Saving Lives By Strengthening Our Regions Trauma Care System

December 5, 2013

KELLI CASPER, APNP

CASE STUDIES
IN NEURO
TRAUMA
GOALS
Brief anatomy review
Discuss important exam findings in brain and
spine trauma
Discuss key management principles in brain
and spine trauma
Case study of Epidural Hematoma
Case study of Diffuse Axonal Injury
Case study of Cervical Spinal Cord Injury
ANATOMY REVIEW
TRAUMATIC BRAIN INJURY
A traumatic brain injury occurs every 7
seconds and results in death every 5
minutes in the US
TBI accounts for 1/3 of all trauma related
deaths in the US
Annual cost of TBI medical care in the US
approximately $56 billion

(Heegaard & Biros, 2007)
MANY FLAVORS OF BLUNT TBI
Skull fractures
Brain contusions
Hematomas/Intracerebral hemorrhages
Epidural Hematoma
Subdural Hematoma
Traumatic SAH
Diffuse axonal injury
CATEGORIZING HEAD INJURY
Minimal: GCS= 15, No loss of consciousness, No amnesia

Mild: GCS= 14 OR GCS= 15 plus EITHER: Brief LOC < 5 min OR impaired alertness
or memory

Moderate: GCS 9-13 OR LOC > 5 min OR Focal neurologic deficit

Severe: GCS 5-8

Critical: GCS 3-4

(Greenberg, 2010)
TBI PATHOGENESIS
Primary injury: immediate impact injury
Secondary injury: ensuing neuropathologic processes after
initial injury

Our job in the hospital is to
intervene and disrupt these
processes and secondary
mechanisms
SECONDARY BRAIN INJURY
Amino acid and
cytokine
release
Free radicals
formed
Mitochondrial
damage
BBB damage
Altered CBF
Increased ICP
Brain damage/cell death
Functional deficits
INTERVENING FACTORS IN TBI
Hypoxia
Hypotension
Cerebral edema
Increased ICP
Reduced cerebral blood flow
Electrolyte imbalance
PRACTICE GUIDELINE DEFINITIONS
Level I: High degree of clinical certainty
Level A: Based on consistent Class I evidence (well-designed,
prospective randomized controlled studies)
Level B: Single Class I study or consistent class II evidence when
circumstances preclude clinical trials
Level II: Moderate degree of clinical certainty
Level C: Usually derived from Class II evidence (one or more well-
designed comparative clinical studies or less well-designed
randomized studies) or a preponderance of Class III evidence
Level III: Unclear clinical certainty
Level D: Generally based on Class III evidence (case series,
historical controls, case reports and expert opinion). Useful for
educational purposes and to guide future research
(Greenberg, 2010)
CASE STUDY #1
51 y/o male fell down a flight of cement stairs
after domestic altercation striking the left
temporal area. Lost consciousness for about 10
minutes.
By the time EMS arrived, the patient was fully
awake. He was brought to the ED for
evaluation. GCS 15 in ED. CT scan without
contrast of head showed a small left temporal
epidural hematoma and left temporal bone
fracture.




EPIDURAL VS SUBDURAL HEMATOMAS
Epidural
1% of head trauma
admissions
Arterial source (MMA)
(85% of cases)
Can expand rapidly
More often requires
surgical evacuation
Mortality 20-55%
Classic presentation
Subdural
Seen in 10-20% of head
trauma cases
Usually venous source of
bleeding (bridging veins)
Usually expand less rapidly
than EDH
More often has associated
underlying brain injury
(contusions, SAH)
Epidural: Usually produces more mass effect
Subudural: Usually more diffuse and concave
appearance
Small epidural hematoma (< 1 cm maximum thickness)
CASE STUDY #1
Patient was admitted to ICU for observation
EDH can rapidly expand
Moderate head injury
Neuro checks every hour
HOB elevated 40 degrees
NPO status
Seizure prophylaxis started
Temporal region associated w/higher seizure risk
Minimize sedation!
Avoid hypertension
UNFOLDING EVENTS
Overnight becoming increasingly agitated followed by
increasing somnolence and difficulty arousing
Thrashing of left extremities only
No longer following commands and not speaking
Left pupil 5mm and fixed, Right pupil 2mm, responsive to
light
Neurosurgeon being called
Patient declined rapidly, developing respiratory distress
Rapid response called and patient emergently intubated
OR was called for emergent craniotomy and evacuation of
hematoma.
DISCUSSION OF EVENTS

Agitation/Restlessness is often first sign of increasing
ICP
Somnolence and hemiparesis will follow as ICP
continues to rise
Pupil dilates (late sign)
TREATMENT COURSE

Surgical evacuation via Craniotomy with
evacuation of EDH
He eventually regained consciousness and
able to ambulate and use right hand
CASE STUDY #2

