Head InjuryHead Injury

Anthony G. Hillier, D.O.Anthony G. Hillier, D.O.

St. John West ShoreSt. John West Shore

Emergency Medicine ResidentEmergency Medicine Resident

Head Injury-EpidemiologyHead Injury-Epidemiology

1.5 million Non-fatal TBI’s1.5 million Non-fatal TBI’s 370,000 Hospitalizations370,000 Hospitalizations 80,000 cases of neurological sequela80,000 cases of neurological sequela 52,000 Die from TBI’s52,000 Die from TBI’s 4 billion annually for cost of treatment4 billion annually for cost of treatment Peak incidence: Peak incidence:

– Males age 15-24 yearsMales age 15-24 years Causes of TBICauses of TBI

– Young: GSWYoung: GSW– Old: Falls Old: Falls

Head Injury-AnatomyHead Injury-Anatomy

ScalpScalp Blood supplyBlood supply CalvariaCalvaria BrainBrain

– Occupies 80% of Occupies 80% of calvariumcalvarium

Head Injury-PathophysiologyHead Injury-Pathophysiology

Primary injuryPrimary injury– Irreversible cellular injury as a direct result of Irreversible cellular injury as a direct result of

the injurythe injury– Prevent the event Prevent the event

Secondary injurySecondary injury– Damage to cells that are not initially injuredDamage to cells that are not initially injured– Occurs hours to weeks after injuryOccurs hours to weeks after injury– Prevent hypoxia and ischemiaPrevent hypoxia and ischemia

Head Injury-Normal PhysiologyHead Injury-Normal Physiology

Brain consumes 20% of total OBrain consumes 20% of total O22 Receives 15% of Cardiac OutputReceives 15% of Cardiac Output Brain tissue perfusionBrain tissue perfusion CPP versus CBFCPP versus CBF

– CPP=MAP-ICPCPP=MAP-ICP MAP=(SBP-DBP/3) + DBPMAP=(SBP-DBP/3) + DBP

– ICP=IVMICP=IVM

AutoregulationAutoregulation– 50-150 mm Hg50-150 mm Hg

ICP

Head Injury-Initial Evaluation Head Injury-Initial Evaluation and Managementand Management

Prevent Secondary Brain InjuryPrevent Secondary Brain Injury– HypoxemiaHypoxemia– HypotensionHypotension– AnemiaAnemia

Airway control with cervical spine immobilizationAirway control with cervical spine immobilization– Orotracheal Rapid Sequence IntubationOrotracheal Rapid Sequence Intubation

Goal is to RSI to blunt rise in ICP and maintain adequate MAPGoal is to RSI to blunt rise in ICP and maintain adequate MAP Pretreatment-Lidocaine 1.5 mg/kg, Vecuronium 0.01 mg/kg Pretreatment-Lidocaine 1.5 mg/kg, Vecuronium 0.01 mg/kg Induction-Etomidate 0.3 mg/kg, Fentanyl 3-5 mcg/kg, Induction-Etomidate 0.3 mg/kg, Fentanyl 3-5 mcg/kg,

Thiopental 3-5 mg/kg, Propofol 1-4 mg/kgThiopental 3-5 mg/kg, Propofol 1-4 mg/kg Paralysis-Succinylcholine 1.5 mg/kgParalysis-Succinylcholine 1.5 mg/kg

– HyperglycemiaHyperglycemia– Evacuation of massEvacuation of mass

Head Injury-Initial Evaluation Head Injury-Initial Evaluation and Managementand Management

CirculationCirculation– Maintain MAP at 90 mm HgMaintain MAP at 90 mm Hg– Aggressive fluid resuscitationAggressive fluid resuscitation

Does not increase ICPDoes not increase ICP

– Vasopressors if crystalloids inadequateVasopressors if crystalloids inadequate– Transfuse if hypotensive and Hct <30Transfuse if hypotensive and Hct <30– Hypertension-Assume Cushing ReflexHypertension-Assume Cushing Reflex

If ICP is normal, gradually reduce MAP no more than If ICP is normal, gradually reduce MAP no more than 30%30%

Spectrum of Traumatic Brain InjurySpectrum of Traumatic Brain Injury

Mild TBIMild TBI– GCS 14-15GCS 14-15– 80% of all TBI80% of all TBI– Low RiskLow Risk

GCS 15 and no LOC, amnesia, vomiting or diffuse HAGCS 15 and no LOC, amnesia, vomiting or diffuse HA Less than 0.1% risk of hematoma requiring evacuationLess than 0.1% risk of hematoma requiring evacuation

– Medium RiskMedium Risk GCS 15 and LOC, amnesia, vomiting or Diffuse HAGCS 15 and LOC, amnesia, vomiting or Diffuse HA 1-3% risk of hematoma requiring evacuation1-3% risk of hematoma requiring evacuation CT should be done in medium risk mild TBICT should be done in medium risk mild TBI

