Head TraumaHead Trauma

Presented byPresented by

Aric Storck, PGY3Aric Storck, PGY3

Precepted byPrecepted by

Dr. Ian RigbyDr. Ian Rigby

August 12, 2004August 12, 2004

OutlineOutline

Primary / Secondary Brain InjuryPrimary / Secondary Brain Injury Minor Head InjuriesMinor Head Injuries

Selective radiographySelective radiography PediatricsPediatrics ConcussionConcussion

Severe Head InjuriesSevere Head Injuries Intracranial hypertensionIntracranial hypertension Neuroprotective measuresNeuroprotective measures Seizure prophylaxisSeizure prophylaxis

Basilar skull fracturesBasilar skull fractures

EpidemiologyEpidemiology>1.1 million ED visits / year in NA>1.1 million ED visits / year in NA

Minor head injuries (GCS 14-15) - 80%Minor head injuries (GCS 14-15) - 80%Moderate head injuries (GCS 9-13) - 10%Moderate head injuries (GCS 9-13) - 10%Severe head injuries (GCS <9) - 10%Severe head injuries (GCS <9) - 10%

50,000 die before reaching hospital50,000 die before reaching hospital20% hospitalized20% hospitalized200,000 permanent disability200,000 permanent disability leading cause of traumatic death in leading cause of traumatic death in

males <25males <25

Primary InjuryPrimary Injury Occurs at time of accidentOccurs at time of accident

Due to direct impact of mechanical forcesDue to direct impact of mechanical forces

Irreversible damage from mechanical cellular Irreversible damage from mechanical cellular and microvascular disruptionand microvascular disruption

Preventable with protective gear, etc.Preventable with protective gear, etc.

No intervention possible in EDNo intervention possible in ED

Primary InjuryPrimary InjurySkull FracturesSkull Fractures

Linear – no specific treatmentLinear – no specific treatment

DepressedDepressed May tear dura or damage brainMay tear dura or damage brain Operative elevation may be requiredOperative elevation may be required

Compound depressed (open)Compound depressed (open) Wound debridement +/- surgical elevationWound debridement +/- surgical elevation

Skull baseSkull base May be complicated by meningitis/abscessMay be complicated by meningitis/abscess

Primary Brain InjuryPrimary Brain Injury Directly under the injury site (coup)Directly under the injury site (coup)

Remote from injury site (contre-coup)Remote from injury site (contre-coup)

ConcussionConcussion

ContusionsContusions Often frontal-temporal due to rough contour of Often frontal-temporal due to rough contour of

skull baseskull base

Intracranial hematomasIntracranial hematomas Epidural hematomasEpidural hematomas Subdural hematomasSubdural hematomas Subarachnoid hematomasSubarachnoid hematomas

Diffuse axonal injuryDiffuse axonal injuryShearing of brain tissue with disruption Shearing of brain tissue with disruption

of neuronal projections in white matterof neuronal projections in white matterMicroscopic injuryMicroscopic injuryNot usually visible on CTNot usually visible on CTMay be visible on MRIMay be visible on MRI

Secondary injurySecondary injury

Injury occurring after primary insultInjury occurring after primary insult

Generally due to poor cerebral perfusionGenerally due to poor cerebral perfusion

All of our therapies are directed All of our therapies are directed at reducing this!at reducing this!

Cerebral Blood FlowCerebral Blood Flow Autoregulation possible over range of Autoregulation possible over range of

CPP’sCPP’s

Vulnerable toVulnerable to Systemic hypotensionSystemic hypotension

SBP<90SBP<90 Reduces cerebral perfusion … ischemiaReduces cerebral perfusion … ischemia Doubles mortality, worsens outcome of Doubles mortality, worsens outcome of

survivorssurvivors Increased ICPIncreased ICP

HypoxiaHypoxia PO2<60PO2<60 Doubles mortalityDoubles mortality

AnemiaAnemia Hematocrit <30%Hematocrit <30% Increases mortalityIncreases mortality

