Consultant Emergency Physician, The Alfred Hospital, Alvin Teo MBBS, MMed, EDIC, FANZCA, FCICM, DDU Melbourne, Victoria Specialist in Intensive Care, The Alfred Hospital, Melbourne, Victoria David Morgan MBBS, FRACS Plastic and Reconstruction Surgeon, The Alfred Hospital Simon Young MBBS(Hons), DipCrim, FACEM and Cabrini Brighton Medical Centre, Melbourne, Victoria Director of Emergency Medicine, Royal Children’s Hospital, Parkville, Victoria Alfredo Mori MBBS, Dip EBHC(Oxon), FACEM Emergency Physician, The Alfred Hospital, Melbourne, Victoria REVIEWERS Noel Eatough BSc(Med), MBBS, FACEM Andrew Pearce BSc(Hons), BMBS, FACEM, PGCert Staff Specialist, Royal North Shore Hospital, Sydney, and Aeromed Ret CareFlight, New South Wales Senior Staff Specialist, Emergency Medicine, Royal Adelaide Hospital, South Australia Michael Facek MBBS(Hons), BSc Associate Professor and Clinical Director, MedSTAR Orthopaedic Registrar, Mater Miscorderiae Hospital, New Emergency Medical Retrieval Service, South Australia South Wales Group Captain, RAAF Specialist Reserves; Clinical Director, Emergency Medicine and Aeromedical Evacuation
  12. 12. 1Epidemiology Peter Bragge, Russell L GruenEvery day, in every country, men, women and chil- a state or a country, this information is essential fordren sustain head injuries. Trips and falls, transport the planning and monitoring of injury preventionaccidents, sporting injuries, interpersonal violence efforts, and treatment and disability services.and military conflict all lead to a spectrum of inju- Of course every country has its own TBI epide-ries to the face, scalp, skull vault, sense organs and, miology. Rather than being a comprehensive reviewmost importantly, to the brain itself. of every country’s experience of TBI, however, this Globally, at least 10 million people each year chapter focuses on the main global patterns of injury,suffer a traumatic brain injury (TBI) that results in how these patterns are changing and the implica-death or hospitalisation, and an estimated 57 million tions for the future.people worldwide have been hospitalised with oneor more TBI.1 Estimates of the annual incidence liebetween 91 and 372 per 100,000,2,3 and estimates of DEFINITION, CLASSIFICATION, DATAmortality range from 9 to 89 per 100,000.4 Almost60% of TBIs worldwide are due to road traffic acci- Epidemiology relies on reliable and valid data, anddents, 20–30% to falls, 10% to violence and 10% to there are important challenges that relate to defini-work or sports injuries5. tions, classification and data availability. Epidemiology is the science that describes the TBI is usually defined as an injury to the brainoccurrence of disease, risk factors, causal mecha- resulting from an external force, leading to transientnisms and outcomes. Epidemiology provides prac- or permanent neurological dysfunction.6 The mosttitioners and policy makers with valuable information commonly used classification for TBI consists ofabout incidence (new cases), disease burden (includ- ‘mild’, ‘moderate’ or ‘severe’, based on duration ofing prevalence and outcomes such as death, dis- loss of consciousness and clinical presentation, theability and cost), and the effect of prevention and first Glasgow Coma Score and the duration of post-treatment initiatives. At the level of a health service, traumatic amnesia, as shown in Table 1.1. TABLE 1.1 Classification of TBI6,7,8,9 Typical duration Typical first Typical duration of LOC Clinical presentation GCS score of PTA Mild TBI 30 mins or less Awake; eyes open. Symptoms can include 14–15 Less than 24 hours (concussion) confusion, memory and attention difficulties, headache, and behavioural problems. Moderate TBI More than 30 mins Lethargic; eyes open to stimulation; sleepy, but 9–13 1–7 days still arousable. Severe TBI More than 30 mins Coma; eyes do not open, even with stimulation. 3–8 1–4 weeksLOC = loss of consciousness; GCS = Glasgow Coma Scale; PTA = post-traumatic amnesia. 1
  13. 13. 2 PRACTICAL TREATMENT OF HEAD AND NECK INJURY The Glasgow Coma Scale (GCS)10 is a clinical of the distribution of pathological types of head prognostic indicator commonly used for the initial injury among major trauma cases (injury severity assessment of severity of injury that requires the score, ISS > 15) for the state of Victoria, Australia, assessment of eye-opening, motor and verbal respon- where motor vehicle crashes, falls and interpersonal siveness. While intended to be used as a repeated violence are the main causes of severe injury and measure, it is often used as a single assessment and firearm use is uncommon. Population-wide data is recorded as such in registry data. captured for all major trauma cases in the Victorian Post-traumatic amnesia (PTA), a term first used State Trauma Registry. In