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Management of Head Trauma in ER
- 1. Management of Head Trauma in ER Sumit Sinha Associate Professor of Neurosurgery Jai Prakash Narain Apex Trauma Center All India Institute of Medical Sciences
- 2. AIIMS Trauma Workshop Case Scenario ● 58-year-old male fell from a roof in a small rural town ● Initial GCS score = 12 ● On admission after 2- hour transfer, GCS score is 6 What injuries would you suspect? What are your priorities in managing this patient?
- 3. AIIMS Trauma Workshop Objectives ■ Initial Management- A (with C1) – B – C ■ Initial Neuro-Assessment-D- Glasgow Coma Scale Pupils ■ Immediate Neurosurgical Management CT Scan - when? Neurosurgical Consult - when? Recognition and treatment of Herniation ■ Other Considerations C-Spine, Bleeding, Extremity #, Rest of Spine ■ Pitfalls TRAUMA 2011
- 4. AIIMS Trauma Workshop Primary Aim of ER management ■ Prevent Secondary Brain damage at all costs TREAT AGGRESSIVELY ❖Hypo tension (MAP > 90mmHg) ❖Hypoxia (PaO2 < 60mmHg) ❖Hypoglycemia ❖Fever ❖Raised Intra-cranial Pressure ❖Seizures TRAUMA 2011
- 5. AIIMS Trauma Workshop Intracranial Pressure (ICP) ● Sustained increased ICP leads to decreased brain function and poor outcome ● Hypotension and low saturation adversely affect outcome 10 mm Hg = Normal >20 mm Hg = Abnormal >40 mm Hg = Severe
- 6. AIIMS Trauma Workshop Cerebral Perfusion Pressure Normal 90 10 80 Cushing’s Response 100 20 80 Hypotension 50 20 30 MAP – ICP = CPP CPP ≠ Cerebral Blood Flow Caution
- 7. AIIMS Trauma Workshop TRAUMA 2011 Concept of ICP & CPP CPP = MAP – ICP Normal : > 60 mm Hg Reduced : < 50 mmHg When will ICP ↑?? Mass Lesions - Bleeding EDH, SDH, Intraparenchymal bleed Cerebral Edema Cytotoxic, Vasogenic
- 8. AIIMS Trauma Workshop Autoregulation ● If autoregulation is intact, CBF is maintained constant between a mean BP of 50 to 150 mm Hg. ● In moderate or severe brain injury, autoregulation is impaired so CBF varies with mean BP. ● The injured brain is more vulnerable to episodes of hypotension, causing secondary brain injury.
- 9. AIIMS Trauma Workshop TRAUMA 2011 Monro-Kellie Doctrine Venous Volume Arterial Volume Brain CSF Normal State – ICP Normal Venous Volume Arterial Volume Brain CSFMASS Compensated State – ICP Normal Arterial Volume Brain Venous Volume MASS CSF Uncompensated State – ICP Raised ICP (mmHg) 35 30 25 20 15 10 5 Volume Volume-Pressure Curve Herniation Point of Decompensation TRAUMA 2011
- 10. AIIMS Trauma Workshop TRAUMA 2011 Initial Management – Airway with C-Spine PATENT ↓ OKAY Don’t Intubate until patient needs sedation for some other procedure THREATENED Remains Unresponsive GCS ≦ 8 (CANNOT PROTECT AIRWAY) Oral bleeding Base of Skull bleeding OBSTRUCTED Massive Maxillofacial Trauma Maxilla Mandible Associated Neck Injury * If C-Spine Injury is suspected, intubation should be performed by the most experienced person available.
