Head InjuryHead InjuryManagementManagement

Man Bahadur PaudyalMan Bahadur Paudyal MBBS,TU Teaching Hospital MBBS,TU Teaching Hospital

Introduction to Head InjuryIntroduction to Head Injury Increase in injury morbidity and mortalityIncrease in injury morbidity and mortality

IndustrializationIndustrialization Increase RTAIncrease RTAProblemsProblems

lack of appropriate transportation & facilitieslack of appropriate transportation & facilitiesInsufficient trained manpowerInsufficient trained manpowerUnderdeveloped trauma care systemsUnderdeveloped trauma care systemsOverall poor infrastructureOverall poor infrastructure

INCIDENCE:INCIDENCE:132 ~ 430/100,000 per year132 ~ 430/100,000 per year

Classification of Head InjuryClassification of Head Injury ScalpScalp

HematomaHematoma LacerationLaceration AvulsionAvulsion Skull FractureSkull Fracture

LinearLinear DepressedDepressed CompoundCompound BasilarBasilar Brain InjuryBrain Injury

ContusionContusion LacerationLaceration PenetratingPenetrating Vascular InjuryVascular Injury

EDHEDH SDHSDH SAHSAHIVHIVH

PathophysiologyPathophysiologyBrain injuryBrain injury

PrimaryPrimary injury injury: : Direct impactDirect impactcontusion (coup, countercoup)contusion (coup, countercoup) lacerationlacerationShearing injuryShearing injury DAIDAISecondarySecondary insults insults: : Developing intracranial mass lesions Developing intracranial mass lesions hematoma(EDH, hematoma(EDH, SDH, ICH)SDH, ICH)cerebral edemacerebral edemaHypoxic-ischemic cerebral injuryHypoxic-ischemic cerebral injuryhypoxiahypoxia hypercarbiahypercarbia hypotensionhypotension acidosisacidosis pyrexiapyrexiahyponatremiahyponatremia vasospasmvasospasm seizureseizure

Degree of Head InjuryDegree of Head Injury

determined by GCS/ LOC@arrivaldetermined by GCS/ LOC@arrivalDegreeDegree GCSGCS LOCLOCMildMild 13 – 1513 – 15 Relatively Relatively

normalnormalModerateModerate 9 – 129 – 12 Altered LOCAltered LOCSevereSevere 3 – 83 – 8 ComatoseComatose

MONROE-KELLIE DOCTRINEMONROE-KELLIE DOCTRINE

Non-elastic, enclosed compartment (Skull)Non-elastic, enclosed compartment (Skull) Uniform pressure throughout cranial cavityUniform pressure throughout cranial cavity Sum of intracranial Volume of blood, brain Sum of intracranial Volume of blood, brain

& CSF & other (tumor, hematoma) is & CSF & other (tumor, hematoma) is constantconstant

Increase in one component must offset by Increase in one component must offset by equal decrease in other component or else equal decrease in other component or else pressure will risepressure will rise

Guideline: Management of Guideline: Management of Severe Head InjurySevere Head Injury

IntroductionIntroduction formulated by joint initiative of Brain Trauma formulated by joint initiative of Brain Trauma

Foundation, AANS and Joint Section on Foundation, AANS and Joint Section on Neurotrauma and Critical Care (1995)Neurotrauma and Critical Care (1995)

Degrees of Certainty:Degrees of Certainty: StandardsStandards: : Class I evidence (randomized)Class I evidence (randomized) GuidelinesGuidelines: : Class II evidence (prospective)Class II evidence (prospective) OptionsOptions: : Class III evidence (retrospective)Class III evidence (retrospective)

Integration of Brain-specific Treatments Integration of Brain-specific Treatments into the Initial Resuscitationinto the Initial Resuscitation

OptionsOptions:: When signs of transtentorial herniation or progressive When signs of transtentorial herniation or progressive

neurologic deterioration not attributable to neurologic deterioration not attributable to extracranial explanations are present, it should be extracranial explanations are present, it should be assumed that intracranial hypertension is present and assumed that intracranial hypertension is present and it should be treated aggressively; including it should be treated aggressively; including hyperventilation, mannitol and adequate volume hyperventilation, mannitol and adequate volume resuscitation. Sedation & neuromuscular blockade resuscitation. Sedation & neuromuscular blockade can be useful when transportation.can be useful when transportation.