Increased ICPIncreased ICPCSF + Blood + Brain + Mass = constantCSF + Blood + Brain + Mass = constant

~100-150cc extra tolerated before ~100-150cc extra tolerated before ICPICP

Multiple therapies targeting Multiple therapies targeting ICPICPMannitolMannitolHTSHTSHyerventilationHyerventilationVentriculostomyVentriculostomyParalysis & sedationParalysis & sedation

22o o systemic insultssystemic insults

HypoxiaHypoxiaHypotensionHypotensionAnemiaAnemiaElectrolyte disturbancesElectrolyte disturbancesHypo/HyperglycemiaHypo/HyperglycemiaHyperthermiaHyperthermiaSeizuresSeizures

Case 1Case 1 21 year old male. Tripped and hit head on 21 year old male. Tripped and hit head on

ground playing soccer. No LOC. Does not ground playing soccer. No LOC. Does not remember details of the incident. remember details of the incident. Previously healthyPreviously healthy

What else do you want to know?What else do you want to know?

O/EO/E 96 14 120/80 36.7 98%96 14 120/80 36.7 98% PERL 4mm PERL 4mm Eyes open, a little confused, follows commandsEyes open, a little confused, follows commands Remainder of exam normalRemainder of exam normal GCS?GCS?

Glasgow Coma ScaleGlasgow Coma Scale Eye Opening (E)Eye Opening (E)

4. Spontaneous4. Spontaneous 3 . To voice3 . To voice 2. To pain2. To pain 1. None1. None

Verbal Responses (V)Verbal Responses (V)― 5. Oriented5. Oriented― 4. Confused4. Confused― 3. Inappropriate words3. Inappropriate words― 2. Incomprehensible 2. Incomprehensible

soundssounds― 1. None1. None

Motor response (M)Motor response (M) 6. Obeys commands6. Obeys commands 5. Localizes pain5. Localizes pain 4. Withdraws from pain4. Withdraws from pain 3. Abnormal flexion3. Abnormal flexion 2. Abnormal extension2. Abnormal extension 1. None1. None

NBNB Developed for Developed for

evaluation of head evaluation of head trauma 6 hours post trauma 6 hours post injuryinjury

Deceased have GCS 3Deceased have GCS 3

What is the severity of his injury?What is the severity of his injury?Minor, Moderate, Severe?Minor, Moderate, Severe?

Does he need neuroimaging?Does he need neuroimaging?CT, MRI, Skull Radiographs?CT, MRI, Skull Radiographs?

If you don’t image them, what are you going to If you don’t image them, what are you going to do?do?

Observe, admit, discharge?Observe, admit, discharge?

What is his risk for a “clinically important” What is his risk for a “clinically important” brain injurybrain injury

Minor Head TraumaMinor Head Trauma

~80% of all head injuries~80% of all head injuries

Originally classified as GCS 13-15Originally classified as GCS 13-15

Now defined as GCS 14-15Now defined as GCS 14-15GCS 13 found to have outcomes more GCS 13 found to have outcomes more

similar to moderate (GCS 9-12) HI group. similar to moderate (GCS 9-12) HI group. More abnormal CT scans than GCS 14-15More abnormal CT scans than GCS 14-15

PresentationPresentationHA, disorientation, confusion, amnesiaHA, disorientation, confusion, amnesiaNo focal neurological deficitsNo focal neurological deficitsPrognostic significance of LOC uncertainPrognostic significance of LOC uncertain

3% will deteriorate 3% will deteriorate

1% have surgical lesions1% have surgical lesions

<0.5% will die<0.5% will die

Minor Head TraumaMinor Head Trauma

Rosen 2002: Rosen 2002: High Risk Minor Head InjuryHigh Risk Minor Head Injury

Focal neurologic findingsFocal neurologic findings

Asymmetric pupilsAsymmetric pupils

Skull fractureSkull fracture

Multiple traumaMultiple trauma

Serious, painful, distracting injuriesSerious, painful, distracting injuries

External signs of traumaExternal signs of trauma

Initial Glasgow Coma Scale score of 13Initial Glasgow Coma Scale score of 13

Loss of consciousness (>2 min)Loss of consciousness (>2 min)

