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Wayne Triner, DO, MPH, FACEPProfessor, Emergency Medicine     Albany Medical College &     State University at Albany
   All TBI                     790    / 100,000 py    Mod to Severe 41    / 100,000 py     1.2 x risk Maori     2-5 x ...
   Primary     Direct tissue injury   Secondary       Cerebral perfusion/edema       Vasoregulation       Tissue isc...
   Cerebral Blood Flow            CBF ~ CPP – CVP   Cerebral Perfusion Pressure            CPP = MAP – ICP            CB...
   Mild     GCS > 12   Moderate     GCS 12-8   Severe     GCS < 8
Eye Opening                        Mild 4=Spontaneous                                     GCS > 12 3=To voice 2=To pa...
   GCS 13-15   < 30 minute LOC   Non-focal exam
   Short term                 Long term     Mood and cognitive         Depression      disturbances               Dem...
The goal being identification of significant  conditions amenable to intervention
LEVEL I RECOMMENDATION                             LEVEL II RECOMMENDATIONA noncontrast head CT is indicated              ...
   Understand the risk factors     Age     Small brains     Inability to fully evaluate     Propensity for bleeding  ...
   Recommendations     “Neuro rest”   Proven     ?????
   ABCs   Limit secondary brain injury   Preservation of CBF   Issues of coagulation     Reversal of coagulopathies  ...
   “Evidence based”   Standards, Guidelines and Options    • Preserve oxygenation      (at all costs)    • Avoidance of ...
Rapid reduction in ICP   3 compartment    model   Below pCO2 < 23,    CBF < 20    ml/100g/min
   Preserve oxygenation (at all costs)     Issues of airway management      ▪ Pre-hospital ETT      ▪ Neuro-protective R...
   Avoidance of hypotension (SBP < 90)     Preserve CBF     Control of cerebral edema      ▪ Brief hyperventilation    ...
   Recommendations;     Level II       ▪ Mannitol is effective for the control of raised         intracranial pressure a...
   Typically uncus herniating across tentorum     CN III compression      ▪ pupillary dilitation        ▪ 80% ipsilatera...
   No Level I or II recommendations   Level III:     No change in all-cause mortality     46% improved chance of favor...
   Most common CT finding    in TBI   Often occurs in concert    with other imaging    abnormalities   Neuro deficits r...
   High Mortality Rate   Association with Skull Fracture
   Acute   Higher Mortality Rate    Than EDH     underlying brain injury     co-morbidity   Chronic   Subacute
   Presence of    contusion does not    independently    predict outcome
• Cisterns• Gray – White  Interface
   Decompressable lesion with neuro findings     SDH, EDH, very few contusions     Traumatic SAH is not decompressable ...
   Cerebral edema              ICP determination   Monitoring                    early detection of mass     GCS < 8 ...
   All about GCS   GSW injury reflect patterns of ballistics
   Issues in    management     Hearing     Antibiotics     Disposition
1 Fearnside MR, Cook RJ, McDougall P, et al.: The Westmead Head Injury Project outcome in severe head injury. A comparativ...
   Strong factor in determining outcome from    severe TBI   This holds true even after correcting for co-    morbid con...
   TBI Biomarkers     Need for imaging     Validation     Prognostication   Intervention     Hypothermia     Proges...
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Head injury