Resuscitation of Blood Pressure Resuscitation of Blood Pressure and Oxygenationand Oxygenation

GuidelinesGuidelines:: HypotensionHypotension (SBP<90mmHg) or (SBP<90mmHg) or hypoxiahypoxia (apnea, (apnea,

cyanosis or PO2<60mmHg) should be cyanosis or PO2<60mmHg) should be avoidedavoided.. OptionsOptions:: MAPMAP should be should be maintained >90mmHgmaintained >90mmHg throughout throughout

treatment to treatment to maintainmaintain CPP >70mmHgCPP >70mmHg  

Intracranial Pressure (ICP) MonitoringIntracranial Pressure (ICP) MonitoringIndications Indications GuidelinesGuidelines:: 1.  1.  Severe head injurySevere head injury with with abnormal CT-scanabnormal CT-scan on admission. on admission. Severe head injury is defined as Severe head injury is defined as GCS of 3-8 after CPRGCS of 3-8 after CPR. . Abnormal CT means with hematoma, contusion, edema, compressed cisterns.Abnormal CT means with hematoma, contusion, edema, compressed cisterns. 2.  2.  Severe head injurySevere head injury with with normal CTnormal CT if two or more of the following if two or more of the following

features features are noted at admission: age> are noted at admission: age> 40 yrs40 yrs, uni/bilateral , uni/bilateral posturingposturing, , SBP<90mmHgSBP<90mmHg.. 3.  3.  Not routinely indicatedNot routinely indicated in mild or moderate head injury. in mild or moderate head injury.

ICP Treatment ThresholdICP Treatment ThresholdGuidelinesGuidelines::

ICP treatmentICP treatment should be initiated at upper should be initiated at upper threshold of threshold of 20-25mmHg20-25mmHg..

Recommendation for ICP MonitorRecommendation for ICP Monitor

Ventricular catheterVentricular catheter connected to an external connected to an external drainage (EVD)is the drainage (EVD)is the most most accurateaccurate, low cost and reliable, low cost and reliable

Other methods: Other methods: Parenchymal ICP monitor (fiberoptic)Parenchymal ICP monitor (fiberoptic) Subarachnoid, subdural, epidural monitors: less accurateSubarachnoid, subdural, epidural monitors: less accurate

HyperventilationHyperventilationStandardsStandards

Chronic Chronic prolonged hyperventilationprolonged hyperventilation therapy (PCO2<25 mmHg) therapy (PCO2<25 mmHg) should be should be avoidedavoided in absence of in absence of ICPICP

GuidelinesGuidelines

Use of Use of prophylactic hyperventilation prophylactic hyperventilation (PCO2<35 mmHg) should be (PCO2<35 mmHg) should be avoidedavoided..

OptionsOptions::

Hyperventilation therapy may be necessary for Hyperventilation therapy may be necessary for brief periodsbrief periods when when there is there is acute neurologic deteriorationacute neurologic deterioration, or for , or for longer periodslonger periods if if there is there is intracranial hypertension refractoryintracranial hypertension refractory to sedation, paralysis, to sedation, paralysis, CSF drainage and osmotic diuretics.CSF drainage and osmotic diuretics.

Jugular venous oxygen saturation (SjO2), arterial-jugular venous Jugular venous oxygen saturation (SjO2), arterial-jugular venous oxygen content differences (AVdO2) and CBF monitoring maybe oxygen content differences (AVdO2) and CBF monitoring maybe helpful when PCO2<30mmHg.helpful when PCO2<30mmHg.

Cerebral Perfusion Pressure (CPP)Cerebral Perfusion Pressure (CPP)

OptionsOptions

CPPCPP should be should be maintained at minimum of 70 maintained at minimum of 70 mmHgmmHg..

Critical parameter for brain function & survival Critical parameter for brain function & survival CBF depends on CPPCBF depends on CPP CPP = MAP – ICPCPP = MAP – ICP In TBI, recommended CPP In TBI, recommended CPP 70 mmHg 70 mmHg

Use of SteroidsUse of Steroids StandardsStandards

NNot recommendedot recommended for improving outcome or for improving outcome or ICP. ICP.

