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Head Trauma Mark Bromley PGY2 Jason Lord FRCPC

Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

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Page 1: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Head Trauma

Mark Bromley PGY2

Jason Lord FRCPC

Page 2: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

• Physiology• Concussion Mild TBI

• Epidural Hematoma• Subdural Hematoma• Traumatic SAH• Contusion• Skull Fractures

• ED Approach to Head Trauma• Severe Head Injury – Mgmt

• How to Read a Head CT Brain Death

Page 3: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Pathophysiology

Page 4: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Cerebral Blood Flow

• CBF is maintained @ MAP of 60-150 mm Hg

• Hypertension, alkalosis, and hypocarbia promote cerebral vasoconstriction

• Hypotension, acidosis, and hypercarbia cause cerebral vasodilation

Page 5: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Hypotension

Page 6: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Cerebral Blood Flow

• In Trauma, ↑ CBF with a disrupted BBB → vasogenic edema

• CBF α CPP• CPP = MAP – ICP • CBF is constant when CPP is 50-160 mm Hg

• If CPP < 40 mm Hgo Øautoregulation of CBF ↓CBF tissue ischemia

Page 7: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Monro-Kellie Doctrine

• Cranial vault is a fixed volume …any change in the contents either o displaces the normal contents or o raises the pressure inside the skull

• The cranial vault is normally filled by three thingso brain o bloodo cerebral spinal fluid.

• If a person were to have a brain tumor:o it displaces one of the normal components (i.e. ↓spinal fluid) o ↑ICP

Page 8: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Direct Injury

• head is struck by an object or its motion is arrested by another object

• skull initially bends inward at the point of contact (coup)

• some energy is transmitted to the brain by shock waves that travel distant to the site of impact or compression

Page 9: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Indirect Injury

• cranial contents are set into motion by forces other than the direct contact of the skull with another object

• acceleration-deceleration injury • as brain moves within the skull, bridging subdural

vessels are strained (subdural hematomas) • shear and strain injuries (diffuse axonal injury or

concussion)• intracranial content movement abruptly arrested

(contrecoup)• penetrating injury - pressure waves can damage

structures distal to the path of the missile.

Page 10: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Primary Injury

• mechanical irreversible damage that occurs at the time of head trauma: o brain lacerations, hemorrhages, contusions, and

tissue avulsions o mechanical cellular disruption and microvascular

injury

• No specific intervention exists to repair or reverse primary brain injury

• Public health interventions aimed at reducing the occurrence of head trauma

Page 11: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Secondary Brain Injury

• intracellular and extracellular derangements (metabolic, ischemic, ion shifting)

• All currently used acute therapies for TBI are directed at reversing or preventing secondary injury

Page 12: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Secondary Brain Injury

• Neurologic outcome is influenced by the extent and degree of secondary brain injury

• Hypotension (sBP < 90 mm Hg) reduces cerebral perfusion (ischemia and infarction)

• Hypoxia (PO2 < 60 mm Hg)o apnea caused by brainstem compression or injuryo partial airway obstructiono injury to the chest wall that interferes with normal

respiratory excursiono pulmonary injury that reduces effective oxygenation

Page 13: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Secondary Brain Injury

• Anemia (reduced oxygen-carrying capacity of the blood) o Increased mortality when Hct < 30%

• Other potential reversible causes of secondary injury in head injury include hypercarbia, hyperthermia, coagulopathy, and seizures

Page 14: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Case• 17 ♂ playing soccer

…was “headed” by another playero No LOCo Pulled from game – kept getting beateno Progressive confusiono Amnestic of the event

Page 15: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

• Now GCS 15

• No Focal Neurologic findings

o ?Imagingo ?Follow-up

Page 16: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Note: Minor Head Injury is defined as a witnessed loss of consciousness, definite amnesia, or witness disorientation in a patient with a GCS 13-15.

Page 17: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Design: prospective cohort study ( June 2000-December 2002). 9 EDs. 2707 adults blunt head trauma → witnessed LOC, disorientation, or definite amnesia and a GCS

13-15. The CCHR and NOC were compared in a subgroup of 1822 adults with minor head injury and GCS 15.

Outcomes Neurosurgical intervention and clinically important brain injury evaluated by CT and a structured follow-up telephone interview.

Results Among 1822 patients with GCS 15, 8 (0.4%) required neurosurgical intervention and 97 (5.3%) had clinically important brain injury. NOC and the CCHR both had 100% sensitivity CCHR was more specific (76.3% vs 12.1%, P.001) (neurosurgical intervention) ↓ CT rates (52.1% vs 88.0%, P.001)

Conclusion For patients with minor head injury and GCS score of 15, the CCHR and the NOC have equivalent high sensitivities for need for neurosurgical intervention and clinically important brain injury, but the CCHR has higher specificity for important clinical outcomes than does the NOC, and its use may result in reduced imaging rates.

