Head Injury

Anthony G. Hillier, D.O. St. John West Shore Emergency Medicine Resident

Head Injury-Epidemiology
1.5 million Non-fatal TBIs 370,000 Hospitalizations 80,000 cases of neurological sequela 52,000 Die from TBIs 4 billion annually for cost of treatment Peak incidence:
Males age 15-24 years

Causes of TBI
Young: GSW Old: Falls

Head Injury-Anatomy
Scalp Blood supply Calvaria Brain
Occupies 80% of calvarium

Head Injury-Pathophysiology
Primary injury
Irreversible cellular injury as a direct result of the injury Prevent the event

Secondary injury
Damage to cells that are not initially injured Occurs hours to weeks after injury Prevent hypoxia and ischemia

Head Injury-Normal Physiology

Brain consumes 20% of total O2 Receives 15% of Cardiac Output Brain tissue perfusion CPP versus CBF
CPP=MAP-ICP
MAP=(SBP-DBP/3) + DBP
ICP=IVM

Autoregulation
50-150 mm Hg

ICP

Head Injury-Initial Evaluation and Management

Prevent Secondary Brain Injury
Hypoxemia Hypotension Anemia
Hyperglycemia Evacuation of mass

Airway control with cervical spine immobilization

Orotracheal Rapid Sequence Intubation
Goal is to RSI to blunt rise in ICP and maintain adequate MAP Pretreatment-Lidocaine 1.5 mg/kg, Vecuronium 0.01 mg/kg Induction-Etomidate 0.3 mg/kg, Fentanyl 3-5 mcg/kg, Thiopental 3-5 mg/kg, Propofol 1-4 mg/kg Paralysis-Succinylcholine 1.5 mg/kg

Head Injury-Initial Evaluation and Management

Circulation
Maintain MAP at 90 mm Hg Aggressive fluid resuscitation
Does not increase ICP

Vasopressors if crystalloids inadequate Transfuse if hypotensive and Hct <30 Hypertension-Assume Cushing Reflex
If ICP is normal, gradually reduce MAP no more than 30%

Spectrum of Traumatic Brain Injury

Mild TBI
GCS 14-15 80% of all TBI Low Risk
GCS 15 and no LOC, amnesia, vomiting or diffuse HA Less than 0.1% risk of hematoma requiring evacuation

Medium Risk
GCS 15 and LOC, amnesia, vomiting or Diffuse HA 1-3% risk of hematoma requiring evacuation CT should be done in medium risk mild TBI

Spectrum of Traumatic Brain Injury

Mild TBI
High Risk
GCS 14-15 Neurologic deficits Up to 10% risk of hematoma requiring evacuation Anyone with coagulopathy, drug/alcohol consumption, epilepsy, age >60 and previous neurosurgery

Disposition
No CT indicated or negative CT with GCS 15-Home GCS 14 and negative CT-Observation admit

Spectrum of Traumatic Brain Injury

Moderate TBI
GCS 9-13 10% of all TBI <20% mortality 50% morbidity 40% positive CT 8% NS intervention <10 make moderate recovery

Severe TBI
GCS <9 10% of all TBI 40% mortality

Intracerebral Pressure
Normal <15 mm Hg ICP >20-25 mm Hg
Increases morbidity and mortality

ICP monitoring rarely available in the ED Must use physical findings

Neurologic deterioration Unilaterally dilated pupil Hemiparesis Posturing

Increased ICP-Management
Hypertonic Saline
Improves CPP and brain tissue O2 levels Decreased ICP by 35% (8-10 mm HG) CPP increased by 14% MAP remained stable Greatest benefit in those with higher ICP and lower CPP Repeated doses were not associated with rebound, hypovolemia or HTN 30 mL of 23.4% over 15 minutes
A. Defillo, Hennepin County Medical Center

Increased ICP-Management
Mannitol
Osmotic agent Effects ICP, CBF, CPP and brain metabolism Free radical scavenger Reduces ICP within 30 minutes, last 6-8 hours Volume expansion, reduces hypotension Dosage
0.25-1 gm/kg bolus

Increased ICP-Management
Hyperventilation
Not recommended as prophylactic intervention Never lower than 25 mm Hg Reduces ICP by vasoconstriction, may lead to cerebral ischemia Used as a last resort measure Maintain PaCO2 at 30-35 mm Hg

Increased ICP-Management
Barbiturate Coma
Not indicated in the ED Lowers ICP, cerebral metabolic O2 demand

Anticonvulsants
Reduce occurrence of post-traumatic seizures No improvement in long-term outcome

ICP Monitoring
Should be performed on TBI with GCS <9 Increased ICP may be managed by drainage

Specific Head Injuries

Scalp Lacerations
May lead to massive blood loss Small galeal lacerations may be left alone

Skull Fracture
Linear and simple comminuted skull fractures
Exploration of wound Prophylactic antibiotics are controversial Occipital fractures have a high incidence of other injury If depressed beyond outer table-requires NS repair

