HEAD TRAUMA

Alyssa Morris, R4August 12, 2010Thanks to Dr Adam Oster

OBJECTIVES

Prehospital intubation of a head injury Anti-seizure prophylaxis Intubation of a head injury

Premedication Induction agent

Management of herniation Mannitol Hypertonic saline

Cooling in TBI CT head rules

CASE

27M restrained driver in a single vehicle MVA at highway speed.

GCS 13, no obvious head trauma, other vitals stable, combative

26F restrained passenger in the rollover GCS 8, obvious lacerations and bleeding from scalp, BP 102/60, P= 110, 02 sats 94% RA

Objective: determine if ALS care in field for trauma patients improves morbidity and mortality

Design: Before-after clinical trial Population: n= 2867, trauma pts

>16y.o, severity score>12 Results: (ALS v. BLS)

Overall Survival 81.1% v. 81.8% (p=0.65)

Survival in GCS<9 50.9% v. 60.0% (p=0.02)

CASE CONT…

The patients are now in the ED. 27M GCS 14 one hour after

exam, no obvious amnesia, slightly agitated, vitals stable and nothing else on exam.

26F GCS 8 obvious depressed skull fracture.

QUESTIONS

1. Do you want to ask radiology for a CT head for these patients?

2. What were the outcomes the rule was predicting?

3. What are the High Risk criteria?4. What are the Medium Risk

criteria?

Objective: develop a highly sensitive clinical decision rule for use of CT in pts w minor head injury

Inclusion Criteria: blunt trauma to the head w witnessed

LOC definite amnesia witnessed deterioration initial ED GCS >=13 injury w/i past 24h

Exclusion Criteria <16y.o Minimal head injury No clear hx of trauma Penetrating skull injury Focal neuro deficit Unstable vital signs Had a seizure before ED assessment Bleeding disorder or anticoagulated pregnant

High Risk (for neurological intervention) GCS < 15 at 2 hrs after injury Suspected open or depressed skull # Any sign of basal skull fracture Vomiting >= 2 episodes Age >= 65

Medium Risk (for brain injury on CT) Amnesia before impact >= 30 min Dangerous mechanism▪ Pedestrian▪ Ejected▪ Fall from elevation >=3ft or 5 stairs

CASE CONT…

The nurse asks if you want to give these patients dilantin to prevent a seizure given they have head injuries. The female reportedly has already had a seizure but the male has not.

Q: Will you give dilantin to the 27M?Q: Will you give dilating to the 26F?

6 randomized controlled trials included Results

For every 100 pts treated with AEDs, 10 would be kept seizure free in 1st week

No reduction in mortality No reduction in neurological disability No reduction in late seizure onset

Conclusion Does reduce early PTS but no outcome

benefit No evidence to support routine use at any

time after injury

Practice Recommendations Prophylactic treatment with

phenytoin, beginning with an IV loading dose, ASAP after injury should be used routinely to prevent early PTS

Prophylactic treatment should not be used beyond first 7 days after injury

Recommendations LEVEL I▪ Insufficient data

LEVEL II ▪ AEDs are indicated to decrease the incidence of early PTS (w/i 7d of injury). However, early PTS is not associated with worse outcomes.▪ Prophylactic use of phenytoin or valproate is not recommended for preventing late PTS

Recommendations Standards▪ Insufficient data

Guidelines▪ Prophylactic use of AEDs to prevent late PTS is not recommended

Options ▪ Prophylactic use of AEDs to prevent early PTS may be considered as a treatment

CASE CONT…

27M is becoming more combative and you are preparing to intubate him.

Q: Will you premedicate?Q: What will you use for

induction?

LIDOCAINE

1.5mg/kg 3 minutes before RSI No article answering our exact

question Found 6 papers

Benefit shown in: Brain neoplasms undergoing resection ETT suctioning (already intubated and

Mx) No benefit or harm shown in:

Prolonged decreased MAP (CPP= MAP-ICP)

Has to be given minutes before RSI

Objective: use swine model with ICP monitors in to monitor changes with different versions of RSI

Groups: 1)Thiopental 2) Thiopental and Sux 3) Lido, Thiopental, Sux 4) pancuronium, lido, thiopental, sux

FENTANYL

Advocated for use in premedication Rosen’s AIME US airway course

3mcg/kg 3 minutes before No evidence from our setting or at

time of ETI

Objective: determine the effect of fentanyl on ICP in head injured sedated patients with monitors in place

Design: randomizedResults:

Significant increase in ICP transiently Significant decrease in MAP Significant decrease in CPP

Objective: determine the effect of fentanyl on ICP and CBF in sedated patients with severe head injury

Design: RandomizedResults:

Significantly increased ICP Significantly decreased MAP No change in CBF

KETAMINE

The case against Ketamine 1. Gardner et al. Intracranial CSF

pressure in man during ketamine. Anesth Analg. 1972;51:741-5.

2. Shapiro et al. Ketamine anesthesia in patients with intracranial pathology. Br J Anesth. 1972;44:1200-04.

3. Takeshita et al. The effects of ketamine on cerebral circulation and metabolism in man. Anesthesiology. 1972;36:69-75.