Posttraumatic confusion/amnesia (>20 min)Posttraumatic confusion/amnesia (>20 min)

Progressively worsening headacheProgressively worsening headache

VomitingVomiting

Posttraumatic seizurePosttraumatic seizure

History of bleeding disorder/anticoagulationHistory of bleeding disorder/anticoagulation

Recent ingestion of intoxicantsRecent ingestion of intoxicants

Unreliable/unknown history of injuryUnreliable/unknown history of injury

Suspected child abuseSuspected child abuse

Age >60 yr, <2 yrAge >60 yr, <2 yr

Rosen 2002: Rosen 2002: Low Risk Minor Head InjuryLow Risk Minor Head Injury

Currently asymptomaticCurrently asymptomatic

No other injuriesNo other injuries

No focality on examinationNo focality on examination

Normal pupilsNormal pupils

No change in consciousnessNo change in consciousness

Intact orientation/memoryIntact orientation/memory

Initial Glasgow Coma Scale score of 14 or Initial Glasgow Coma Scale score of 14 or 1515

Accurate historyAccurate history

Trivial mechanismTrivial mechanism

Injury >24 hr agoInjury >24 hr ago

Reliable home observersReliable home observers

CT Scans in Minor Head InjuryCT Scans in Minor Head Injury

1,000,000 Minor HI scanned annually in 1,000,000 Minor HI scanned annually in USUS

$750,000,000 in charges$750,000,000 in charges

Significant intracranial injury in <6%Significant intracranial injury in <6%

So … ~95% incur expense and radiation So … ~95% incur expense and radiation exposure with negative examinationexposure with negative examination

CT scan in minor head injuryCT scan in minor head injury

An ongoing and evolving issueAn ongoing and evolving issue scan everyonescan everyone scan no onescan no one selective scanningselective scanning wide variation in inter-physician and teaching wide variation in inter-physician and teaching

hospital scanning rateshospital scanning rates

Conflicting goalsConflicting goals Minimize the number of unnecessary scans Minimize the number of unnecessary scans

performedperformed Not miss any significant HI’sNot miss any significant HI’s

““The New Orleans Rules”The New Orleans Rules”Indications for CT in patients with minor HIIndications for CT in patients with minor HI

Haydel et al. NEJM 2000;343:100-5.Haydel et al. NEJM 2000;343:100-5.

Minor HIMinor HI Any LOC or amnesiaAny LOC or amnesia Normal neuro examNormal neuro exam

Derived with 520 Derived with 520 patientspatients

Validated on 909 Validated on 909 patientspatients

CT patients with 1 CT patients with 1 or more ofor more of H/AH/A VomitingVomiting Age>60Age>60 Drug or ETOH Drug or ETOH

intoxicationintoxication AmnesiaAmnesia SeizureSeizure Trauma above the Trauma above the

claviclesclavicles

Sens for CT abnormality 100% (95%-Sens for CT abnormality 100% (95%-100%)100%)

Would reduce CT ordering rate by Would reduce CT ordering rate by 22% at study site22% at study site

Would increase CT usage in Would increase CT usage in CanadaCanada

Canadian CT Head RuleCanadian CT Head RuleStiell, I Stiell, I et al.et al. Lancet 2001;357:1391-96. Lancet 2001;357:1391-96.

3121 patients3121 patients Multicentred, prospective Multicentred, prospective

cohort studycohort study

Inclusion criteriaInclusion criteria blunt traumablunt trauma GCS 13-15 in EDGCS 13-15 in ED witnessed LOC, amnesia witnessed LOC, amnesia

or disorientationor disorientation injured within the past injured within the past

24hrs24hrs

Exclusion criteriaExclusion criteria <16 years<16 years no LOC, amnesia, or no LOC, amnesia, or

disorientationdisorientation obvious depressed skull obvious depressed skull

## penetrating skull injurypenetrating skull injury focal neurological focal neurological

deficitdeficit post-injury seizurepost-injury seizure pregnantpregnant congenital or acquired congenital or acquired

bleeding disorder.bleeding disorder.