47 y/o male in MCA on highway, lost control,
no helmet, thrown from motorcycle.
Unresponsive at scene, CPR initiated
Intubated at scene, arrived to ED GCS 3,
chemically paralyzed and sedated.
Neuro exam very limited
DIFFUSE AXONAL INJURY
INITIAL PERTINENT CLINICAL INFORMATION
SBP on admit to ICU 140s. MAP 80s.
Pupils unequal, R= 4mm, reactive to 2mm,
L= 8mm, non-reactive to light.
Sodium: 141
H/H: 13.3/38.8
Platelet: 227,000
PCO2 = 37, PO2 = 129
INITIAL TREATMENT COURSE
Arterial line inserted. Central line inserted.
HOB elevated 40 degrees
Sedated with propofol / fentanyl drips
Loaded with Cerebyx (Fosphenytoin) 20 mg PE/kg, then
TID
ICP bolt placed by Neurosurgeon. Initial ICPs 7-9mm Hg.
CPP 60s
Mannitol 25 gm IV every 6 hours started
Stress ulcer prophylaxis, Protonix 40 mg IV daily
Bilateral SCDs placed for DVT prophylaxis
Serum electrolytes / osmolality q 6 hrs
DISCUSSION OF TREATMENT
ICP monitoring & goals
CPP monitoring & goals
Sedation goals
Mannitol treatment
3% saline treatment
DVT prophylaxis
Stress ulcer prophylaxis (SUP)
Nutrition goals
Refractory increased ICP
Barbituate coma
Decompressive Craniectomy
TYPES OF ICP MONITORING DEVICES
Goal ICP < 20
CEREBRAL PERFUSION PRESSURE

Importance of Cerebral Perfusion Pressure
CPP = Mean arterial pressure (-) Intracranial
pressure
Goal > 60 mm Hg, prefer > 70 mm HG
MANNITOL
(LEVEL II RECOMMENDATION FOR INTRACRANIAL HTN AFTER SEVERE TBI)
Pros
Increases cerebral
blood flow by its
plasma expansion and
osmotic effect
Reduces ICP within
minutes
Possible free radical
scavenging


(Greenberg, 2010)
Cons
Risk of acute renal
failure
Risk of hypotension
May draw more fluid
into CNS causing
worsening cerebral
edema
Electrolyte
disturbances due to
excessive urinary
output
HYPERTONIC SALINE
Pros
Effective at reducing
ICP through osmotic
effects similar to
Mannitol
Less risk of
hypovolemic
hypotension



(Greenberg, 2010)
Cons
May cause severe
hypernatremia
Electrolyte
disturbances
Not enough convincing
evidence to support
use over Mannitol
No changes in
neurologic outcome
over Mannitol

SUPPORTIVE CARE
Sedation / Pain management
Nutrition
Stress Ulcer prophylaxis
DVT prophylaxis
Skin care
Oral hygiene
CONTINUED HOSPITAL COURSE
IVC filter placed (DVT risk with ICH)
Percutaneous bedside tracheostomy placed, dobbhoff placed for
nutrition
Required a few days of Levophed for goal CPP > 60
ICPs remained relatively normal
Gradually began to open eyes, and although not commanding,
localized purposefully to stimulus
~ 12 days post-injury, nodding to questions, trying to mouth
words, began sitting on edge of bed
~ 18 days post-injury, speaking more sense, less agitation,
progressing in PT/OT/Speech, trach removed
Discharge to a brain rehab facility ~ 3 weeks post-injury
SPINAL CORD INJURY

12,000 new cases each year
Average age at time of injury ~ 40 years
77% of these are males
$4 Billion spent annually on acute and
chronic care of spinal cord injured patients

(Chittiboina, et al. 2012)
CAUSES OF SCI
Cause%
MVC's
Falls
Violence
Other/unknown
Sports
(Chittiboina, et al. 2012)
CASE STUDY #3

22 y/o male dove into shallow lake. Friends
pulled him out of water, patient unable to
move arms or legs. In ED, cervical CT scan
showed at C7 burst fracture.
CT CERVICAL SPINE
MRI CERVICAL SPINE
INITIAL NEUROLOGICAL EXAM
Alert and oriented with normal speech
CN II XII grossly intact
Motor exam showed preserved biceps 3+/5,
triceps 2/5 bilaterally, Hand intrinsics absent
on right side, subtle finger movement on left
side
No motor or sensory perception below C7
+ priapism
DISCUSSION


Level of Injury
Complete Injury vs Incomplete Injury
Spinal shock
LEVEL OF INJURY
Some use level of completely normal
function
Some use most caudal segment with motor
function at least 3/5
Know the major spinal nerve root motor
distribution
Know the major spinal nerve root sensory
dermatomes
MAJOR SPINAL NERVE ROOT MOTOR
DISTRIBUTIONS
Segment Muscle Action to Test
C1 C4 Neck muscles
C3, C4, C5 Diaphragm Inspiration/FEV1
C5, C6 Deltoid, Biceps Abduct arm, Elbow flexion
C6, C7 Extensor carpi radialis Wrist extension
C7, C8 Triceps, Extensor digitorum,
hand intrinsics
Elbow Extension, Finger
Extension
L2, L3 Iliopsoas Hip flexion
L3, L4 Quadriceps Knee extension
L4, L5 Medial hamstrings, tibialis
anterior
Ankle dorsiflexion
L5, S1 Lateral hamstrings, posterior
tibialis, extensor hallucis
longis
Foot inversion, great toe
extension, ankle
plantarflexion
MUSCLE STRENGTH
Grade Strength
0 No contraction
1 Flicker or trace contraction
2 Movement with gravity eliminated
3 Movement against gravity
4 Movement against resistance
4 slight resistance
4 moderate resistance
4+ strong resistance
5 Normal strength
SENSORY DERMATOMES
DISCUSSING SPECIAL REFLEXES IN SCI