Page 18: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Concussion and Mild TBI

Page 19: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Concussion

“grossly normal structural neuroimaging”

Signs: GCS 13-15 at 30 min post injury Symptoms: confusion and amnesia +/- LOC

↓focus ↓orientation slurred speech / poor coordination emotional

Course: resolution of symptoms follows a sequential course

Page 20: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Observation and disposition

• Observation is recommended for 24 hours after a mild TBI because of the risk of intracranial complications

• Hospital admission is recommended for patients at risk for immediate complications from head injury o GCS <15 o Abnormal CT scan: intracranial bleeding, cerebral edema o Seizures o Abnormal INR PTT

Page 21: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

• His Dad take you aside and says there’s a big tourney on the weekend with scouts flying in to watch.

…can he play?

Page 22: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Return to play• Rest until all symptoms have resolved• Graded program of exertion• > 1 day at each level is needed • If any symptoms appear, patients drop back to the previous

asymptomatic level and try again after 24 h

McCrory P, Johnston K, Meeuwisse W, Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med 2005;39(4):196-204.

Page 23: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures
Page 24: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Take Home – Concussion • Players should not be allowed to return to play in

the current game or practice • Players should not be left alone, and regular

monitoring for deterioration is essential during the initial few hours after injury

• Return to play must follow a medically supervised series of steps

• Players should never return to play while symptoms persist

Page 25: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Case• 20 year-old ♂ university student • presents after a morning game of baseball in which he

collided with another player• Brief LOC …meanwhile she bled profusely from the chin • When he recovered, she offered him a ride to the

emergency room, which he declined, saying "it's just a bump on the head"

• He returned to his room and told his roommates the story, and remained lucid through the morning.

• After lunch → restless with a severe HA → seizure.

• OE: ↓LOC R pupil dilated

Page 26: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures
Page 27: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Epidural Hematoma

Page 28: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Epidural Hematoma

• Usually due to arterial injury o trauma to the skull base → tearing of middle meningeal arteryo results in hemorrhage

Occasionally • anterior cranial fossa → rupture of the anterior meningeal artery• vertex → dural arteriovenous fistula

• In ~15 % of cases, injury to one of the dural sinuses, or the confluence of sinuses in the posterior cranial fossa, is the source of hemorrhage

Page 29: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Epidural-Pathophysiology

• Blow to the head fractures the temporal bone and ruptures branches of the middle meningeal artery, lies outside the dura.

• The ruptured artery then leaks blood between the inner skull and the dura.

• The increasing volume of blood strips the dura from the inside of the skull, forming, in effect, a large blood blister which pushes against the brain as it expands.

• The hematoma may strip the dura from the bone as far as the sutures of the skull.

• This stripping of the dura from the calvarium may be part of the reason for the severe headache.

Page 30: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures
Page 31: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Epidural Hematoma - Hx

• Mean age 20-30 years

• Caused by MVC, Falls, Assaultso Skull # present 75-95% of the time

• Transient LOC with a “lucid interval”

• Symptoms: HA, N/V, drowsiness, confusion, aphasia, seizures, and hemiparesis

Page 32: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Epidural Hematoma - Imaging

• Head CT – fast, simple

• “lens-shaped” pattern

• collection is limited by dural attachments at cranial sutures

Page 33: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures
Page 34: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Epidural - Management• Neurologic emergency

o hematoma expansion o elevated intracranial pressureo brain herniation

• Operativeo Craniotomy and hematoma evacuationo Burr Hole

• Non-Operativeo Close observationo serial brain imaging

• hematoma enlargement • neurologic deterioration

Page 35: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

• An EDH > 30 cm3 should be surgically evacuated regardless of the patient's GCS

• GCS < 9 with anisocoria → evacuation ASAP• An EDH

o < 30 cm3

o < 15-mm thicknesso < 5-mm midline shift (MLS) in patients o with a GCS > 8 o w/o focal deficit

…non-operative mgmt with serial CTs and close neurological observation in a neurosurgical center

Epidural - ?Surgical

Page 36: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Case

• 83 ♀ presents with confusion• Gradually increasing over the past week• No history of trauma

• GCS: 14• CN: ii-xii normal – no focal findings• Urine + nitrates/leuks –epithelials• CT Head

Page 37: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures
Page 38: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures
Page 39: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures
Page 40: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Subdural Hematoma

Page 41: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Subdural Hematoma

• SDHs form b/w the dura and the brain• Usually they are caused by the movement of the brain

relative to the skull o acceleration-deceleration injuries

• Common in patients with brain atrophy (EtOH or elderly)

• Superficial bridging vessels traverse greater distances than in patients with no atrophy (more likely to rupture with rapid movement of the head)