- 11. AIIMS Trauma Workshop TRAUMA 2011 Initial Management - Breathing HYPOXIA HYPERCARBIA Maintain PaO2 > 60 mmHg Maintain Normocarbia Maintain SpO2 > 95% PaCO2 – 30-35 mmHg
- 12. AIIMS Trauma Workshop TRAUMA 2011 Initial Management - Circulation TREAT HYPOTENTION Maintain Mean Arterial Pressure above 90 mm Hg USE Crystalloids – RL/NS Ionotrope Infusion if needed
- 13. AIIMS Trauma Workshop TRAUMA 2011 Initial Neuro-Assessment ■ Key History ◻ Mechanism of Injury ◻ Response at scene → Neuro-exam at scene → Change in status ■ Note Glasgow Coma Scale (GCS 3-15) ■ Note Pupils : Size / Shape / Reaction Note the symmetry of motor Score Eye Opening Best Verbal Response Best Motor Response 6 Obeys Commands 5 Oriented Localizes Pain 4 Spontaneous Confused Flexed to Pain 3 To Speech Inappropriate Words Flexion of arms with ext of legs(decorticate) 2 To Pain Incomprehensive sounds Extension 1 None No Verbalization None
- 14. AIIMS Trauma Workshop TRAUMA 2011 Classification of Head Injuries A. Blunt or Penetrating B. Mild, Moderate, Severe (Based on GCS) Mild 14-15 Moderate 9-13 Severe 3-8 C. Morphology (Fracture and Intracranial)
- 15. AIIMS Trauma Workshop TRAUMA 2011 Mild Head Injuries ■ GCS 14-15 ■ CT if LOC, Amnesia, Severe Headache, Anticoagulation ■ Evaluate C-Spine ■ Prognosis is excellent ■ Mortality rate < 1%
- 16. AIIMS Trauma Workshop TRAUMA 2011 Moderate Head Injuries ■ Patients may be confused, somnolent ■ GCS 9-13 ■ Admit observe ,repeat head CT with frequent neuro checks ■ Prognosis is good ■ Mortality rate < 5 %
- 17. AIIMS Trauma Workshop TRAUMA 2011 Severe Head Injuries ■ GCS < 8/15 ■ Mortality rate > 40% ■ Securing of A,B,C’s highest priority ■ Early Intubation ■ Hypotension associated with twice mortality ■ Maintain Pco2 25-35 mm/Hg
- 18. AIIMS Trauma Workshop TRAUMA 2011 Initial Neurosurgical Management ■ WHEN TO GET A CT-SCAN ? ■ Patient Comatose (GCS<13) ■ Penetrating Trauma ■ Suspect Skull # ■ CSF Leak ■ Post Trauma Seizures ■ Focal Neurological signs (Motor/Pupils) ■ WHEN TO CALL A NEUROSURGEON? ■ All of the above ■ Abnormal CT Scan
- 19. AIIMS Trauma Workshop TRAUMA 2011 Initial Neurosurgical Management Abnormal CT Scan
- 20. AIIMS Trauma Workshop TRAUMA 2011 Medical Management ■ Recognize and treat ↑ICP / Herniation Monitor : Decrease in Pulse+Ventilation+ ↑B.P. Decrease in level of Consciousness Dilated Pupil Decrease in motor power (Contralateral - Dilat pupil) ■ Cerebral Resuscitation ◻ Euventilation ◻ Intubate if (Orotracheal) if GCS<8 ◻ Mannitol Infusion 0.25-1.0 gm/Kg IV over 15 min (Not in Hypotensives) ◻ Monitor Urine Output ◻ Spine Cleared – Elevate the Head to 30°
- 21. AIIMS Trauma Workshop TRAUMA 2011 Other Considerations ■ Seizure Focus/Post Traumatic Seizures (2-5%) SAH, Bleed (Intracerebral, sub or extradural) Witnessed seizure Load Phenytion ≈ 11-15mg/Kg IV slow with cardiac monitoring ■ C-Spine 5%-20% of patients with severe HI will have C-spine injury 5%-10% with one spine # will have another one too Therefore C-Spine motion restriction and log-rolling till full spine cleared ■ Control of Bleeding ■ Immobilize other extremity fractures
- 22. AIIMS Trauma WorkshopALGORITHM FOR Mx OF MILD HEAD INJURY •History •G/E •Neurological examination •Skull X-Ray •Cervical spine X-Ray •Blood Alcohol levels CT HEAD - ideally in all but completely asymptomatic pts ADMIT DISCHARGE •Amnesia •H/o LOC •Deteriorating consciousness •Moderate-severe headache •Alcohol/drug intoxication •Skull fracture •CSF leak •Significant ass injuries •Abnormal CT scan •Does not meet criterion for admssion •Discuss need to return if problem