Canadian CT Head RuleCanadian CT Head Rule Primary outcome Primary outcome

need for neurological need for neurological intervention within 7 daysintervention within 7 days

Death from head injury Death from head injury IntubationIntubation CraniotomyCraniotomy elevation of skull#elevation of skull# ICP monitoringICP monitoring

Secondary outcomesSecondary outcomes Clinically Important Brain Injury Clinically Important Brain Injury

(CIBI)(CIBI) ““an injury which would normally an injury which would normally

require admission and neuro require admission and neuro follow-up”follow-up”

consensus of EPs, consensus of EPs, neurosurgeons and neurosurgeons and neuroradiologistsneuroradiologists

CIBI definedCIBI defined All lesions unless All lesions unless

neurologically intact withneurologically intact with Solitary contusion Solitary contusion

<5mm<5mm Localized SAH <1mmLocalized SAH <1mm SDH<4mmSDH<4mm Isolated pneumocephalyIsolated pneumocephaly Closed and depressed Closed and depressed

skull#, not through skull#, not through inner tableinner table

Canadian CT Head RuleCanadian CT Head Rule

Study DesignStudy DesignPatients assessed for 22 standardized Patients assessed for 22 standardized

findings on Hx, PE and neurological findings on Hx, PE and neurological exam.exam.

CT scan at discretion of physicianCT scan at discretion of physicianFollow-up by phone at 14 days for those Follow-up by phone at 14 days for those

who did not have a CT to determine the who did not have a CT to determine the presence of CIBI.presence of CIBI.

Canadian CT Head RuleCanadian CT Head Rule

ResultsResults 1% (44) required neurosurgical intervention1% (44) required neurosurgical intervention 0.13% (4) died0.13% (4) died 8% (254) clinically important brain injury8% (254) clinically important brain injury 4% (94) clinically unimportant brain injury4% (94) clinically unimportant brain injury

small SAH, contusions <5mmsmall SAH, contusions <5mm

67% had CT, 33% phone follow-up, 1358 eligible 67% had CT, 33% phone follow-up, 1358 eligible patients not enrolled, 363 lost to follow-uppatients not enrolled, 363 lost to follow-up

Canadian CT Head RuleCanadian CT Head Rule7 variables with good interobserver 7 variables with good interobserver

agreement and strong association with agreement and strong association with the outcomethe outcome

Goal was highest sensitivity while still Goal was highest sensitivity while still achieving greatest specificityachieving greatest specificity

Stratifies patients into three groupsStratifies patients into three groupshigh riskhigh risk for the primary outcomes for the primary outcomesmedium riskmedium risk for the secondary outcome for the secondary outcomeLow riskLow risk for either outcome for either outcome

Canadian CT Head RuleCanadian CT Head Rule High riskHigh risk (for neurological intervention) (for neurological intervention)

GCS score <15 at 2 hours after injuryGCS score <15 at 2 hours after injury Suspected open or depressed skull fractureSuspected open or depressed skull fracture Any sign of basal skull fractureAny sign of basal skull fracture

hemotympanum, "raccoon" eyes, CSF otorrhea or hemotympanum, "raccoon" eyes, CSF otorrhea or rhinorrhea, Battle's sign)rhinorrhea, Battle's sign)

Vomiting 2 or more timesVomiting 2 or more times Age 65 or olderAge 65 or older

CT “mandatory”CT “mandatory” for these patients for these patients (4.6% (4.6% chance of requiring neurological intervention) chance of requiring neurological intervention) Sens 100% (92%-100%)Sens 100% (92%-100%) Spec 69% (67%-70%)Spec 69% (67%-70%) CT ordering proportion 32%CT ordering proportion 32%