the 5 years from 2005 to in 1928, refers to the period between the injury and 2009, there were 11,608 cases of major trauma in the return of full, continuous memory, including any Victoria, and among these 6963 patients (60%) were time during which the patient was unconscious.11 coded as having a type of head injury. Of the major PTA is a condition following a TBI that is charac- trauma patients with head injury, the most frequently terised by confusion, disorientation, loss of memory coded ICD codes were concussion, subdural haem- post-injury and ‘clouded’ consciousness.12,13 Conse- orrhage, fractured base of skull, subarachnoid quently, patients in PTA may be unable to state their haemorrhage, diffuse brain injury and focal brain name and may be unaware of the time and where injury (Table 1.2). Four per cent of patients who had they are.12 While a patient is in PTA, the ability to moderate-to-severe head injury also had a cervical store new events in the memory is lost14; therefore, spine injury. a hallmark of PTA resolution is the return of con- Other ways of classifying TBI, including clinical tinuous memory.15 In approximately one-third of descriptions of the lesion and the presentation, vary PTA cases, a patient has ‘islands of memory’ and with the nature, intensity, direction and duration of can recall some, but not all, events.14 ‘Retrograde the external forces to the brain.19 The four main amnesia’ refers to failure to recall events prior to the patho-anatomical sequelae of TBI are contusion, injury, and ‘anterograde amnesia’ refers to failure to subarachnoid haemorrhage, haematoma (including lay down new memories for a period following the extradural, subdural and intraparenchymal lesions) injury. and diffuse axonal injury (DAI).17 Contusion arises Differences in classification systems affect com- from contact impact. Haematoma is present in parability of data.3 While the mild / moderate / severe 25–35% of patients with severe TBI and 5–10% of distinction is useful for epidemiological purposes, moderate TBI cases. DAI, which is characterised by there is ongoing debate about its validity for clas- multiple small lesions in white matter tracts, causes sification and prognostication. Difficulties in using profound early coma and is associated with poor these categories, which can lead to inaccuracies, outcomes.19 These sequelae are often found to co- include the effects of sedation, intoxication, facial exist in patients with severe and fatal TBI but injury and intubation on GCS scores, the effect of can also do so in the setting of mild and moderate the exact timing of measurement and the potential injuries.17 Also important to the clinician is the influence of shock and other organ system failure on presence of secondary insults, including ischaemia, the evaluation of GCS, consciousness and the dura- hypoxia, cerebral oedema, hypotension, hypergly- tion of PTA, and missing documentation of severity caemia and hypercapnia / hypocapnia.17,19,20 data in medical records.16 Furthermore the poor cor- Irrespective of the classification system used relation of GCS with the pathophysiological mecha- for coding TBI, there are factors limiting the nisms underlying the neurological deficits gives availability and comparability of data within and little direction to further management.17 between systems. These limitations include the New means of assessment of global severity are following: emerging, including newer-generation imaging tech- • Most brain injuries (up to 80%) are mild (mTBI), niques such as diffusion tensor imaging (DTI), but, but data on mTBI are difficult to capture, as such for the present, the mild / moderate / severe classifica- injuries may receive no medical treatment, or tion based on clinical features is likely to remain in may not be treated in hospitals where TBI data- widespread use.17 bases are kept.21,22 Pathological classification, the most widely used • TBI often occurs with multi-trauma and in mili- being the 10th edition of the International Classi- tary settings, and therefore is underreported or fication of Diseases (ICD-10),18 complements func- rolled into more general death and injury tional severity scoring. We provide here an example statistics.21,22