- 23. AIIMS Trauma WorkshopALGORITHM FOR Mx OF MODERATE HEAD INJURY •Initial w/u •CT SCAN IN ALL CASES ADMIT even if CT is normal Frequent neurological examinations FU CT Scan if deteriorates/before discharge If pt improves (90%) Discharge when stable If pt deteriorates (10%) Repeat CT Scan Manage as per severe HI
- 24. AIIMS Trauma WorkshopALGORITHM FOR Mx OF SEVERE HEAD INJURY •History •Rescuscitation- ABC •Catheters •X-Rays- Cx/Chest/Skull/Abdomen/Pelvis/Extremities •G/E Emergency measures for ass injuries: •Tracheostomy •Chest tubes •Neck stabilization •Abdominal paracentesis Neurological examination
- 25. AIIMS Trauma WorkshopALGORITHM FOR Mx OF SEVERE HEAD INJURY Intubate, Hyperventilate, Sedate, Mannitol (1g/kg) CT Scan Diffuse lesion Not Available Exploratory burr holes ICU •Monitor ICP •Elevate Head end •Sedate •Maintain Pao2 100 mm Hg •Maintain PaCo2 27-30 mm Hg ICP still high Treat ICP Surgical Lesion → OT
- 26. AIIMS Trauma Workshop Monitor ICP ICP<20 ICP>20Check PaO2, PacO2 Head/ Neck position Treat pain, Fever Recalibrate ICP system Repeat CT Surgical Mass Lesion Craniotomy No Surgical mass lesion •Mannitol •Hyperventilate •Barbiturate Coma •DC •Lobectomy
- 27. AIIMS Trauma Workshop TRAUMA 2011 Spine Trauma ■ C. Spine- 55% ■ Thoracic spine- 15% ■ T.L.Junction- 15% ■ L.S. spine-15% ➢ 5% of head injury pt.have spine injury
- 28. AIIMS Trauma Workshop TRAUMA 2011 Exclusion ■ Awake: Simple N. intact,Absence of pain, tenderness along whole spine ■ Comatose: X-rays/ C.T. scan
- 29. AIIMS Trauma Workshop TRAUMA 2011 Goals ■ Maintain Immobilization ■ Avoid excessive manipulation ■ Minimize second injury/insult
- 30. AIIMS Trauma Workshop TRAUMA 2011 ASCI- Types ■ Complete: No motor/ sensory function below the level of injury ■ Incomplete:Any motor/sensory below the level- prognosis for recovery is better ■ Peri-anal sensation may be the only sign of incomplete SCI
- 31. AIIMS Trauma Workshop TRAUMA 2011 Neurogenic Shock ■ Loss of sympathetic outflow from S. cord ■ Loss of vasomotor tone & sympathetic supply to heart ■ Vasodilatation & pooling of blood- hypotension ■ Bradycardia- No H.R. in response to hypotension
- 32. AIIMS Trauma Workshop TRAUMA 2011 Neurogenic Shock ■ I.V. fluids alone may not help ■ Danger of fluid overload/P.Edema ■ Vasopressors / Atropine –significant Bradycardia
- 33. AIIMS Trauma Workshop TRAUMA 2011 Spinal Shock ■ Complete flaccidity & loss of reflexes ■ Gen. lasts 24- 48 hrs ■ Anal & bulbo-cavernosus –first to return
- 34. AIIMS Trauma Workshop TRAUMA 2011 Pitfalls ■ Never attribute neurological abnormality solely to the presence of alcohol / drugs. ■ Assume spinal Injury till ruled out ■ No naso-gastric / naso-tracheal tube if base skull # suspected ■ Treat other life threatening bleeding first ■ Systolic pressure < 90 mmHg will lead to secondary brain Injury ■ Poor Ventilation and Oxygenation will Increase
- 35. AIIMS Trauma Workshop TRAUMA 2011 Summary ■ Comatose patient- secure airway ■ Treat shock aggressively ■ Hypoxia and hypervolemia kill more patients than brain injury. ■ Secondary brain injury makes primary brain injury worse ■ If sedation or paralysis makes assessment difficult, then treat the patient until the brain can be assesed.
- 36. AIIMS Trauma Workshop TRAUMA 2011 Jai Prakash Narain Apex Trauma Center All India Institute of Medical Sciences