• Occurs in ~30% of patients with severe head trauma• slow bleeding of venous structures delays clinical signs

Page 42: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Acute SDH

• 24 hours post trauma

• ↓ LOC;

• lucid interval: 50% - 70% → ↓mentation

Page 43: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Subacute SDH

• symptomatic 24h - 2 wks post injury

• CT: hypodense or isodense lesion

absence of sulci

shift

• contrast detection of isodense lesions

Page 44: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Chronic SDH

• >2 weeks post trauma

• Hemiparesis or Weakness: ~45%

• ↓LOC: ~50%

Page 45: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Case• 51 ♂ MVC – single vehicle at highway

speeds off road and into a tree

• ?LOC

• GCS 8 (scene) 8 (now)

Page 46: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures
Page 47: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Subarachnoid Hemorrhage

Page 48: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Traumatic SAH

• TSAH is defined as blood within the CSF and meningeal intima o results from tears of small subarachnoid vessels

• detected on the first CT scan in up to 33% of patients with severe TBI (incidence of 44% in all cases of severe head trauma)

• incidence of skull fractures and contusions o ↓GCS → SAHo SAH → ↓Outcome

Page 49: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Traumatic SAH

• Øcontrast CT: density in basilar cisterns

density interhemispheric fissures/sulci

• prognosis reasonable

• cerebral vasospasm → cerebral ischemia

Page 50: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Chicken vs Egg

• Did this patient lose consciousness while driving because of spontaneous SAH and subsequently crash his car, or did the patient sustain head injury from the motor vehicle accident causing traumatic SAH?

• cerebral angiogram to exclude an underlying aneurysm or vascular malformation

Page 51: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

SKULL FRACTURES

Page 52: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Linear skull fracture

• low-energy blunt trauma over a wide surface area of the skull.

• Full thickness through bone • …of little significance except

• when it runs through a vascular channel, • venous sinus groove• suture

• Then, it may cause • epidural hematoma • venous sinus thrombosis and occlusion • sutural diastasis

Page 53: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Fractures• Greater than 3 mm in width • Widest at the center and

narrow at the ends • Runs through both the outer

and the inner lamina of bone, hence appears darker

• Usually over temporoparietal area

• Usually runs in a straight line • Angular turns

Sutures• Less than 2 mm in width • Same width throughout • Lighter on x-rays compared

with fracture lines • At specific anatomic sites • Does not run in a straight line • Curvaceous

Page 54: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Basilar skull fracture• Petrous temporal bone: CSF otorrhea and bruising over mastoids

(Battle sign) • Anterior cranial fossa: CSF rhinorrhea and bruising below eyes

(raccoon eyes) • Longitudinal temporal bone → ossicular chain disruption and

conductive deafness Facial palsy, nystagmus, and facial numbness are 2’ to VII, VI, and V CN palsy

• Transverse temporal bone: VIII CN palsy and labyrinth injury → nystagmus, ataxia, and permanent neural hearing loss

• Occipital condylar fracture: coma and have other associated c-spine injuries

• Vernet syndrome or jugular foramen syndrome is involvement of IX, X, and XI CN → difficulty in phonation, aspiration and ipsilateral motor paralysis of the vocal cord, soft palate (curtain sign), superior pharyngeal constrictor, sternocleidomastoid, and trapezius.

Page 55: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Depressed Skull Fracture

• Elevation o depressed segment is > 5mm below inner

table o gross contamination, o dural tear with pneumocephaluso underlying hematoma

• Craniectomy o underlying brain is damaged and swollen

Page 57: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

ED Approach to Head Trauma

Page 58: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Focused Hx

• Mechanism

• LOC

• Ambulatory at scene

• GCS at scene

Page 59: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Focused Physical

• ABC’s

• ATLS protocol

• GCS

• Signs of external injury

• Pupils

• Check Ears/Nose

• Extremities - movement

Page 60: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Glasgow Coma Scale*Eye Opening (E)

4. Spontaneous

3. To voice

2. To pain

1. None

Verbal Responses (V)5. Oriented

4. Confused

3. Inappropriate words

2. Incomprehensible sounds

1. None

Motor response (M)6. Obeys commands

5. Localizes pain

4. Withdraws from pain

3. Abnormal flexion

2. Abnormal extension

1. None

*Developed for evaluation of head trauma 6 hours post injury Deceased and rocks have GCS 3

Page 61: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Emergent Management of Closed Head Injury

Page 62: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Case

• 22 ♀ bicycle vs truck

• LOC

• Agitated at the scene

• GCSo Opens eyes to paino Withdraws o Sounds – no inteligible words

2

4

2

Page 63: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Outline• Airway• Avoid Hypoxia • Avoid Hypotension

• Brain Specific Therapieso Positiono Hyperventilationo Mannitolo Hypertonic Salineo Cooling

• Indications for ICP Monitoring• Surgical Management

Page 64: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Airway• Capture it!