Priapism
Cremasteric reflex
Anal cutaneous reflex (anal wink)
Bulbocavernous reflex
COMPLETE VS INCOMPLETE SCI
Incomplete lesion
Any residual motor or
sensory function more
than 3 segments below the
level of injury
Sensation or voluntary
movements in LEs
Preserved sensation
around anus, voluntary
rectal sphincter
contraction
Complete lesion
No preservation of any
motor and/or sensory
function more than 3
segments below the level
of injury
SPINAL SHOCK
Hypotension following spinal cord injury
Interruption of the sympathetics (implies
injury above T1)
Loss of vascular tone below level of injury
Leaves parasympathetics relatively unopposed causing a
relative bradycardia
Loss of muscle tone results in venous
pooling
Blood loss from other associated wounds
TREATMENT COURSE
Cervical immobilization with rigid collar initially
Methylprednisolone drip started per protocol
Placed in cervical tongs by Neurosurgeon in ICU
Central/Arterial lines placed
Levophed drip used in ICU for maintaining SBP > 90
SCDs for DVT prophylaxis
Foley catheter insertion
NPO
SUP: Protonix 40 mg IV daily
Anxiety & Pain control with small doses Ativan/Fentanyl as
needed
Pre-operative readiness for surgical stabilization
CERVICAL TRACTION
Level III recommendation
Purpose: to restore anatomic alignment
Complications:
Skull penetration of pins
Reduction of cervical dislocations may cause neurologic
deterioration (i.e. retropulsed disc)
Higher level injuries (C1-C3) need caution (fragments
pulled toward canal)
Infection (Osteomyelitis) good pin care is essential
SURGICAL STABILIZATION
HOSPITAL COURSE / OUTCOME

Early physical and occupational therapies
Improving left hand intrinsics by POD 2
Transferred to a Spinal Cord Rehab facility
by POD 3
STEROID PROTOCOL IN SCI
Still highly controversial
Considered Level III Recommendation
Asserted that beneficial (sensory & motor)
effects at 6 weeks, 6 months and 1 year are
seen for both complete and incomplete
injuries only if given within 8 hour of injury

(Greenberg, 2010)
STEROID PROTOCOL
Administration:
16 Gm/256 ml bacteriostatic water
30 mg/kg initial IV bolus over 15 minutes, followed by 45
minute pause, then maintenance drip at 5.4 mg/kg/hour x
23 or 47 hours**




(Greenberg, 2010)
DVT PROPHYLAXIS IN SCI
Level I
Recommendation
Level II
Recommendations
Level III
Recommendations
* LMW heparin, rotating bed,
adjusted dose heparin or
some combination of these
measures
* Low dose heparin +
pneumatic compression
stockings or electrical
stimulation
Not recommended: low-
dose heparin used alone
Not recommended: oral
anticoagulation alone
Duplex doppler
ultrasound, venography
are recommended as
diagnostic tests for DVT
in patients with SCI
Vena Cava interruption
filters for patients who do
not respond to or are not
candidates for
anticoagulation
*Titrate dose of SQ heparin q 12
hours to a PTT of 1.5 x control
*Heparin 5000 units q 12 hours
(Greenberg, 2010)
EVALUATING STABILITY
TYPES OF VERTEBRAL FRACTURES
BRACING OPTIONS
REFERENCES
Blumenfeld, H. Neuroanatomy through Clinical Cases. Sinauer
Associates, Inc., Sunderland, Massachusetts; 2002.
Fix, J.D. Neuroanatomy. Lippincott Williams & Wilkins, 3
rd

edition, 2002.
Greenberg, M.S. Handbook of Neurosurgery. Thieme Publishing,
7
th
edition, 2010.
Heegard, W. & Biros, M. (2007). Traumatic Brain Injury.
Emergency Medicine Clinics of North America, 25, 655-678.
Lindsay, K.W., Bone, I. & Callander, R. Neurology and
Neurosurgery Illustrated. Churchill Livingstone, 4
th
edition, 2004.
Ling, G. & Marshall, S. A. (2008). Management of Traumatic Brain
Injury in the Intensive Care Unit, Neurologic Clinics, 26, 409-426.
Chittibonia et al. (2012). Head and Spinal Cord Injury. Neurology
Clinics, 30 (1), 241-276.