Spectrum of Traumatic Brain InjurySpectrum of Traumatic Brain Injury

Mild TBIMild TBI– High RiskHigh Risk

GCS 14-15GCS 14-15 Neurologic deficitsNeurologic deficits Up to 10% risk of hematoma requiring evacuationUp to 10% risk of hematoma requiring evacuation Anyone with coagulopathy, drug/alcohol consumption, Anyone with coagulopathy, drug/alcohol consumption,

epilepsy, age >60 and previous neurosurgeryepilepsy, age >60 and previous neurosurgery

– DispositionDisposition No CT indicated or negative CT with GCS 15-HomeNo CT indicated or negative CT with GCS 15-Home GCS 14 and negative CT-Observation admitGCS 14 and negative CT-Observation admit

Spectrum of Traumatic Brain InjurySpectrum of Traumatic Brain Injury

Moderate TBIModerate TBI – GCS 9-13GCS 9-13– 10% of all TBI10% of all TBI– <20% mortality<20% mortality

Severe TBISevere TBI– GCS <9GCS <9– 10% of all TBI10% of all TBI– 40% mortality40% mortality

– 50% morbidity50% morbidity– 40% positive CT40% positive CT– 8% NS intervention8% NS intervention

– <10 make moderate <10 make moderate recoveryrecovery

Intracerebral PressureIntracerebral Pressure

Normal <15 mm HgNormal <15 mm Hg ICP >20-25 mm Hg ICP >20-25 mm Hg

– Increases morbidity and mortalityIncreases morbidity and mortality

ICP monitoring rarely available in the EDICP monitoring rarely available in the ED Must use physical findingsMust use physical findings

– Neurologic deteriorationNeurologic deterioration– Unilaterally dilated pupilUnilaterally dilated pupil

– HemiparesisHemiparesis– PosturingPosturing

A. Defillo, Hennepin County MedicalA. Defillo, Hennepin County Medical Center Center

Increased ICP-ManagementIncreased ICP-Management Hypertonic SalineHypertonic Saline

– Improves CPP and brain tissue OImproves CPP and brain tissue O22 levels levels

– Decreased ICP by 35% (8-10 mm HG)Decreased ICP by 35% (8-10 mm HG)– CPP increased by 14%CPP increased by 14%– MAP remained stableMAP remained stable– Greatest benefit in those with higher ICP and Greatest benefit in those with higher ICP and

lower CPPlower CPP– Repeated doses were not associated with Repeated doses were not associated with

rebound, hypovolemia or HTNrebound, hypovolemia or HTN– 30 mL of 23.4% over 15 minutes30 mL of 23.4% over 15 minutes

Increased ICP-ManagementIncreased ICP-Management

MannitolMannitol– Osmotic agentOsmotic agent– Effects ICP, CBF, CPP and brain metabolismEffects ICP, CBF, CPP and brain metabolism– Free radical scavengerFree radical scavenger– Reduces ICP within 30 minutes, last 6-8 hoursReduces ICP within 30 minutes, last 6-8 hours– Volume expansion, reduces hypotensionVolume expansion, reduces hypotension– DosageDosage

0.25-1 gm/kg bolus0.25-1 gm/kg bolus

Increased ICP-ManagementIncreased ICP-Management

HyperventilationHyperventilation– Not recommended as prophylactic interventionNot recommended as prophylactic intervention– Never lower than 25 mm HgNever lower than 25 mm Hg– Reduces ICP by vasoconstriction, may lead to Reduces ICP by vasoconstriction, may lead to

cerebral ischemiacerebral ischemia– Used as a last resort measureUsed as a last resort measure

– Maintain PaCOMaintain PaCO22 at 30-35 mm Hg at 30-35 mm Hg

Increased ICP-ManagementIncreased ICP-Management

Barbiturate ComaBarbiturate Coma– Not indicated in the EDNot indicated in the ED

– Lowers ICP, cerebral metabolic OLowers ICP, cerebral metabolic O22 demand demand

AnticonvulsantsAnticonvulsants– Reduce occurrence of post-traumatic seizuresReduce occurrence of post-traumatic seizures– No improvement in long-term outcomeNo improvement in long-term outcome

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

Specific Head InjuriesSpecific Head Injuries

Scalp LacerationsScalp Lacerations– May lead to massive blood lossMay lead to massive blood loss– Small galeal lacerations may be left aloneSmall galeal lacerations may be left alone

Skull FractureSkull Fracture– Linear and simple comminuted skull fracturesLinear and simple comminuted skull fractures