• How you do it probably does not have a great effect on neurological outcome unless you cause hypoxemia or hypotension

• There is little evidence-based medicine to guide the choice of agents

Page 65: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Intubation – Indications*• Coma (i.e. GCS 8) or significantly deteriorating LOC• Loss of protective laryngeal reflexes• Copious bleeding into mouth• Respiratory arrhythmia• Ventilatory insufficiency

o clinical decision - not necessarily requiring ABG• Bilateral mandibular fracture• Any facial injury compromising airway• Seizures• Any other injury that requires ventilation/intubation

*Eastern Association For The Surgery of Trauma, 2003; NICE guidelines, 2003

Page 66: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Case

• Paramedics state his GCS “…was 7 or 8 at the scene”

• Should they have intubated?

Page 67: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Methods: Before–After system wide controlled clinical trial conducted in 17 cities. Adult patients who had experienced major trauma in a BLS phase and a subsequent ALS phase (during which paramedics were able to perform intubation and administer fluids and drugs intravenously). The primary outcome was survival to hospital discharge.

Results: • Survival did not differ overall (81.1% ALS v. 81.8% among those in the BLS; p=0.65) • Among patients with GCS < 9, survival was ↓ with ALS (50.9% v. 60.0%; p=0.02)• The adjusted odds of death for the advanced life-support v. basic life-support phases were non-

significant (1.2, 95% confidence interval 0.9–1.7; p=0.16)

Interpretation: The OPALS Major Trauma Study showed that systemwide implementation of full advanced life-support programs did not decrease mortality or morbidity for major trauma patients. We also found that during the ALS phase, mortality was greater among patients with GCS < 9.

Page 68: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Airway• Preparation and Preoxygenation • Prevent ICP rise

o Lidocaine 1.5-2 mg/kg IV o Rocuronium 0.06 - 0.1 mg/kg (defasciculating dose) o Fentanyl 3 ug/kg IVP

• Prevent Vagally stimulated bradycardiao Atropine 0.01 mg/kg IV (Minimum dose: 0.1 mg)

• Sedation o Etomidate 0.3 mg/kg IVP OR o Thiopental (Pentothal) 4 mg/kg IVP (IF BP stable) ORo Propofol 2mg/kg IVP ORo Midazolam 0.1mg/kg (max 5mg) IVP

• Apply cricoid pressure • Muscle relaxants

o Succinylcholine 1.5 mg/kg IV OR o Rocuronium 0.6 mg/kg IV

Page 69: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Airway - Intubation• Lidocaine (1.5 to 2 mg/kg IV push)

…may ↓ cough reflex, HTN response, ICP

• Succinylcholine – fasciculations ↑ICP• premedicate w a subparalytic dose of a nondepolarizing agent

• Etomidate (0.3 mg/kg IV)• good effect on ICP ↓CBF and metabolism

• minimal adverse effects on BP

• Minimal respiratory depressant effects

Page 70: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Methods: Medline literature search was undertaken for evidence of the effect of succinylcholine (SCH) on the intracranial pressure (ICP) of patients with acute brain injury and whether pretreatment with a defasciculating dose of competitive neuromuscular blocker is beneficial in this patient group.

Conclusions: Studies were weak and small

For those patients suffering acute TBI the authors could find no studies that investigated the issue of pretreatment with defasciculating doses of competitive neuromuscular blockers and their effect on ICP in patients given SCH.

SCH caused ↑ ICP for patients undergoing neurosurgery for brain tumours with elective anaesthesia and that pretreatment with defasciculating doses of neuromuscular blockers reduced such increases. ?impact on outcome.

Page 71: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Background: laryngeal instrumentation and intubation is associated with a marked, transient rise in ICP.

Methods: A literature search was carried out to identify studies in which intravenous lidocaine was used as a pretreatment for RSI in major head injury. Any link to an improved neurological outcome was also sought.

Results: No evidence was found to support the use of intravenous lidocaine as a pretreatment for RSI in patients with head injury and its use should only occur in clinical trials.

Page 72: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Case

• 22 ♀ with presumed CHI

• Now intubated.

• What are your priorities?

Page 73: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

AVOID HYPOXEMIA

Page 74: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Volume 40(5) May 1996 pp 764-767

Hypoxemia and Arterial Hypotension at the Accident Scene in Head Injury

Stocchetti, Nino MD; Furlan, Adriano MD; Volta, Franco MD Design: Prospective, observational study.

Materials and Methods: Arterial Hbo2 was measured before tracheal intubation at the accident scene in 49 consecutive patients with head injuries. Arterial

pressure was measured using a sphygmomanometer.