  14. 14. 1 • Epidemiology 3 TABLE 1.2 Distribution of International Classification of Diseases 10th edition (ICD-10) codes of head injury in Victoria, Australia, 2005–09 Number of cases % major % cases with ICD Code Injury (1 Jan 2005 – 31 Dec 2009) trauma cases head injury S060 Concussive injury 3899 33.6% 56.0% S065 Traumatic subdural haemorrhage 2929 25.2% 42.1% S021 Fractured base of skull 2027 17.5% 29.1% S066 Traumatic subarachnoid haemorrhage 1888 16.3% 27.1% S062 Diffuse brain injury 1725 14.9% 24.8% S063 Focal brain injury 1534 13.2% 22.0% S020 Fractured skull vault 987 8.5% 14.2% S064 Extradural haemorrhage 798 6.9% 11.5% S061 Cerebral oedema 432 3.7% 6.2% S068 Other intracranial injuries 259 2.2% 3.7% S069 Intracranial injury, unspecified 62 0.5% 0.9%Data provided with permission from the Victorian State Trauma Outcomes Registry (VSTORM).• Injury reporting and surveillance systems vary increase in high-income countries. Furthermore, across the world.21 Hospital records, death cer- by 2020 traffic-related injuries will become the tificates, trauma registries and purpose-designed third-ranked cause of disability-adjusted life years prospective observational studies provide the (DALYs) lost (second-ranked cause of DALYs lost most reliable sources of data on occurrence and in low-to-middle income countries), with 71.2 outcomes of TBI, but such data rarely capture all million DALYs lost worldwide, representing 5.1% dimensions of brain injury. of the global burden of disease.24There is a need for more accurate monitoring of the Motorcycle riders are at particular risk. Foroccurrence, severity and outcomes of TBI using example, in the UK, motorcyclists comprise understandardised measures and processes of data collec- 1% of road users but represent 14% of road deathstion and reporting. National trauma registries are and serious injuries. They are killed or seriouslywell suited to this purpose. injured at twice the rate of pedal cyclists and at more than 16 times the rate of car occupants.25,26 Alcohol is a major contributing factor to traffic-INCIDENCE AND MECHANISMS OF TBI related head injury in many countries. For example,Throughout the world, TBI incidence by age is tri- 64% of deaths and over a third of non-fatal injuriesmodal, with peaks in early childhood, late adoles- in child passengers in the USA have been linked tocence and the elderly.2 Data from the USA and drink-driving.27 Of course other causes of traffic-Australia show that, overall, males are twice as related injury include speeding, sleepiness, failurelikely as females to experience TBI.22,23 This is pre- to use safety harnesses, drugs that impair conscious-dominantly because of the adolescent male’s ness and driver response time, as well as character-involvement in violence and traffic-related injuries. istics that make the vehicles or roads usafe.At the extremes of age, males and females have a Of the remaining causes of TBI, falls producesimilar incidence of TBI.2 20–30% of TBIs worldwide, especially among Traffic-related injuries account for 1.2 million young children and the elderly. The Internationaldeaths each year worldwide. The World Health Multicenter Study of Head Injury in Children,28 con-Organization Global Burden of Disease Study fore- ducted in five countries, revealed the relative pro-casts that by 2020 traffic-related injuries will become portion of minor, moderate and severe TBI sustainedthe sixth-ranked major cause of death worldwide, was 56%, 39% and 5%, respectively, with a caserepresenting 3.4% of all deaths worldwide. An 80% fatality rate of 1.6. However, the burden of injuryincrease in traffic-related deaths is forecast in low- in children falls disproportionately upon poorerincome to middle-income countries and a 30% regions; the WHO estimates that over 95% of injury
  15. 15. 4 PRACTICAL TREATMENT OF HEAD AND NECK INJURY deaths in children occur in low- and middle-income PTA duration is significantly associated with attained countries.29 educational level, cognitive function, anxiety and In the elderly, a fall may be the result of a trip or recovery, as measured by the Extended Glasgow stumble, a cardiac or cerebrovascular event, or other Outcome Scale.33 co-morbidities, including the effects of psychoactive or cardiovascular drugs such as antihypertensives. Moderate-to-severe TBI Elucidating the actual cause of falls in the elderly In the state of Victoria, the mortality rates in 2007–8 can be difficult. Falls incidence also varies by in the first year after injury were 22.6% for moderate country; the incidence of TBI due to falls in India is TBI and 35.1% for severe TBI.23 US-based data 43 per 100,000 compared to a worldwide falls- indicates that mortality from TBI has decreased related TBI incidence of 13.3 per 100,0001; India from 19.3 to 17.8 per 100,000 in the period 1997– accounts for 50% of the known worldwide falls- 2007,34 continuing a downward trend established in related TBI.21 earlier studies.35,36 Assault and violence contribute a further 10% of Most survivors of moderate-to-severe TBI face the world’s TBI cases. The incidence is dramatically a range of long-term disabilities. For example, in a higher in some populations. For example, while the study of civilians in the USA, three years after worldwide incidence of TBI due to assault is 43 per severe