Exploration of woundExploration of wound Prophylactic antibiotics are controversialProphylactic antibiotics are controversial Occipital fractures have a high incidence of other Occipital fractures have a high incidence of other

injuryinjury If depressed beyond outer table-requires NS repairIf depressed beyond outer table-requires NS repair

Specific Head InjuriesSpecific Head Injuries Skull FracturesSkull Fractures

– Basilar FractureBasilar Fracture Most common-petrous portion of temporal bone, Most common-petrous portion of temporal bone,

the EAC and TMthe EAC and TM Dural tearDural tear

– CSF otorrheaCSF otorrhea– CSF rhinorrheaCSF rhinorrhea– Battle SignBattle Sign– Raccoon SignRaccoon Sign

CSF testingCSF testing– Ring sign, glucose or CSF transferrinRing sign, glucose or CSF transferrin

Should be started on prophylactic antibioticsShould be started on prophylactic antibiotics– Ceftriaxone 1-2 gmCeftriaxone 1-2 gm

– HemotympanumHemotympanum– VertigoVertigo– Hearing lossHearing loss– Seventh nerve palsySeventh nerve palsy

The Ring SignThe Ring Sign Ann Emerg Med. 1993 Apr;22(4):718-20.Ann Emerg Med. 1993 Apr;22(4):718-20.   

The 'ring sign': is it a reliable indicator for cerebral spinal fluid?The 'ring sign': is it a reliable indicator for cerebral spinal fluid?

Dula DJDula DJ, , Fales WFales W..

Department of Emergency Medicine, Geisinger Medical Center, Department of Emergency Medicine, Geisinger Medical Center, Danville, Pennsylvania.Danville, Pennsylvania.

STUDY OBJECTIVE: To study the development of a ring sign when STUDY OBJECTIVE: To study the development of a ring sign when blood is mixed with various fluids. METHODS: blood is mixed with various fluids. METHODS: One drop of blood and One drop of blood and one drop of either spinal fluid, saline, tap water, or one drop of either spinal fluid, saline, tap water, or rhinorrhearhinorrhea fluid fluid were placed simultaneously on filter paper, and the specimens were were placed simultaneously on filter paper, and the specimens were examined after ten minutes for the development of a ring. A variety of examined after ten minutes for the development of a ring. A variety of filter paper agents were used, including standard laboratory filter filter paper agents were used, including standard laboratory filter paper, paper towels, coffee filters, and bed linens. RESULTS: paper, paper towels, coffee filters, and bed linens. RESULTS: All fluids, All fluids, when mixed with blood, gave rise to a ring signwhen mixed with blood, gave rise to a ring sign; blood alone did not. ; blood alone did not. The type of filter paper did not affect the development of a ring. The type of filter paper did not affect the development of a ring. CONCLUSION: CONCLUSION: In this experimental setting, the ring or halo sign is In this experimental setting, the ring or halo sign is reliable for detecting cerebrospinal fluids but is not exclusive for reliable for detecting cerebrospinal fluids but is not exclusive for cerebrospinal fluid.cerebrospinal fluid.

Specific Head InjuriesSpecific Head Injuries

Brain HerniationBrain Herniation– Four TypesFour Types

Uncal TranstentorialUncal Transtentorial Central TranstentorialCentral Transtentorial CerebellotonsillarCerebellotonsillar Upward Posterior Upward Posterior

FossaFossa

Case 1Case 1

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Specific Head InjuriesSpecific Head Injuries

Traumatic Subarachnoid HemorrhageTraumatic Subarachnoid Hemorrhage– Most common CT finding in moderate to severe Most common CT finding in moderate to severe

TBITBI– If isolated head injury, may present with If isolated head injury, may present with

headache, photophobia and meningismusheadache, photophobia and meningismus– Early tSAH development triples mortalityEarly tSAH development triples mortality– Size of bleed and outcomeSize of bleed and outcome– Timing of CTTiming of CT– Nimodipine reduces death and disability by 55%Nimodipine reduces death and disability by 55%

Case 2Case 2

Specific Head InjuriesSpecific Head Injuries

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

Specific Head InjuriesSpecific Head Injuries

Subdural HematomaSubdural Hematoma– Sudden acceleration-deceleration injury with Sudden acceleration-deceleration injury with

tearing of bridging veinstearing of bridging veins– Common in elderly and alcoholicsCommon in elderly and alcoholics– Classified as acute, subacute or chronicClassified as acute, subacute or chronic

Acute <2 weeksAcute <2 weeks Chronic >2 weeksChronic >2 weeks

Specific Head InjuriesSpecific Head Injuries

Diffuse Axonal InjuryDiffuse Axonal Injury– Disruption of axons in white matter and Disruption of axons in white matter and

brainstembrainstem– Injury occurs immediately and is irreversibleInjury occurs immediately and is irreversible– Seen after MVC or shaken baby syndromeSeen after MVC or shaken baby syndrome– Usually have persistent vegetative stateUsually have persistent vegetative state– CT usually normalCT usually normal– MRI with multiple, diffuse abnormalitiesMRI with multiple, diffuse abnormalities