Main Results: Mean arterial saturation was 81% (SD 24.24); mean arterial systolic pressure was 112 mm Hg (SD 37.25). Airway obstruction was detected in 22 cases. Twenty-seven patients showed an arterial saturation lower than 90% on the scene, and 12 had a systolic arterial pressure of less than 100 mm Hg. The

outcome was significantly worse in cases of hypotension, desaturation, or both.

Conclusions: Hypoxemia and shock are frequent findings on patients at the accident scene. Hypoxemia is more frequently detected and promptly corrected, while arterial hypotension is more difficult to control. Both insults may have a significant impact on outcome

Page 75: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Methods: 846 cases of severe TBI (GCS ≤ 8) were analyzed retrospectively to clarify the effects of multiple factors on the prognosis of patients.

Results: • Worse outcomes were strongly correlated (p < 0.05) with GCS score, age,

pupillary response and size, hypoxia, hyperthermia, and high intracranial pressure (ICP).

• Even a single O2 sat reading < 90% was associated with a significantly worse outcome

Conclusions: These findings indicate that prevention of hypoxia, control of high ICP, and prevention of hyperthermia may improve outcome in patients with TBI

Page 76: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

desaturation occurs rapidly below SpO2 of 90–92%

Page 77: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

AVOID HYPOTENSION

Page 78: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

010

203040

50607080

90100

none early late both

% o

f p

atie

nts

in o

utc

om

e g

rou

p

Timing of hypotension (SBP < 90 mmHg)

Traumatic Coma Data Bank 1991

Favourable outcome

Unfavourable outcome

Page 79: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Hypotension

• Single occurrence of ↓BP (SBP<90mmHg)o doubles mortality*o ↑ disability in survivors of head injury*

• ↑duration and ↑ frequency = ↓ prognosis**

*Chesnut et al., 1993; Management and Prognosis of Severe Traumatic Brain Injury, 2000

**Schierhout and Roberts, 2000

Page 80: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Hypotension

Page 81: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Mean Arterial Pressure

• What is adequate?o Enough to maintain CBFNormally (MAP 60-150 mmHg and ICP ~10 mmHg)o CPP is normally between 70 and 90 mmHgo <70 mmHg for a sustained period → ischemic injury

• Outside of the limits of autoregulationo ↑ MAP raises CPP o ↑ ICP lowers CPP

Page 82: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Blood pressure control

• BP should maintain CPP>60 mmHg o pressors can be used safely without further ↑ ICP

…in the setting of sedation → ?iatrogenic ↓BPo Hypertension should generally not be treated

• Avoid CPP <60 mmHg oro normalization of BP in chronic HTN

…the autoregulatory curve has shifted to the right

Page 83: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Case

• Asymetric Pupils – L fixed and dilated

• What is happening?

• What would you like to do?

Page 84: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Herniation

1) The brain squeezes under the falx cerebri in cingulate herniation 2)The brainstem herniates caudally3) The uncus and the hippocampal gyrus herniate into the tentorial notch 4)The cerebellar tonsils herniate through the foramen magnum in tonsillar herniation.

Page 85: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

• Uncus can squeeze the third cranial nerve which controls ipsilateral parasympathetic input to the eye o pupillary dilatation o deviation of the eye to "down and out"

Page 86: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Brain Specific Therapies

Page 87: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Position• Maximize venous outflow from the head

o ↓ excessive flexion or rotation of the neck o avoid restrictive neck tapingo minimize stimuli that could induce Valsalva (i.e. suctioning)

• Position the head above the heart (30o) o head elevation may lower CPP

Page 88: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Hyperventilation

• Once a mainstay for treatment of ↑ICP

• Concerns about cerebral ischemia o difficult to demonstrate

• Outcome worse with hyperventilation in some studies of head injury

Page 89: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Adverse effects of prolonged hyperventilation in patients with severe head injury: a randomized clinical trial

Methods: RCT normal ventilation PaCO2 35Hg

hyperventilation PaCO2 25Hg hyperventilation plus THAM

Outcome: GCS at 3/6/12 months

Results:Those in the 25 mm Hg group did worse

Muizelaar et. al. 1991

Page 90: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

0m

l/1

00

g/m

in6

0

0m

l/1

00

g/m

in6

0

Acute head injury (6 hrs post impact)Areas in red show regions with rCBF < 20 ml/100g/min)

(Coles et al. Crit Care Med 2002)

PaCO2: 25 mmHgPaCO2: 38 mmHg

Page 91: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures
Page 92: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Mannitol

Page 93: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Mannitol

Benefits:o Plasma expanding effecto Reduces hematocrit and viscosityo ↑ cerebral blood flowo Osmotic effect creates a fluid gradient out

of cells. This osmotic effect initially decreases intracellular edema, thus decreases ICP