head injury only 3 of 45 survivors did not 100,000,1 in Johannesburg the incidence of fatal TBI suffer persisting and disabling symptoms.37 Survi- in 2003 was 138 per 100,000 in males and 24 per vors face cognitive problems (for example, difficul- 100,000 in females.2 At a time when the incidence ties with concentration, memory and attention), of assault-related TBI in the whole Australian popu- psychological problems (depression and other lation was 41 per 100,000, in Australian Indigenous mood disorders) and physical disabilities (spasticity, communities it was 855 per 100,000, with Indi- speech problems). Although physical disabilities are genous females having a nearly 70 times higher rate challenging, the neurobehavioural consequences of than non-Indigenous females.30 In Europe, the rate TBI have a comparatively greater impact on quality of assault-related TBI is significantly higher in of life.6 Cognitive and behavioural deficits drive lower and upper-middle income countries than it is many of the lifestyle consequences of TBI, such as in high-income countries.31 unemployment, relationship difficulties and loss of independence.6,38 The eventual outcome of TBI is determined by OUTCOMES AND THE OVERALL the initial pathology, management of the head injury BURDEN OF TBI and of the associated disability, and the presence of co-morbidities and concomitant injuries. Identified Mild TBI predictors of TBI outcome include age, neurological Mild TBI patients make a full recovery in most status, trauma severity and CT characteristics.31,39 cases. However, 10–15% of mTBI patients experi- Owing to the costs associated with providing optimal ence ongoing problems, known as post-concussion TBI care, it has also been demonstrated that the syndrome (PCS).6 This is characterised by a range economic status of a region is significantly associ- of problems, including physical symptoms (e.g. ated with the outcome of patients with severe TBI.31 headache, vestibular problems, fatigue and sleep disturbance), cognitive deficits (problems with Burden of disease attention, memory, concentration) and behavioural Costs of TBI can be divided into direct costs of changes (irritability, emotional lability).6,7 These medical and other care, and indirect costs—those non-specific symptoms may present some time after relating to the loss, or partial loss, to society of the mTBI, when patients attempt to return to previous productive efforts (both paid and unpaid) of injury activities,7 making the diagnosis of PCS potentially victims and their caregivers. challenging. The mechanisms of how mTBI leads to An economic analysis has estimated that each PCS remain uncertain,32 and a range of factors other incident case of TBI in Australia presents an average than those relating to injury severity, most notably lifetime cost of A$2.5 million for moderate TBI and psychological factors, are thought to play a role in A$4.8 million for severe TBI.23 The total cost of PCS development.32,33 A 10-year follow up study moderate and severe TBI in Australia is estimated found that, among patients with mild head injury, to be A$8.6 billion per year (A$3.7 billion for
  16. 16. 1 • Epidemiology 5 TABLE 1.3 Direct and indirect cost estimates for TBI in Australia23 Cost (A$ millions) Category Definition / Examples Moderate TBI Severe TBI Burden of disease Estimated dollar value of the loss of wellbeing due to TBI, 2206.6 2691.9 using DALYs multiplied by the value given to a year of life (A$157,795 in Australia in 2008) Lifetime lost earnings due 452.9 256.3 to reduced employment Long-term care Attendant care, integration teacher aide, accommodation or 300.0 962.5 respite care, independent living unit, special accommodation and nursing-home supported community options Healthcare costs Ambulance, hospital, medical, paramedical and administration 269.1 308.0 Administrative costs The costs of administering welfare pensions and raising 174.6 150.5 additional taxation revenues Aids and modifications Wheelchairs and gait aids, environmental modifications, hoists, 59.7 158.5 home modifications Lifetime carer costs Informal care: e.g. family and friends 25.1 28.5moderate TBI and A$4.8 billion for severe TBI). CHANGES IN TBI PATTERNS ANDThe breakdown of these costs is given in Table 1.3. In 2002, TBI patients in the USA averaged an FUTURE IMPLICATIONSestimated US$65,600 in direct medical costs In global terms, patterns of TBI are changing as a(US$4330 per day), US$1,003,140 in societal costs result of trends in motorisation, prevention andper deceased person, up to US$74,673 in societal ageing. In high-income countries, road-traffic relatedcosts for non-fatal injuries and US$1631 per day for TBI has declined (Fig 1.1).35,43 Despite large numbersrehabilitation services.40 Economic