Canadian CT Head RuleCanadian CT Head Rule

Medium riskMedium risk (for CIBI on CT) (for CIBI on CT) Amnesia before impact >30 minutesAmnesia before impact >30 minutes Dangerous mechanism Dangerous mechanism

pedestrian struck by motor vehiclepedestrian struck by motor vehicle occupant ejected from motor vehicleoccupant ejected from motor vehicle fall from height >3 feet or 5 stairsfall from height >3 feet or 5 stairs

At risk for CIBI on CTAt risk for CIBI on CT NotNot at risk for neurological intervention at risk for neurological intervention Can manage with CT or observation depending on local Can manage with CT or observation depending on local

resourcesresources Sens. 98.4% (96%-99%)Sens. 98.4% (96%-99%) Spec. 49.6% (48%-51%)Spec. 49.6% (48%-51%)

Canadian CT Head RuleCanadian CT Head Rule

QuestionsQuestionsIs the sensitivity (95% confidence Is the sensitivity (95% confidence

intervals) high enough?intervals) high enough?

Will it reduce the frequency of scanning Will it reduce the frequency of scanning Mild HI patients?Mild HI patients?

The Future …The Future …

NEXUS IINEXUS II

National Emergency X-Ray Utilization StudyNational Emergency X-Ray Utilization Study

Taking place in 21 US and Canadian EDsTaking place in 21 US and Canadian EDs

28,320 patients (~10x as many as next 28,320 patients (~10x as many as next largest study)largest study)

Will be published ????Will be published ????

Case 2Case 240 y.o. homeless man40 y.o. homeless man

Brought in by EMSBrought in by EMSFound on bike pathFound on bike path++ intoxicated++ intoxicatedsome vomiting with ++ coffee some vomiting with ++ coffee

groundsgroundsOpens eyes to pain, Inappropriate angry Opens eyes to pain, Inappropriate angry

words, localizes pain. VSSwords, localizes pain. VSSWhat would you do?What would you do?

Same guy but you’ve been busy. Same guy but you’ve been busy. Now he’s been here 4 hours.Now he’s been here 4 hours.Neurologically unchangedNeurologically unchangedStill reeks like EtOHStill reeks like EtOHNow what?Now what?

Actual case Was seen by GI for

workup of hematemesis

Head injury initially missed

On re-examination a large, boggy scalp lesion and palpable skull fracture was found

Px is +++ important!

Patient died a week later of neurogenic pulmonary edema

Case 3Case 3

60 year old man60 year old manFell 4 feet off ladderFell 4 feet off ladderHit head on grassHit head on grassInitially very confused, now GCS 15Initially very confused, now GCS 15Otherwise healthyOtherwise healthyNormal ExamNormal Exam

Case 4Case 4

16 yo boy fell and hit head while 16 yo boy fell and hit head while skateboardingskateboarding

No LOC No LOC Was confused initially - now feels fineWas confused initially - now feels fineGCS 15, normal examGCS 15, normal examCT or not?CT or not?What kind of head injury is this?What kind of head injury is this?Management?Management?

Case 5Case 5 16 year hockey player16 year hockey player

Checked hard and hit head on iceChecked hard and hit head on ice

Brief (~15 seconds) LOCBrief (~15 seconds) LOC

He was disoriented for ~ 10 minutes but He was disoriented for ~ 10 minutes but now seems finenow seems fine

You are the only doctor in the arena, the You are the only doctor in the arena, the coach asks if his star player has to go to coach asks if his star player has to go to the hospitalthe hospital

Can he keep playing?Can he keep playing?

ConcussionConcussion““temporary and brief interruption of temporary and brief interruption of

neurologic function after minor head neurologic function after minor head trauma, which may involve LOCtrauma, which may involve LOC” (Rosen ” (Rosen 2002)2002)

Usually have normal neuroimagingUsually have normal neuroimaging

Cerebrovascular regulation difficulties Cerebrovascular regulation difficulties for several days after accidentfor several days after accidentVery vulnerable to repeat injuries (second Very vulnerable to repeat injuries (second

impact syndrome)impact syndrome)

AAN. Practice Parameter: The management of AAN. Practice Parameter: The management of concussion in sports. Neurology 1997:48-581-585. concussion in sports. Neurology 1997:48-581-585.