Page 94: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Mannitol

• Drawbacks:o Osmotic diuresiso HYPOTENSIONo May accumulate in the brain and result is a

“reverse osmotic shift” potentially increasing ICP

o Acute renal failure

Page 95: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Mannitol

Indications: (prior to ICP monitoring) 1. Signs of transtentorial herniation2. Progressive neurological deterioration

• not attributable to extra-crainal complications

Dose: 0.25 – 1g/kg IV bolusAvoid hypovolemia

(foley recommended)

Page 96: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Hypertonic Saline

Page 97: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Hyperosmotic agents• Mannitol effective through non- osmotic effects

• Problems with big fluid shifts from diuresis

• Increasing interest in use of hypertonic saline (3-24%)

• ? more effective with fewer side effects.

• Outcome with Na+; survival with Na+ 180 mmol/l!

Munar et al. J Neurotrauma 2000. 17:41-51. Horn et al. Neurol Res 1999;21: 758-64

Quereshi et al. J Trauma 1999;47:659-65. Simma et al. Crit Care Med 1998;26:1265-70.

Clark & Kochanek. Crit Care Med 1998;26:1161-2.Doyle et al. J Trauma 2001; 50: 367-383.

Petersen et al. Crit Care Med 2000;28:1136-1143Dose: 2-4 ml/Kg 5% NaClMax Na+ ~ 160 mmol/lMax osmol ~ 325 mOsm/l

Page 98: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Methods: Consecutive patients with clinical TTH treated with 23.4% saline (30 to 60mL) were included in a retrospective cohort. Factors associated with successful reversal of TTH were determined.

Results: 76 TTH events. In addition to 23.4% saline, TTH management included hyperventilation (70% of events), mannitol (57%), propofol (62%), pentobarbital (15%), ventriculostomy drainage (27%), and decompressive hemicraniectomy (18%). Reversal of TTH occurred in 57/76 events (75%). Reversal of TTH was predicted by a 5 mmol/L rise in serum sodium concentration (p 0.001) or an absolute serum sodium of 145 mmol/L (p 0.007) 1 hour after 23.4% saline. Adverse effects included transient hypotension in 13 events (17%); no evidence of central pontine myelinolysis was detected on post-herniation MRI (n 18). Twenty-two patients (32%) survived to discharge, with severe disability in 17 and mild to moderate disability in 5.

Conclusion: Treatment with 23.4% saline was associated with rapid reversal of transtentorial herniation (TTH) and reduced intracranial pressure, and had few adverse effects. Outcomes of TTH were poor, but medical reversal may extend the window for adjunctive treatments.

Page 99: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Case

• The R2 ER resident on NSx asks what you think his chances are of putting in a EVD?

• What are the indications for ICP monitoring?

Page 100: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures
Page 101: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Antiepileptic therapy

Page 102: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Antiepileptic therapy• Seizure incidence

• 12% blunt trauma • 50% penetrating head injury

• Seizures can contribute to • Hypoxia, Hypercarbia• Release of excitatory neurotransmitters • ↑ICP

• Anticonvulsant therapy → if seizing• ?Prophylaxis

o There are no clear guidelines o ? high-risk mass lesions

Page 103: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Anti-epilepticAcute Treatment• Lorazepam (0.05-0.15 mg/kg IV, over 2-5 min - max 4 mg)

• Diazepam (0.1 mg/kg, up to 5 mg IV, Q10 min - max20 mg)

Prophylaxis• phenytoin (13 to 18 mg/kg IV) • fosphenytoin (13 to 18 phenytoin equivalents/kg)

Page 104: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

• Selection criteriao All randomised trials of anti-epileptic agents, in which study participants had a clinically defined

acute traumatic head injury of any severity. Trials in which the intervention was started more than eight weeks after injury were excluded.

• Data collection and analysiso Two reviewers o Relative risks and 95% confidence intervals (95%CI) were calculated

• Main resultso 10 eligible RCTs, 2036 participantso (RR) for early seizure prevention was 0.34 (95%CI 0.21, 0.54)o ↓ risk of early seizures by 66% o Seizure control in the acute phase did not show ↓ mortality (RR = 1.15; 95%CI 0.89, 1.51) ↓ death/disability (RR = 1.28; 95%CI 0.90, 1.81)

• Authors' conclusionso Prophylactic anti-epileptics reduce early seizures o No reduction in late seizures o No effect on death and neurological disabilityo Insufficient evidence is available to establish the net benefit of prophylactic treatment at any time

after injury.

Page 105: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Seizure Prophylaxis in Severe Head Trauma  

• Indications*• Depressed skull fracture   

• Paralyzed and intubated patient   

• Seizure at the time of injury   

• Seizure at ED presentation   

• Penetrating brain injury   

• Severe head injury (GCS ≤8)   

• Acute subdural hematoma   

• Acute epidural hematoma   

• Acute intracranial hemorrhage   

• Prior Hx of seizures

*Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th ed.