No known beneficial role.No known beneficial role.

  

Use of MannitolUse of Mannitol Hyperosmolar TherapyHyperosmolar Therapy

GuidelinesGuidelines Effective for control of raised ICPEffective for control of raised ICP after severe HI. after severe HI. Intermittent boluses Intermittent boluses more effective than continuous infusion.more effective than continuous infusion. Effective doses:Effective doses: 0.25g ~ 1 ~1.5 g/Kg0.25g ~ 1 ~1.5 g/Kg.. OptionsOptions

Indications for its use prior to ICP monitoring are signs of Indications for its use prior to ICP monitoring are signs of transtentorial herniation or progressive neurological deterioration not transtentorial herniation or progressive neurological deterioration not attributable to systemic pathology.attributable to systemic pathology.

Serum osmolalitySerum osmolality should be kept should be kept below 320 mOsmbelow 320 mOsm.. EuvolemiaEuvolemia should be maintained by fluid replacement. should be maintained by fluid replacement. Foley catheter should be inserted.Foley catheter should be inserted.

Use of BarbituratesUse of Barbiturates

GuidelinesGuidelinesHigh-dose barbiturate maybe considered in High-dose barbiturate maybe considered in hemodynamically hemodynamically stablestable salvageable severe head injury patients with salvageable severe head injury patients with intracranial hypertension refractory intracranial hypertension refractory to maximal medical to maximal medical and surgical ICP lowering therapy.and surgical ICP lowering therapy.

Barbiturate ComaBarbiturate ComaIndicationsIndications: otherwise intractable intracranial hypertension: otherwise intractable intracranial hypertension

Barbiturates Barbiturates functionsfunctions: : ICP by ICP by cerebral metabolism cerebral metabolism

O2 use & blood flowO2 use & blood flow

Nutritional Support Nutritional Support GuidelinesGuidelines

Replace Replace 140% of BMR140% of BMR in in non-paralyzed non-paralyzed patientspatients 100% of BMR100% of BMR in in paralyzed paralyzed patients(15% of cal as patients(15% of cal as

protein)protein)

OptionsOptions Use of feeding via Use of feeding via gastrojejunostomygastrojejunostomy is preferable. is preferable.

Prophylactic Use of Anti-Epileptic DrugsProphylactic Use of Anti-Epileptic Drugs

StandardsStandards Prophylactic use Prophylactic use of AED is of AED is not recommendenot recommended for d for prevention of late posttraumatic seizures (PTS).prevention of late posttraumatic seizures (PTS).

It isIt is recommended recommended as optional treatment to as optional treatment to prevent early prevent early PTSPTS in patients at high risk for seizures following head injury. in patients at high risk for seizures following head injury.

IIndicationsndicationsAll pts with clinically severe head injury and those All pts with clinically severe head injury and those predisposed to early epilepsy with Phenytoin for at lest 7 days.predisposed to early epilepsy with Phenytoin for at lest 7 days.

DosagesDosagesPhenytoin: 15 ~ 18 mg/Kg (loading)Phenytoin: 15 ~ 18 mg/Kg (loading) 5 mg/Kg/day 5 mg/Kg/day

Management of InfectionsManagement of Infections No antibiotic for basilar skull fx No antibiotic for basilar skull fx CSF leak CSF leak Perioperative prophylactic IV antibiotic; Perioperative prophylactic IV antibiotic; single dose I hr prior to cranial surgery & 2 doses single dose I hr prior to cranial surgery & 2 doses

postoperative.postoperative. If drain is present continue until drain is removed.If drain is present continue until drain is removed.