Specific Head Injuries

Skull Fractures
Basilar Fracture
Most common-petrous portion of temporal bone, the EAC and TM Dural tear
CSF otorrhea CSF rhinorrhea Battle Sign Raccoon Sign Hemotympanum Vertigo Hearing loss Seventh nerve palsy

CSF testing
Ring sign, glucose or CSF transferrin

Should be started on prophylactic antibiotics

Ceftriaxone 1-2 gm

The Ring Sign

Ann Emerg Med. 1993 Apr;22(4):718-20. The 'ring sign': is it a reliable indicator for cerebral spinal fluid? Dula DJ, Fales W. Department of Emergency Medicine, Geisinger Medical Center, Danville, Pennsylvania. STUDY OBJECTIVE: To study the development of a ring sign when blood is mixed with various fluids. METHODS: One drop of blood and one drop of either spinal fluid, saline, tap water, or rhinorrhea fluid were placed simultaneously on filter paper, and the specimens were examined after ten minutes for the development of a ring. A variety of filter paper agents were used, including standard laboratory filter paper, paper towels, coffee filters, and bed linens. RESULTS: All fluids, when mixed with blood, gave rise to a ring sign; blood alone did not. The type of filter paper did not affect the development of a ring. CONCLUSION: In this experimental setting, the ring or halo sign is reliable for detecting cerebrospinal fluids but is not exclusive for cerebrospinal fluid.

Specific Head Injuries

Brain Herniation
Four Types
Uncal Transtentorial Central Transtentorial Cerebellotonsillar Upward Posterior Fossa

Case 1

Specific Head Injuries

Traumatic Subarachnoid Hemorrhage
Most common CT finding in moderate to severe TBI If isolated head injury, may present with headache, photophobia and meningismus Early tSAH development triples mortality Size of bleed and outcome Timing of CT Nimodipine reduces death and disability by 55%

Case 2

Specific Head Injuries

Epidural Hematoma
Occurs in 0.5% of all head injuries Blunt trauma to temporoparietal region Eighty percent with associated skull fracture May occur with venous sinus tears Classic presentation only 30% of the time

Specific Head Injuries

Subdural Hematoma
Sudden acceleration-deceleration injury with tearing of bridging veins Common in elderly and alcoholics Classified as acute, subacute or chronic
Acute <2 weeks Chronic >2 weeks

Specific Head Injuries

Diffuse Axonal Injury
Disruption of axons in white matter and brainstem Injury occurs immediately and is irreversible Seen after MVC or shaken baby syndrome Usually have persistent vegetative state CT usually normal MRI with multiple, diffuse abnormalities

Specific Head Injuries

Penetrating Injury
Gunshot Wounds
Injury due to direct brain injury and cavitary effects GCS predicts prognosis
GCS >8 and reactive pupils = 25% mortality GCS <5 = nears 100% mortality

Stab wounds

Complications-Long Term Sequela

Seizure Disorder
2% Early post-traumatic incidence Increased to 30% in children, alcoholics and with intracranial hematoma
Prophylactic antiepileptics reduce early occurrence Use not supported by the literature

Concussion
- Brief LOC
- Dizziness - Photophobia - Vertigo - Nausea - Headache - Vomiting - Cognitive/Memory dysfunction

Complications-Long Term Sequela

Concussion
Up to 80% may have symptoms at 3 months 15% may have symptoms at 1 year Persistence of these symptoms is termed Postconcussive Syndrome 85-90% recover after 1 year Risk factors:
- Female - Litigation - Low socioeconomic status

Complications-Long Term Sequela

Infection
Skull fracture CSF leak Intubation History of Fracture
Fever Signs of meningitis
3rd generation cephalosporin Vancomycin

ICU Treatment
Prophylactic antibiotics

Questions?

Lecture Questions
1. Which of the following modalities is not recommended for head injured patients with elevated ICP?
a. b. c. d. e. Hypertonic saline Hyperventilation to CO2 of <30 mm Hg Mannitol ICP monitoring Barbiturate coma

2. Which of the following are true regarding TBI?

a. Post-concussive symptoms are common b. It is expensive to society c. Preventing secondary brain injury is critical in the management d. All of the above are correct

3. Epidural hematomas are associated with all of the following except:

a. b. c. d. e. Trauma to the temporoparietal region Extremes of age Have classic presentation only 30% of the time Damage to the middle meningeal artery Damage to a venous sinus

4. Traumatic subarachnoid hemorrhage has all the following features except:

a. Has a higher mortality than an equal aneurysmal SAH b. Mortality is reduced with nimodipine c. Surgical drainage is usually unnecessary d. Most common CT finding in TBI e. Size of bleed is unrelated to mortality

5. Concerning basilar skull fractures which of the following is not true?

a. The ring sign is both sensitive and specific for CSF otorrhea/rhinorrhea b. The only physical exam finding may be a hemotympanum c. Battle and Raccoon signs are usually not initially present in the ED d. Most commonly occurs in the temporal bone
b, d, b, e, a