Practice “Practice “OptionsOptions”” Grade 1Grade 1

Remove from contestRemove from contest Examine q5 minutesExamine q5 minutes May return to contest if concussive May return to contest if concussive

symptoms clear within 15 minutessymptoms clear within 15 minutes A second grade 1 concussion A second grade 1 concussion

eliminates the player from the game. eliminates the player from the game. Return in one week only if Return in one week only if asymptomatic.asymptomatic.

Grade 2Grade 2 Remove from contest with no return Remove from contest with no return

that daythat day Repeated neuro exams until symptoms Repeated neuro exams until symptoms

resolve and again the next dayresolve and again the next day MD to perform neuro exam prior to MD to perform neuro exam prior to

returning to play after 1 asymptomatic returning to play after 1 asymptomatic weekweek

Following 2Following 2ndnd grade 2 concussion no grade 2 concussion no return to play until 2 weeks return to play until 2 weeks asymptomaticasymptomatic

CT/MRI if HA or other symptoms worsen CT/MRI if HA or other symptoms worsen or persist >1 weekor persist >1 week

End of season if any CT/MRI abnormalityEnd of season if any CT/MRI abnormality

Grade 3Grade 3

Transport to EDTransport to ED +/- neuroimaging+/- neuroimaging +/- admission+/- admission No return to play until asymptomatic one weekNo return to play until asymptomatic one week Following 2Following 2ndnd grade 3 concussion no return to grade 3 concussion no return to

play until asymptomatic one monthplay until asymptomatic one month CT/MRI if HA or other symptoms worsen or CT/MRI if HA or other symptoms worsen or

persist >1 weekpersist >1 week End of season (or career) for any CT/MRI End of season (or career) for any CT/MRI

abnormalityabnormality

Case 6Case 6 2 year old girl2 year old girl

Tripped and fell down stairsTripped and fell down stairs Hit head on floorHit head on floor Brief (~10 second) LOCBrief (~10 second) LOC No seizures/vomitingNo seizures/vomiting

O/E: eyes open, normal spontaneous O/E: eyes open, normal spontaneous movements, persistent crymovements, persistent cry

What is her GCSWhat is her GCS

CT or not?CT or not?

Applies to Applies to 2-20 year olds2-20 year olds Isolated minor HIIsolated minor HI Normal neurological Normal neurological

examexam No sign of skull fractureNo sign of skull fracture Can include those withCan include those with

LOC<1 minuteLOC<1 minute Seizure immediately post Seizure immediately post

injuryinjury VomitedVomited HA, lethargyHA, lethargy

Does not apply toDoes not apply to PolytraumaPolytrauma Unobserved LOCUnobserved LOC ? C-spine injury? C-spine injury Compounding medical Compounding medical

conditions (eg:bleeding conditions (eg:bleeding diathesis, AVM, etc.)diathesis, AVM, etc.)

Non-accidental traumaNon-accidental trauma Language barrierLanguage barrier

Head Injury in ChildrenHead Injury in ChildrenAAP, AAFP. The Management of Minor Closed Head Injury in AAP, AAFP. The Management of Minor Closed Head Injury in

Children. Pediatrics 1999:104(6)1407-1415.Children. Pediatrics 1999:104(6)1407-1415.

Based on evidence and expert consensus

Summary of Summary of recommendationsrecommendations

Minor HI and no LOCMinor HI and no LOC

ObservationObservation ED or at homeED or at home

CT / SR not indicatedCT / SR not indicated Side-effects (sedation, radiation, unnecessary Side-effects (sedation, radiation, unnecessary

interventions for incidental findings, etc.) outweigh interventions for incidental findings, etc.) outweigh benefits of early detectionbenefits of early detection

Risk of clinically important ICI estimated at Risk of clinically important ICI estimated at <1/5000 (based on large adult study and 2 <1/5000 (based on large adult study and 2 small peds studies)small peds studies)