Objective: determine effect of IV Ketamine on ICP/CPP/MAP

Population: 8 ventilated patients with ICP monitors in place

Intervention:1.5, 3 and 5mg/kg IVResults:

Significant reduction in ICP

Design: prospective double-blind RCT Population: 25 pts with severe head

injury Intervention: continuous infusion of

ketamine-midazolam v. sufentanil-midazolam

Results No significant difference in daily ICP No significant change in daily CPP

Design: prospective RCTPopulation: 35 patients with

moderate or severe head injury Intervention: ketamine-midazolam

v. fentanyl-midazolam infusionsResults

Slightly higher ICP in ketamine group (2mmHg)

Slightly higher CPP in ketamine group (8mmHg)

KETAMINE THEORIES

Increases ICP Old studies in patients with abnormal CSF

flow Increases CPP▪ Not sure of the effect this has on regional

blood flow to penumbra and outcome assoc w this

Neuroprotective NMDA R antagonist decreases glutamate

(neurotoxic) ?neuroprotective Some animal models, nothing strong in

humans

CASE CONT…

Your patients are now both intubated.

What are you initial vent settings and what goal(s) do you give the RT?

If the patient shows evidence of herniation how does this change you approach to ventilation?

VENTILATION HEAD INJURY

Not Herniating Mode: AC Vt= 8cc/kg PEEP= 5 PCO2= 35-40 RR= 10-18

Herniating Hyperventilate until clinical recovery or

definitive Mx

LEVEL I Insufficient evidence

LEVEL II Prophylactic hyperventilation (PaCO2 of

25) isnot recommended LEVEL III

Hyperventilation is recommended as a temporizing measure for the reduction in elevated ICP

STANDARDS Insufficient data

GUIDELINES Insufficient data

OPTIONS Mild hyperventilation (PCO2<35) should be

avoided Mild hyperventilation may be considered for

long periods of refractory high ICP Aggressive hyperventilation (PCO2<30) may be

considered for brief periods in cases of cerebral herniation or acute neuro deterioration

CASE CONTINUED

The female patient now has a blown pupil.

How do you want to manage this?

HERNIATION MX

1. HYPEROSMOLAR THERAPY1. Mannitol2. Hypertonic Saline3. Barbiturates

2. HYPERVENTILATION3. SURGERY

Objective: Compare high dose barbiturates to mannitol for ICP control

Design: RCTResults:

ICP significantly lowered in mannitol group

CPP significantly improved Mortality improved

MANNITOL

Level I Evidence Insufficient data to support level I

evidence Level II Evidence

Mannitol is effective for control of ICP Dose of 0.25g/kg-1g/kg Avoid SBP<90

Level III Evidence Restrict to use in patients with signs of

herniation OR w an ICP monitor in

Design: ProspectiveObjective: effect 3% Saline

continuous infusion on refractory elevated ICP in severe HI pediatric patients

Results Statistically significant decrease in ICP Statistically significant decrease in #

of ICP spikes Statistically significant increase in CPP

Design: prospective RCT pilotPopulation: 9 patients with ICP>20 Intervention: 200cc bolus of 20%

Mannitol v 100cc bolus of 7.5% Saline over 5 minutes

Results: Significant reduction in ICP with HS

compared to mannitol Both reduced ICP (13mmHg v

7.5mmHg)

HYPERTONIC SALINE

Current evidence is not strong enough to make recommendations on the use, strength and method of administration of hypertonic saline

Standards Not enough evidence

Guidelines▪ Not enough evidence

Options HS is effective for control of ICP after

severe head injury▪ 3% Saline 0.1mL/kg to 1.0mL/kg continuous

Mannitol is effective for control of ICP after severe head injury▪ 0.25-1.0g/kg bolus

CASE CONT…

Your patients are now intubated, stable and ICU is rounding so want you to manage them for a few hours.

The nurse asks if you want to cool the patients.

Are you going to cool this patient?

Design: large multicenter RCT Intervention: hypothermia (33C)

initiated w/i 6 hrs for 48hrs v. normothermia

Population: n= 362, age 16-65 with coma after CHI

Results: (hypo v. normo) Poor functional outcome: 57% vs 57% Mortality: 28% vs 27% Fewer hypothermic patients had high ICP

Design: multicenter, international, RCT

Intervention: hypothermia (32.5C for 24hr w/i 8hrs of injury) v. normothermia (37C)

Population: n= 225, Age 1-17 with TBI and GCS<8, CT w brain injury and need for mechanical ventilation

Results: (hypo v. normo) Unfavorable outcome 31% v 22% P=

0.14 Deaths 23 v 14 P=0.06

LEVEL I EVIDENCE Insufficient data

LEVEL II EVIDENCE Insufficient data

LEVEL III EVIDENCE Pooled data indicate hypothermia is not

significantly associated with decreased mortality

It is associated with significantly higher outcome scores

Need to maintain for >48hrs

STANDARDS Insufficient data

GUIDELINES Insufficient data

OPTIONS Extrapolated from adult data,

hyperthermia should be avoided Despite lack of evidence, hypothermia

may be considered in cases of refractory intracranial htn

TEMP CONTROL

Maintain normothermiaWhat if they are febrile?

CASE IN REVIEW

Intubate in field? CT head rules pocket guide AED prophylaxis? Premedication with lido/fentanyl? Induction with ketamine? In whom? Use of mannitol for herniation? Use of hypertonic saline for

herniation? Vent strategies? Cooling?

CASE 2 5M who fell off a chair and hit the

temporal side of his head on the side of a table. No loss of consciousness. Next day vomits 6 times and complains of headache

7F falls from the Jungle Gym (7ft) and hits her head. No amnesia, no LOC, normal exam

18m.o. M fell from change table onto hardwood floor. Cried immediately. Has had a good feed but is slightly irritable when you examine him