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To CT or Not To CT

Brian Bizik MS PA-C

What I feared most in

acute/emergency medicine

($ sign means board question!)

Lawyers are out there. . .

You need to have a plan:

- Visualize yourself in charge

- What will the patient look like?

- What will they present like?

- You should, very quickly, know what course you are likely headed down. Pun intended.

Some stats -

- Half a million head injuries

- 10% (severe) die before they get to you

- 80% are considered mild

- 10% moderate and 10% severe

- 1 in 5 have lingering affects of the head trauma – $post concussive syndrome etc.

First some terms . . . . - Primary Injury – initial blow/injury

- Secondary Injury – hypoxic, metabolic, hypoperfusion changes

- Concussion – trauma induced alteration in mental status ($CT changes?)

- $Glasgow Coma Scale – see next slide

An anatomy review –

SCALP:

- Skin

- Connective Tissue

- Aponeurosis (Galea)

- Loose areolar tissue

- Pericranium

Meninges – the bad place

- these separate the brain and the skull and contain blood vessels, CSF and a lot of potential spaces.

Skull

Dura mater

Arachnoid Layer

Pia Mater

Brain

Meningeal arteries (epidural)

Bridging veins (subdural)

CSF circulation (sub arachnoid)

Interior Skull SurfaceThe base of the skull is rough, with many bony protuberances.

These ridges can result in injury to the temporal lobe of the brain during rapid acceleration.

Bony ridges

Injury from contact with skull

Blood Vessels of the Skull The brain requires a

rich blood supply, and the space between the skull and cerebrum contains many blood vessels.

These blood vessels can be ruptured during trauma, resulting in bleeding.Groove for

middle meningeal artery

Lobes of the Cerebrum

Occipital Lobe

Parietal Lobe

Temporal Lobe

Frontal Lobe

Limbic Lobe

Occipital Lobe

The occipital lobe is at the rear of the brain and controls vision and recognition.

Frontal LobeThe frontal lobe is the area of the brain responsible for higher cognitive functions.

These include:

• Problem solving

• Spontaneity• Memory• Language• Motivation• Judgment• Impulse

control• Social and

sexual behavior.

Temporal LobeThe temporal lobe plays a role in emotions, and is also responsible for smelling, tasting, perception, memory, understanding music, aggressiveness, and sexual behavior.

The temporal lobe also contains the language area of the brain.

Parietal Lobe

The parietal lobe plays a role in our sensations of touch, smell, and taste. It also processes sensory and spatial awareness, and is a key component in eye-hand co-ordination and arm movement.

The parietal lobe also contains a specialized area called Wernicke’s area that is responsible for matching written words with the sound of spoken speech.

Limbic LobeThe limbic lobe is located deep in the brain, and makes up the limbic system. This system contains the fornix and hypothalamus (among others) and controls emotion, feelings etc. It also connects higher and lower thought processes.

Cerebrospinal fluid is a colorless liquid that bathes the brain and spine.

It is formed within the ventricles of the brain, and it circulates throughout the central nervous system.

Cerebrospinal fluid fills the ventricles and meninges allowing the brain to “float” within the skull.

A Nice, normal CT!

A bit about the physiology of the brain then we will put it all together and you will be smart.

First some ideas about pressure in your head.

This looks harder than it is. The volume in your brain is fixed. Add a huge glob of anything and eventually the mechanisms for keeping things in control break down and pressure builds. Bad, very bad.

This is more complex than it looks but it is the same idea. For awhile everything is fine. The patient looks normal, but pressure is building, when it hits a critical mass, ICP rises quickly and neurologic demise is coming.

Brain Metabolism & Perfusion

• Perfusion– Cerebral Blood Flow (CBF)

• dependent upon CPP• flow requires pressure gradient

– $Cerebral Perfusion Pressure (CPP)• pressure moving the blood through the cranium

• autoregulation allows BP change to maintain CPP

• CPP = Mean Arterial Pressure (MAP) - Intracranial Pressure (ICP)

Brain Metabolism & Perfusion• Perfusion

– Mean Arterial Pressure (MAP)• largely dependent on cerebral vascular resistance (CVR) since diastolic is main component

• blood volume and myocardial contractility

• MAP = Diastolic + 1/3 Pulse Pressure• usually require MAP of at least 60 mm Hg to perfuse brain

– Intracranial Pressure (ICP)• edema, hemorrhage• ICP usually 10-15 mm Hg

So. . .

CPP = MAP – ICPIf CPP drops your patient could have many more problems from secondary injury than the primary injury. Keep the CPP up at all costs. So you will need to keep the MAP up and the ICP down. More later. . . .