Minor HI and brief LOCMinor HI and brief LOC

Observation or CTObservation or CTStudies suggest 0-7% may have ICIStudies suggest 0-7% may have ICI

2-5% may need neurosurgical intervention2-5% may need neurosurgical interventionNo evidence to suggest CT better than No evidence to suggest CT better than

observation in asymptomatic patientsobservation in asymptomatic patients$(observation) < $(CT) < $$(observation) < $(CT) < $

(hospitalization)(hospitalization)

DispositionDisposition CT NormalCT Normal

Extremely low risk for subsequent problemsExtremely low risk for subsequent problems 3 studies3 studies

Incidence of deterioration was 0 Incidence of deterioration was 0 (95% CI 0-1.4%) (95% CI 0-1.4%)

Reliable observation still prudentReliable observation still prudent

CT AbnormalCT Abnormal D/C with observation vs admission for D/C with observation vs admission for

observationobservation Careful consideration of abnormalitiesCareful consideration of abnormalities

Case 7Case 79 month old boy9 month old boy

Fell 2 feet from car seat and hit head on Fell 2 feet from car seat and hit head on linoleumlinoleum

Cried immediately, no vomiting, no Cried immediately, no vomiting, no seizuresseizures

O/E: Neurologically normal, small O/E: Neurologically normal, small boggy scalp hematomaboggy scalp hematoma

CT – yes or no?CT – yes or no?

Pediatric (<2 years) HIPediatric (<2 years) HISchutzman S Schutzman S et alet al. Evaluation and Management of Children . Evaluation and Management of Children Younger Than Two Years Old With Apparently Minor Head Younger Than Two Years Old With Apparently Minor Head

Trauma: Proposed Guidelines. Pediatrics 2001:107(5)983-993.Trauma: Proposed Guidelines. Pediatrics 2001:107(5)983-993.

Little research and no clear Little research and no clear guidelines for management of minor guidelines for management of minor HI in young childrenHI in young children

Evidence and expert consensus used Evidence and expert consensus used to derive guidelinesto derive guidelines

404 articles reviewed404 articles reviewed

Children <2 years differ from older Children <2 years differ from older kidskidsClinical assessment difficultClinical assessment difficultAsymptomatic ICI more commonAsymptomatic ICI more commonHigher risk of nonaccidental traumaHigher risk of nonaccidental traumaHigher risk for skull fracturesHigher risk for skull fracturesLeptomeningeal cysts may developLeptomeningeal cysts may develop

Minor Head Injury Minor Head Injury DefinedDefined History, or physical History, or physical

signs, of blunt trauma signs, of blunt trauma to the scalp, skull, or to the scalp, skull, or brain in an infant or brain in an infant or child who is alert or child who is alert or awakens to voice or awakens to voice or light touchlight touch

Does not attempt Does not attempt to addressto address Birth traumaBirth trauma Penetrating traumaPenetrating trauma Neuro disorderNeuro disorder Bleeding diathesesBleeding diatheses Prior neurosurgeryPrior neurosurgery PolytraumaPolytrauma Non-accidental Non-accidental

traumatrauma

Intracranial InjuryIntracranial InjuryIntracranial hematomaIntracranial hematomaCerebral contusionCerebral contusionCerebral edemaCerebral edema

GuidelinesGuidelinesFlexible and follow the general Flexible and follow the general

principlesprinciples

The younger the child, the lower the The younger the child, the lower the threshold for imagingthreshold for imaging

The greater the severity and number or The greater the severity and number or symptoms, the lower the threshold for symptoms, the lower the threshold for imagingimaging

Must consider non-accidental traumaMust consider non-accidental trauma

ResultsResultsHigh Risk GroupHigh Risk Group

CT is Indicated for any of the followingCT is Indicated for any of the following Depressed mental statusDepressed mental status Focal neurological findingsFocal neurological findings Signs of depressed / basilar skull fractureSigns of depressed / basilar skull fracture Acute skull fracture by Px or skull x-raysAcute skull fracture by Px or skull x-rays IrritabilityIrritability Bulging fontanelleBulging fontanelle