Page 106: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Blood Glucose

Page 107: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Blood Glucose

• Lam et al found 43% of patients with severe brain injury to have admission blood glucose levels above 11.1 mM

• Rovlias and Kotsou showed postoperative glucose levels, independent of their relationship with GCS, significantly contributed to the prediction of the patients’ prognosis

Page 108: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Hyperglycemia-Induced Neuronal Injury

• ? increased tissue lactic acidosis• Brain tissue acidosis is associated with mortality following

head injury• ↑ glucose supply during incomplete ischemia may allow

continuation of anaerobic glycolysis, which would lead to accumulation of lactate and subsequently to tissue acidosis

• Injured brain cells may not be able to metabolize excess or even normal levels of glucose through the oxidative pathway.

Page 109: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Hyperglycemia-Induced Neuronal Injury

• Intracellular acidosis triggers calcium entry into the cell, lipolytic release of cytotoxic free fatty acids and glutamate and eventually cell death

• ↓ glucose available to the glycolytic pathway, treatment of hyperglycemia could theoretically ↓ lactate production, ↑ pH, result in less neuronal damage, and improve patient outcome

Page 110: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Brain Tissue pH and Blood GlucoseB

rain

pH

Glucose0 5 10 15 20

6

6.5

7

7.5

Brain p

H

Page 111: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Steroids

Page 112: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Steroids

• Beneficial in tumors

• Decreases cerebral edema

• Many reasonable sized RCTs that have failed to show benefit.

• Some have shown mild benefits in subgroup analysis

• Not recomended

Page 113: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Cooling

Page 114: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

On Injuries of the Head 400 B.C.E

“…a man will survive longer in winter than in summer, whatever be the part of the head in

which the wound is situated.”

Page 115: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Therapeutic Hypothermia:Experimental Evidence

Page 116: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

NABIS:H I

AIM

To determine whether surface-induced moderate hypothermia (33.0o C), begun rapidly after severe traumatic brain injury (GCS 3-8) and maintained for 48 hours will improve outcome with low toxicity

Page 117: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

NABIS:H I Outcomes

56.85 56.01

27.92 26.59

0

10

20

30

40

50

60

% o

f P

atie

nts

Poor Outcome Mortality

Hypothermia Normothermia

Page 118: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

NABIS:H I Temperature Data

30

32

34

36

38

40

0 8 16 24 32 40 48 56 64 72 80 88 96

Hours from Hospital Arrival

Tem

per

atu

re (

C)

hypo mean +1 SD -1 SD normo mean +1 SD -1 SD

Target Temp8.4 + 3 hrs

Page 119: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Therapeutic Hypothermia: Cardiac Arrest

Page 120: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Hypothermia Treatment Window

Page 121: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Future Directions

Page 122: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

ER physician’s role in brain death

• Hope Programhttp://iweb.calgaryhealthregion.ca/hope

Page 123: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Questions?

Page 124: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Acknowledgements

Dr. Jason LordDr. David Zygun

Page 125: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

How to Read a Head CT

Page 126: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

How to Read a Head CT• Has assumed a critical role in the daily practice

of Emergency Medicine for evaluating intracranial emergencies

• Most practitioners have limited experience with interpretation

• In many situations, the Emergency Physician must initially interpret and act on the CT without specialist assistance

Page 127: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Trauma CT• Is there evidence of hemorrhage?

o Within the ventricleso Within the subdural spaceo Within the subarachnoid spaceo Within the epidural space

• Is there mass effect?o Effacement of sulci

• Is there cerebral edema?o Small ventricleso Small basilar cisternso General effacement of cortical sulcio Diffuse loss of grey-white differentiation

• Is there local loss of grey-white differentiation?o Infarction/Inflammation/Tumor

• Is there Hydrocephalus?o Communicating vs non-communicating

• Have the cisterns been scrutinized for hemorrhage and size?• Is there evidence of infarction?• Is there calcification?• Have the midline structures been examined?• Have all images been analyzed?

o Scout and bone windows• Will contrast be helpful?• Is the CT interpritation consistent with clinical findings

Page 128: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Head CT

“Blood Can Be Very Bad”

Page 129: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Blood Can Be Very Bad

• Blood

• Cisterns

• Brain

• Ventricles

• Bone

Page 130: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Blood Can Be Very Bad

• Blood

• Cisterns

• Brain

• Ventricles

• Bone

Page 131: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Blood Can Be Very Bad

• Blood

• Cisterns

• Brain

• Ventricles

• Bone

Page 132: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Blood Can Be Very Bad

• Blood

• Cisterns

• Brain

• Ventricles

• Bone

Page 133: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Blood Can Be Very Bad