Now onto the classification of Head Injuries

1.Mechanism of Injury:

A. Blunt injury – MVA, falls, hits

B. Penetrating – GSW and stabbing

2.Severity:

This is where the GCS comes in

Classification of Head Injuries3. Morphology:

A. Skull fractures- linear, stellate, may be on the skull base. A few terms and pictures:

$Racoon eyes – periorbital ecchymosis

$Battle sign – retroauricular ecchymosis

Rhinorrhea – CSF from the nose

Otorrhea – CSF from the ear

HEAR THIS – a skull fracture of any kind (depressed or not) increases the risk of an intracranial bleed 400X baseline. Don’t miss this diagnosis.

Linear Skull fractures(aka can you find the headache?)

Depressed Linear

Stellate

Basilar

Skull Fractures

B. Intracranial Lesions

1. Diffuse Brain injuries – this can be anything from a concussion to a massive Diffuse Axonal Injury pattern. Many times this shows as punctate lesions on CT. This can also can be called an Axonal Shearing Injury.

Diffuse Brain Injury example

Diffuse Brain Injury example

B. Intracranial Lesions cont -

2. Epidural Hematomas – Uncommon but often fatal. Remember, these are found inside the skull but outside the dura. These are an arterial bleed, usually $middle meningeal artery. $Lucid interval-Rapid deterioration possible, HA, decreased LOC-Increased ICP a big problem (arterial bleed)-Looks crescent shaped on CT-Hemiparesis, hemiplegia, -Unequal pupils (dialated on side of clot)-Increased BP with decreased pulse (Cushing’s reflex)

Epidural Hematoma

Epidural Hematoma

Epidural Hematoma

Epidural Hematoma

B. Intracranial Lesions cont -

3. Subdural Hematomas – Venous in nature. Much more common and tend to be slower to develop. Come on with HA, altered LOC, unequal pupils.

Up to 1/3 of patients have a lucid period. Majority are drowsy/comatosed. Arousable patients may complain of unilateral

headache and frequently have an enlarged pupil on that side.

Brain damage more severe, prognosis worse. Deteriorating level of consciousness and

worsening neuro exam are a hallmark.

Subdural Hematoma

Subdural Hematoma

Subdural Hematoma

Subdural Hematoma

Treatment!

Again, have a plan in mind. Within 1-2 minutes you should have a good idea of what level of care the patient will need. Then, based on that level, move quickly to evaluation and management.

Treatment!Three levels of head injuries (note

surgical evaluation different than all others):

1.Mild head trauma - GCS 14-15, typically mild mechanism of injury. Patient doing well.

2.Moderate head trauma – GSC 9-13, more severe mechanism, obvious injury/LOC changes.

3.Severe head trauma – GSC 3-8, severe injury. Often life threatening, intubation mandatory, surgery often needed.

Let’s build a chart and have a good visual picture of how to manage each of these levels.LEVEL GCS PATIENT

APPEARANCE

TREATMENT

MILD 14-15(real

world is 15 only)

Good, talking, walking, short LOC, min amnesia if any, Neuro exam(s) ALL normal.A concussion!

Get great historyExamine, more than once (serial!)Watch, 2-6 hours Labs (ETOH, preg) if neededLow risk= no HA/no sustained emesis/no ETOH, no Coumadin, not over 60 Y, not alone, no distractionDon’t CT (typically) Don’t x-ray, MRI is TMI. D/C with Head Trauma Precautions

MODERATE

9-13

SEVERE 3-8

Get great history – full mechanism of injury, witnesses, time of events, neuro status then and now. Examine, more than once (serial!) – full primary and secondary survey, find those other injuriesWatch, 2-6 hours, keep them till you are happy.Labs (ETOH, preg) often not needed. Decide if low risk - no HA, no sustained emesis, no ETOH, no Coumadin, >60 Y, not alone, no distracting injuries.Don’t CT (typically) – Don’t x-ray, MRI is TMI. If all above okay, then D/C with Head Trauma Precautions (see FYI section)

Pre-arrival

Resource identification and allocation

1o Survey 2o Survey

Basic Studies Specialty Studies

Reevaluation

Resuscitation

1o Therapy Definitive Therapy

Moderate or Severe Head Trauma:Initial Management Priorities Components of Management

1 Hour

LEVEL GCS PATIENT APPEARANCE

TREATMENT

MILD 14-15(real

world is 15 only)

MODERATE

9-13 Can be confusing.Some lingering symptoms, somnolent, decreased LOC, amnesia, trauma to scalp, distracting injuries.

IF STABLE (ABC’s all okay) – non declining neurologic exam then:initiate CT, IV line, labs, monitor, equipment to bedside, primary survey/secondary survey. IF UNSTABLE – Transfer or consult with neuro while starting all of above. Do not delay transfer for anything outside of ABC’s. DECESION TIME!