Metabolic CareMetabolic Care

SIADHSIADH

Fluid Restriction Fluid Restriction 1L/day1L/day

High Salt diet/ 3% NaClHigh Salt diet/ 3% NaCl HyperglycemiaHyperglycemia

BS> 200mg/dl treated with InsulinBS> 200mg/dl treated with Insulin

Summary of Head Injury Summary of Head Injury ManagementManagement

Avoid Hypotension & HypoxiaAvoid Hypotension & HypoxiaMaintain MAP > 90 mmHgMaintain MAP > 90 mmHgMaintain CPP .> 70 mmHgMaintain CPP .> 70 mmHgICP Monitoring: IVC (best)ICP Monitoring: IVC (best)No benefit with use of steroidsNo benefit with use of steroidsAvoid prophylactic use of Anti-convulsivesAvoid prophylactic use of Anti-convulsivesAvoid prolong/prophylac hyperventilationAvoid prolong/prophylac hyperventilationMannitol: effective in control of IC-HTNMannitol: effective in control of IC-HTN

Intermittent bolus Intermittent bolus Euvolemic Euvolemic Avoid hyperosmolalityAvoid hyperosmolality

Protocol for Management IC-HTN in Head Protocol for Management IC-HTN in Head Injury at TUTHInjury at TUTH

General MeasuresGeneral Measures Elevate HOB Elevate HOB 30 30 Midline head positionMidline head position Avoid hypotension Avoid hypotension Use pressors if reqdUse pressors if reqd Maintain euvolemiaMaintain euvolemia Control severe HTN Control severe HTN Mild sedationMild sedation NormoventilationNormoventilation Avoid prophylactic HyperventilationAvoid prophylactic Hyperventilation Intubation if GCS < 8 or with resp distressIntubation if GCS < 8 or with resp distress

Protocol (cont’d)Protocol (cont’d)First Line TherapyFirst Line Therapy

Heavy sedationHeavy sedationMannitolMannitolMild HyperventilationMild HyperventilationCSF DrainageCSF Drainage

Second Line TherapySecond Line TherapyHypothermiaHypothermiaModerate HyperventilationModerate HyperventilationHigh-dose BarbiturateHigh-dose BarbiturateDecompressive craniectomyDecompressive craniectomy

Management of Increased ICPManagement of Increased ICP Controlled hyperventilationControlled hyperventilation Mannitol 0.25 – 0.5g/Kg IV bolusesMannitol 0.25 – 0.5g/Kg IV boluses Furosemide (Lasix)Furosemide (Lasix) Elevation of CPPElevation of CPP Head of bed elevated @ 30Head of bed elevated @ 30 Sedation for restlessnessSedation for restlessness Paralytics for severe agitationParalytics for severe agitation BarbituratesBarbiturates

Level of consciousnessLevel of consciousness I Alert (aware os surrounding)I Alert (aware os surrounding) II Awake (well-oriented but not aware of II Awake (well-oriented but not aware of

surrounding)surrounding) III Lethargic (can converse, drowsy)III Lethargic (can converse, drowsy) IV Stuporous (drowsy, can’t converse, only IV Stuporous (drowsy, can’t converse, only

moans and groans, echolalia)moans and groans, echolalia) V Semi-comatose (if painful simulus given, will V Semi-comatose (if painful simulus given, will

respond)respond) VI ComatoseVI Comatose

Coma: three stages Coma: three stages Decorticate: no cortical activityDecorticate: no cortical activity

internally rotated flexed hands legs in response internally rotated flexed hands legs in response to painful stimulusto painful stimulus

Decerebrate: hand extended, internally rotated, Decerebrate: hand extended, internally rotated, and leg extended in response to painand leg extended in response to pain

Non-responsive: No response to painNon-responsive: No response to pain

Linear Skull Fracture (Pingpong)

Preope CT

Linear (Stellate) Skull Fracture

Compound Depressed Skull Fracture

Epidural Hematoma

FrontalPosterior Fossa

Preope Postope

Epidural Hematoma

Gun Shot Wound

PostoperativePostoperative Preope CT

Skull X-ray

Preope CT(Bone Window)

Preperative Postoperative

Gund Shot WoundIntraoperative View

Bullet Bone Fragments

Before Cranioplasty After Cranioplasty Pericranial flap

Penetrating Brain Injury (Sharp Glass)

Cerebral Contusion

Preope CT Postope CT

Scalp Laceration

Skull Fracture

Tension Pneumocephalus

Cerebellar Contusion Transverse Sinus Laceration

Preope CT