Specific Head InjuriesSpecific Head Injuries

Penetrating InjuryPenetrating Injury– Gunshot WoundsGunshot Wounds

Injury due to direct brain injury and cavitary effectsInjury due to direct brain injury and cavitary effects GCS predicts prognosisGCS predicts prognosis

– GCS >8 and reactive pupils = 25% mortalityGCS >8 and reactive pupils = 25% mortality– GCS <5 = nears 100% mortalityGCS <5 = nears 100% mortality

– Stab woundsStab wounds

Complications-Long Term SequelaComplications-Long Term Sequela Seizure DisorderSeizure Disorder

– 2% Early post-traumatic incidence2% Early post-traumatic incidence– Increased to 30% in children, alcoholics and Increased to 30% in children, alcoholics and

with intracranial hematomawith intracranial hematoma Prophylactic antiepileptics reduce early occurrence Prophylactic antiepileptics reduce early occurrence Use not supported by the literatureUse not supported by the literature

Concussion Concussion - - Brief LOCBrief LOC - Vertigo- Vertigo - -

NauseaNausea

- Dizziness- Dizziness - Headache- Headache - Vomiting- Vomiting

- Photophobia- Photophobia - Cognitive/Memory dysfunction- Cognitive/Memory dysfunction

Complications-Long Term SequelaComplications-Long Term Sequela

ConcussionConcussion– Up to 80% may have symptoms at 3 monthsUp to 80% may have symptoms at 3 months– 15% may have symptoms at 1 year15% may have symptoms at 1 year– Persistence of these symptoms is termed Persistence of these symptoms is termed

Postconcussive SyndromePostconcussive Syndrome– 85-90% recover after 1 year85-90% recover after 1 year– Risk factors:Risk factors:

- FemaleFemale - Litigation- Litigation - Low socioeconomic - Low socioeconomic statusstatus

Complications-Long Term SequelaComplications-Long Term Sequela

InfectionInfection– Skull fractureSkull fracture– CSF leakCSF leak– IntubationIntubation

– History of FractureHistory of Fracture FeverFever Signs of meningitisSigns of meningitis

– 33rdrd generation cephalosporin generation cephalosporin– Vancomycin Vancomycin

– ICUICU

– TreatmentTreatment Prophylactic antibioticsProphylactic antibiotics

Questions?Questions?

Lecture QuestionsLecture Questions

1.1. Which of the following modalities is not Which of the following modalities is not recommended for head injured patients recommended for head injured patients with elevated ICP?with elevated ICP?

a.a. Hypertonic salineHypertonic saline

b.b. Hyperventilation to COHyperventilation to CO22 of <30 mm Hg of <30 mm Hg

c.c. MannitolMannitol

d.d. ICP monitoringICP monitoring

e.e. Barbiturate comaBarbiturate coma

2.2. Which of the following are true regarding Which of the following are true regarding TBI?TBI?

a.a. Post-concussive symptoms are commonPost-concussive symptoms are common

b.b. It is expensive to societyIt is expensive to society

c.c. Preventing secondary brain injury is critical in Preventing secondary brain injury is critical in the managementthe management

d.d. All of the above are correct All of the above are correct

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

a.a. Trauma to the temporoparietal regionTrauma to the temporoparietal region

b.b. Extremes of ageExtremes of age

c.c. Have classic presentation only 30% of the timeHave classic presentation only 30% of the time

d.d. Damage to the middle meningeal arteryDamage to the middle meningeal artery

e.e. Damage to a venous sinus Damage to a venous sinus

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

a.a. Has a higher mortality than an equal Has a higher mortality than an equal aneurysmal SAHaneurysmal SAH

b.b. Mortality is reduced with nimodipineMortality is reduced with nimodipine

c.c. Surgical drainage is usually unnecessarySurgical drainage is usually unnecessary

d.d. Most common CT finding in TBIMost common CT finding in TBI

e.e. Size of bleed is unrelated to mortalitySize of bleed is unrelated to mortality

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

a.a. The ring sign is both sensitive and specific for The ring sign is both sensitive and specific for CSF otorrhea/rhinorrheaCSF otorrhea/rhinorrhea

b.b. The only physical exam finding may be a The only physical exam finding may be a hemotympanumhemotympanum

c.c. Battle and Raccoon signs are usually not Battle and Raccoon signs are usually not initially present in the EDinitially present in the ED

d.d. Most commonly occurs in the temporal boneMost commonly occurs in the temporal boneb, d, b, e, ab, d, b, e, a