SEVERE 3-8

*Get history – from patient and witnesses, compare*Examine – they are ABC stable so do a quick primary and neuro exam once.*Initiate CT - start machine, call tech in, *Labs - CBC, CMP, ETOH, Preg, drug level (Dilantin etc.), hold type and cross, urine tox. *IV/monitor – check BP q5min, pulse and cardiac monitor, O2, IV (at least one 16g in large vein).Full secondary survey – what else is going on, detailed neuro exam.$Get CT - “Death begins in CT”, send someone, YOU read this initially, make decision.

STABLE moderate head injury

* Happens simultanously

If bleed on CT – send patient without delay or get consult without delay. Don’t wait for radiology read. Monitor vitals and do serial neuro exams. If no bleed on CT – if no bleed admit patient. If normal neuro for 12+ hours and they meet the “minor head trauma” guidelines, d/c with close follow up with PCP.

STABLE moderate head injury

LEVEL GCS PATIENT APPEARANC

E

TREATMENT

MILD 14-15(real

world is 15 only)

MODERATE

9-13 Poor or declining responses. Somnolent, dizzy, confused, amnesic. Decreased or agonal respirations, slow pulse, BP?

All patients with unstable moderate or severe head trauma must be moved to a definitive care facility without delay. Perform resuscitation only. Do not order tests if this will delay transfer. Blood work ok if no delay. CT not recommended. If neurologist on staff consult immediately.

SEVERE 3-8

ABCs – intubation mandatory if GCS 8 or less or if any concern about patients ability to maintain airway.Initiate Transport/Consultation – start this process as appropriate for the facility. Do not delay for any non-ABC reason.

UNSTABLE moderate or severe head trauma

Resuscitation – 1. Airway/Breathing – intubate following RSI

guidelines (more in a minute). Don’t hyperventilate. Shoot for a normal PCO2. (Note: you should have one focused neuro exam done and if possible, blood gasses, before sedation)

2. Circulation – 2 large bore (16g) IV’s. Hang 2 bags of NS or LR. Watch BP carefully. Low BP is deadly. Keep CPP up. Shoot for a MAP of 100+. Control all bleeding with direct pressure. Most rec. elevation of head of bed.

-Transport/Consult is pending - 3. Focused serial neuro exams – GSC and pupillary

light response. (no doll’s eye test)4. CT not recommended unless a definitive care

facility.

Medicines – 1. O2 – yes, non-rebreather at 15 LMP.2. IV fluids – yes, NS or LR. (hypertonic maybe)3. $Mannitol – yes, if declining LOC or Neurologist

recommendation. Good data. 1g/kg bolus over 5 min.4. Phenytoin – yes, with Neurologist

recommendation. Ask first, don’t piss of the Neurologist. Usually no time for this however. Prevents early traumatic seizure activity.

5. Steroids – no, no data at all.6. Benzos – no, no data.7. Lasix – generally no. Some Neurologists like it,

see #4 above. 8. Anything else – no, no data yet.

Last thoughts –

Parents fear head trauma and rightfully so. If true mild head trauma and parents want CT, get it.

Three peaks to a bleeding – 1-2 hours, 2-3 days and 2-6 weeks (Coumadin). So if they are a repeat patient, typically scan

Scalp Lacerations –1. Very fun to repair. 2. Very bloody which is good, infection rare. Control

bleeding with direct pressure. 3. Carefully clean wound with saline under medium

pressure.4. Careful examination of skin, galea, and skull.

Probe thoroughly for skull fxr and foreign body. Skull FXR is an automatic moderate head trauma protocol.

5. Must close galea first with Vicryl. Don’t use nylon on galea . . . photo on next slide.

6. Close with staples/sutures (what would you do for your kid??)

7. Do serial neuro checks. 8. Tetanus shot yes, $antibiotics not unless dirty

wound. 9. Full head trauma precautions.

Scalp Lacerations –

Rapid Sequence Intubation:Head trauma is largely the same as any other RSI1. Prepare – get all your gear together including blade,

suction, reversal agents and back up plan. For kids use Braeslow Tape.

2. Preoxygenate – 100% O2 by mask for 5 min if possible or 8 breaths if time short.

3. Pretreat – gets the body ready for intubation. Lidocaine – to blunt rise in ICPAtropine – in kids under 10Vecuronium or Pancuronium – at a

defasciculating does4. Paralysis (w or w/out induction) –

Benzo’s or Etomidate optionalSuccinylcholine or Vec or Roc.

5. Placement – intubate6. Proof – verify placement

(note that some say use only Rocuronium and Etomidate)

Some C-spine stuff – 1.Assume c-spine injury if head trauma

present.2.If unsure, get c-spine CT at time of head

CT if safe to do so. 3.You can be sure there is no cervical

fracture if there is NONE of the following (Nexus study):

• Midline cervical tenderness• Altered level of alertness• Evidence of intoxication• Neurological abnormality• Presence of distracting injury

You can be great at head trauma. Study

hard.

Visualize the plan and practice and you will

be confident and calm!