modelling not of motor vehicles, fewer transport-related injuriesonly reveals important aspects of the burden of are occurring because of safer roads, safer cars, saferinjury, but has also been used to demonstrate the drivers and more timely and higher-quality emer-cost savings of care improvements. Faul et al esti- gency health services.44 In Australia, much of themated that if every patient received care consistent fall in the fatality rate since the late 1960s has beenwith the Brain Trauma Foundation guidelines, 3,607 attributed to the introduction of seat belts, randomlives would be saved in the USA, and the savings in breath testing and speed cameras.45annual medical costs, annual rehabilitation costs and However, the contribution of transport-relatedlifetime societal costs would be US$262 million, TBI mortality continues to rise in low- and middle-US$43 million and US$3.84 billion, respectively.41 income countries (Fig 1.2). While traffic-related The burden of TBI in low-income and middle- injuries are projected to be the third-highest causeincome countries, therefore, has four important of DALYs lost worldwide by 2020, they are fifth indimensions to it. First, there is a high preponderance their contribution to the burden of disease in devel-of risk factors for TBI. Second, healthcare systems oped regions and second in developing regions.46in low-income and middle-income countries are the This disparity parallels the dramatic increase inleast prepared to address TBI when it occurs.21 motorisation without a similar increase of invest-Third, the increased percentage of poor outcomes ment in injury prevention in low-income andfrom TBI relative to high-income countries further middle-income countries. In many countries, thestrains long-term or community services of these growth in use of motorcycles, often without protec-often poorly resourced health systems. It is esti- tive helmets, has led to dramatic increases in themated that 80% of the world’s disabled population incidence of TBI. For example, in eastern China,live in low-income and middle-income countries, traffic-related incidence of TBI rose by 30% in 20but only 2% can access rehabilitation.42 Fourth, low- years, over 50% of which cases did not involveincome countries are less equipped to implement occupants of cars (20% pedestrians, 13% bicycles,strategies to abate TBI risk. 20% motorcycles).47
  17. 17. 6 PRACTICAL TREATMENT OF HEAD AND NECK INJURY FIG 1.1 Road traffic fatality trends in three high-income countries (Australia, UK, USA). (Reproduced from world report on road traffic injury prevention.24) Ageing of populations has also had an important of the negative effect on outcomes of age itself effect on the incidence of TBI. In many high-income and of age-associated comorbidities and medica- countries, for the first time ever there are now more tions, such as anticoagulants. people over the age of 60 than children under the Changes in demography and exposure to risk age of 15. One-fifth of the population of high- factors are changing the profile of head injury in all income countries is already over 60 years of age, countries. To properly plan for the future, clinicians, and it is estimated that by 2050 this age group will policy makers, and injury-prevention programs will account for one-third of the population. The popula- need to take these trends into account. Because TBI tion of low-income and middle-income countries is can profoundly effect patients, their families and also ageing, albeit more slowly. their communities, as well as the costs borne by As the older population has increased, the inci- governments, insurers, individuals and workplaces, dence of falls-related TBI has increased. In the prevention is the key. Clinicians have an important USA, the number of road-traffic crash and firearm- role in advocating safety initiatives to reduce the related TBI deaths has fallen over the period 1990– burden of TBI around the world. 2007, but the number of falls-associated TBI deaths has risen. TBI death rates for the period 1997–2007 SUMMARY have fallen in persons aged 0–44, but increased in persons over 75 years of age.34 Similarly, in Austra- 1. At least 10 million people each year suffer a TBI lia hospitalised head injury in those aged over 60 that results in death or hospitalisation. years increased 1.4 times in the 5 years to 2. Almost 60% of TBIs worldwide are due to road 2004–05. traffic accidents, 20–30% to falls, 10% to vio- In addition to increased incidence of TBI, ageing lence and 10% to work or sports injuries. of the population also affects the pattern of TBI 3. Several classification systems exist, and mild TBI through increased mortality and morbidity because is grossly underreported.
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