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Head injury

  1. 1. Wayne Triner, DO, MPH, FACEPProfessor, Emergency Medicine Albany Medical College & State University at Albany
  2. 2.  All TBI 790 / 100,000 py Mod to Severe 41 / 100,000 py  1.2 x risk Maori  2-5 x risk in ruralthe incidence of TBI per 100 000 peopleper year (790 cases), especially mild TBI(749 cases), in New Zealand wassubstantially greater than in other high-income countries. in Europe (47–453cases) and North America (51–618cases).
  3. 3.  Primary  Direct tissue injury Secondary  Cerebral perfusion/edema  Vasoregulation  Tissue ischemia  Herniation
  4. 4.  Cerebral Blood Flow CBF ~ CPP – CVP Cerebral Perfusion Pressure CPP = MAP – ICP CBF ~ (MAP – ICP) - CVP
  5. 5.  Mild  GCS > 12 Moderate  GCS 12-8 Severe  GCS < 8
  6. 6. Eye Opening  Mild 4=Spontaneous  GCS > 12 3=To voice 2=To pain  Moderate 1=None  GCS 12-8  SevereVerbal  GCS < 8 5=Normal conversation 4=Disoriented conversation 3=Words, but not coherent 2=No words......only sounds 1=NoneMotor 6=Normal 5=Localizes to pain 4=Withdraws to pain 3=Decorticate posture 2=Decerebrate 1=None
  7. 7.  GCS 13-15 < 30 minute LOC Non-focal exam
  8. 8.  Short term  Long term  Mood and cognitive  Depression disturbances  Dementia  Validation  Parkinson’s  Variable rate of CT  Cognitive deficits abnormalities
  9. 9. The goal being identification of significant conditions amenable to intervention
  10. 10. LEVEL I RECOMMENDATION LEVEL II RECOMMENDATIONA noncontrast head CT is indicated A noncontrast head CT should bein head trauma patients with loss of considered in head trauma patientsconsciousness or pos- traumatic with no loss of consciousness oramnesia only if one of the post-traumatic amnesia if there isfollowing is present: focal deficit, vomiting, severeheadache, vomiting, age > 60 headache, age > 65 years, signs ofyears, drug or alcohol basilar skull Fx, GCS < 15,intoxication, deficits in short-term coagulopathy or dangerousmemory, physical evidence of mechanism (ejection from vehicle,trauma above the pedestrian struck, fall of more thanclavicle, posttraumatic seizure, GCS 3 ft or 5 stairs)< 15, focal deficit or coagulopathy. Clinical Policy: Neuroimaging and Decisionmaking in Adult Mild Traumatic Brain Injury in the Acute Setting ACEP 2008
  11. 11.  Understand the risk factors  Age  Small brains  Inability to fully evaluate  Propensity for bleeding  Mechanism and evidence of trauma Recognize neurological abnormalities  HA, vomiting, focal deficits
  12. 12.  Recommendations  “Neuro rest” Proven  ?????
  13. 13.  ABCs Limit secondary brain injury Preservation of CBF Issues of coagulation  Reversal of coagulopathies ▪ F VIIa ▪ Prothrombin complex concentrate ▪ Vit K and FFP
  14. 14.  “Evidence based” Standards, Guidelines and Options • Preserve oxygenation (at all costs) • Avoidance of hypotension (SBP < 90) • Euventilation
  15. 15. Rapid reduction in ICP  3 compartment model  Below pCO2 < 23, CBF < 20 ml/100g/min
  16. 16.  Preserve oxygenation (at all costs)  Issues of airway management ▪ Pre-hospital ETT ▪ Neuro-protective RSI ▪ Laryngeal manipulation ▪ Hypotension ▪ ICP management
  17. 17.  Avoidance of hypotension (SBP < 90)  Preserve CBF  Control of cerebral edema ▪ Brief hyperventilation  Hyperosmolar therapy
  18. 18.  Recommendations;  Level II ▪ Mannitol is effective for the control of raised intracranial pressure at doses of 0.25 to 1 g/kg. Hypotension (SBP < 90) should be avoided  Level III ▪ Restrict mannitol use prior to ICP monitoring to patients with signs of transtentorial herniation or deteriorating mental status not attributable to other causes Mechanism of Action  Blood rheology ▪ immediate plasma volume expansion  Osmotic redistribution Hypertonic Saline  23.4% 50 ml
  19. 19.  Typically uncus herniating across tentorum  CN III compression ▪ pupillary dilitation ▪ 80% ipsilateral to side of structural lesion  Pyramidal tract compression ▪ Contralateral weakness ▪ 80% contralateral to side of structural lesion  Rapid deterioration of mental status  Cushing’s reflex
  20. 20.  No Level I or II recommendations Level III:  No change in all-cause mortality  46% improved chance of favorable outcome (GOS 4-5)  Some evidence of improved outcome with > 48 hours of cooling
  21. 21.  Most common CT finding in TBI Often occurs in concert with other imaging abnormalities Neuro deficits reflect parenchymal injury and generally not a vascular insult
  22. 22.  High Mortality Rate Association with Skull Fracture
  23. 23.  Acute Higher Mortality Rate Than EDH  underlying brain injury  co-morbidity Chronic Subacute
  24. 24.  Presence of contusion does not independently predict outcome
  25. 25. • Cisterns• Gray – White Interface
  26. 26.  Decompressable lesion with neuro findings  SDH, EDH, very few contusions  Traumatic SAH is not decompressable and not an indication for aneurysm screening Indications of increasing ICP  Deteriorating mental status  Herniation syndromes Decompressive craniectomy
  27. 27.  Cerebral edema  ICP determination Monitoring  early detection of mass  GCS < 8 and Abnormal lesions Head CT  limit potentially harmful  GCS < 8 and Normal therapies Head CT with...  determination of ▪ age > 40 prognosis ▪ posturing  CSF drainage* ▪ hypotension
  28. 28.  All about GCS GSW injury reflect patterns of ballistics
  29. 29.  Issues in management  Hearing  Antibiotics  Disposition
  30. 30. 1 Fearnside MR, Cook RJ, McDougall P, et al.: The Westmead Head Injury Project outcome in severe head injury. A comparative analysis of pre-hospital, clinical, and CT variables. Br J Neurosurg 7:267-279, 1993.2 Braakman R: Interactions between factors determining prognosis in populations of patients with severe head injury. In Frowein RA, Wilcke O,Karimi-Nejad A, et al. Advances in Neurosurgery: Head Injuries-Tumors of the Cerebellar Region. Springer-Verlag, Berlin: 12-15, 1978.3 Phuenpathom N, Choomuang M, Ratanalert S: Outcome and outcome prediction in acute subdural hematoma. Surg Neurol 40:22-25, 1993
  31. 31.  Strong factor in determining outcome from severe TBI This holds true even after correcting for co- morbid conditions.
  32. 32.  TBI Biomarkers  Need for imaging  Validation  Prognostication Intervention  Hypothermia  Progesterone  Reduction of oxidative stress

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