• Blood

• Cisterns

• Brain

• Ventricles

• Bone

Page 134: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

CT Scan Basics• A CT image is a computer-generated

picture based on multiple x-ray exposures taken around the periphery of the subject

• X-rays are passed through the subject, and a scanning device measures the transmitted radiation

• The denser the object, the more the beam is attenuated, and hence fewer x-rays make it to the sensor

Page 135: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

CT Scan Basics• The denser the object, the whiter it is on CT

• Bone is most dense = + 1000 Hounsfield U • Air is the least dense = - 1000 Hounsfield U

Page 136: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

CT Scan Basics: Windowing

Focuses the spectrum of gray-scale used on a particular image

Page 137: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

•Brainstem•Cerebellum•Skull Base

–Clinoids–Petrosal bone–Sphenoid bone–Sella turcica–Sinuses

Posterior Fossa

Page 138: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Sagittal View

Page 139: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Cisterns

Page 140: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

CT Scan

Page 141: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Brainstem Lateral View

Page 142: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

2nd Key Level2nd Key Level Sagittal View

2nd Key Level

Page 143: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Cisterns at Cerebral Peduncles Level

Page 144: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

CT Scan

Page 145: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

CT Scan

Page 146: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

3rd Key Level

Page 147: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Cisterns at High Mid-Brain Level

Page 148: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

CT Scan

Page 149: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Ventricles

Page 150: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

CSF Production

• Produced in choroid plexus in the lateral Ventricles Foramen of Monroe IIIrd Ventricle Acqueduct of Sylvius IVth Ventricle Lushka/Magendie

• 0.5-1 cc/min• Adult CSF volume is approx. 150 cc’s• Adult CSF production is ~ 500-700 cc/day

Page 151: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

B is for Blood• Is blood present?

o If so, where is it?o If so, what effect is it having?

Page 152: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Blood becomes hypodense at approx 2 weeks

Blood becomes isodense at approx 1 week

Acute blood is bright white on CT (once it clots)

Page 153: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Blood becomes hypodense at approximately 2 weeks

Blood becomes isodense at approx 1 week

Acute blood is bright white on CT (once it clots)

Page 154: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Blood becomes hypodense at approximately 2 weeks

Blood becomes isodense at approximately 1 week

Acute blood is bright white on CT (once it clots)

Page 155: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Epidural Hematoma• Lens shaped• Does not cross sutures• Classically described with

injury to middle meningeal artery

• ↓ mortality if treated prior to unconsciousness (< 20%)

Page 156: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

CT Scan

Page 158: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Subdural Hematoma• Typically falx or sickle-shaped• Crosses sutures• Does not cross midline• Acute subdural is a marker

for severe head injury (Mortality ~ 80%)

• Chronic subdural usually slow venous bleed and well tolerated

Page 159: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

CT Scan

Page 160: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

CT Scan

Page 161: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Subarachnoid Hemorrhage

Page 162: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Subarachnoid Hemorrhage• Blood in the cisterns/cortical gyral surface

o Aneurysms responsible for 75-80% of SAHo AVM’s responsible for 4-5%o Vasculitis accounts for small proportion (<1%)o No cause is found in 10-15%o 20% will have associated acute hydrocephalus

Page 163: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

163

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164

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C is for CISTERNS

• 4 key cisternso Circummesencephalico Suprasellaro Quadrigeminalo Sylvian

((BBlood lood CCan an BBe e VVery ery BBad)ad)

Page 167: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Cisterns• 2 Key questions to answer regarding

cisterns:o Is there blood?o Are the cisterns open?

Page 168: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures
Page 169: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures
Page 170: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures
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B is for BRAIN((BBlood lood CCan an BBe e VVery ery BBad)ad)

171

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Tumor

Page 174: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Atrophy

Page 175: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Abscess

Page 176: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Hemorrhagic Contusion

Page 177: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Mass Effect

Page 178: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Stroke

Page 179: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Intracranial Air

Page 180: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Intracranial Air

Page 181: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Intracranial Air

Page 182: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

V is for VENTRICLES

((BBlood lood CCan an BBe e VVery ery BBad)ad)

Page 183: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures
Page 184: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures
Page 185: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures
Page 186: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures
Page 187: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

BONE

Page 188: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures
Page 189: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures
Page 190: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures
Page 191: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

If…• No blood is seen• All cisterns are present/open• The brain is symmetric

• with Normal gray-white diff • The ventricles are symmetric

• without dilation• There is no fractured bone

No Worries…

Page 192: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures

Practice CT

Page 193: Head Trauma Mark Bromley PGY2 Jason Lord FRCPC. Physiology Concussion Mild TBI Epidural Hematoma Subdural Hematoma Traumatic SAH Contusion Skull Fractures