No data to support inclusion of seizure, No data to support inclusion of seizure, vomiting, or LOC in decision makingvomiting, or LOC in decision making But suggest that they be taken into But suggest that they be taken into

considerationconsideration

Intermediate Risk GroupIntermediate Risk Group CT or observation (4-6 hours) are CT or observation (4-6 hours) are

acceptableacceptable

Includes children with any ofIncludes children with any of >2 episodes of vomiting>2 episodes of vomiting LOC <1 minuteLOC <1 minute History of lethargy/irritability (resolved)History of lethargy/irritability (resolved) Behaviour not normal as reported by caregiversBehaviour not normal as reported by caregivers Nonacute skull fracture (>24hours old)Nonacute skull fracture (>24hours old) Concerning or unknown mechanismConcerning or unknown mechanism Scalp hematomas (esp. temporoparietal) Scalp hematomas (esp. temporoparietal)

CT if deterioration during observationCT if deterioration during observation

Low Risk GroupLow Risk Group

CT not indicatedCT not indicated

Observation by responsible adultObservation by responsible adult

Includes patients whoIncludes patients whoLow energy mechanisms (fall<3 feet)Low energy mechanisms (fall<3 feet)No SSx >2 hours after injuryNo SSx >2 hours after injury

CATCH CT StudyCATCH CT Study

Clinical Indicators of Intracranial Injury in Clinical Indicators of Intracranial Injury in Head-injured InfantsHead-injured Infants

Greenes D, Greenes D, et alet al. Pediatrics 1999:104(4) 861-867.. Pediatrics 1999:104(4) 861-867.

Prospective study of infants <2 yearsProspective study of infants <2 years N=608N=608 GoalGoal

Identify low-risk criteria to determine which Identify low-risk criteria to determine which patients do not need neuroimagingpatients do not need neuroimaging

HypothesesHypotheses Some ICI’s in asymptomatic patients will be Some ICI’s in asymptomatic patients will be

diagnosed by scalp hematoma on Pxdiagnosed by scalp hematoma on Px Asymptomatic patients with no scalp Asymptomatic patients with no scalp

abnormalities can safely be discharged abnormalities can safely be discharged without neuroimagingwithout neuroimaging

Subjects asymptomatic if lacked all ofSubjects asymptomatic if lacked all ofHx of LOC or lethargyHx of LOC or lethargyIrritabilityIrritabilitySeizuresSeizures>1 emesis>1 emesisDepressed mental statusDepressed mental statusBulging fontanelleBulging fontanelleAbnormal vital signs consistent with Abnormal vital signs consistent with

increased ICPincreased ICPFocal neurological signsFocal neurological signs

Scalp hematomas rated asScalp hematomas rated asSmall (“barely perceptible”)Small (“barely perceptible”)ModerateModerateLarge (“obvious swelling and/or boggy Large (“obvious swelling and/or boggy

consistency”)consistency”)

Scalp hematomas considered Scalp hematomas considered significant ifsignificant if<1 y.o. with any hematoma<1 y.o. with any hematoma>1 y.o. with moderate – large hematoma>1 y.o. with moderate – large hematoma

ResultsResults

30 (5%) had ICI30 (5%) had ICI

Relationship of age and ICIRelationship of age and ICI12/92 (13%) of <2 m.o. had ICI12/92 (13%) of <2 m.o. had ICI13/224 (6%) of 3-11 m.o. had ICI13/224 (6%) of 3-11 m.o. had ICI5/292 (2%) of 12-24 m.o. had ICI5/292 (2%) of 12-24 m.o. had ICI

14 asymptomatic patients had ICI14 asymptomatic patients had ICI 13/14 (93%) had significant scalp hematoma13/14 (93%) had significant scalp hematoma Among patients with significant scalp hematoma Among patients with significant scalp hematoma

who had a CT - OR for ICI 2.78 (95% CI 1.15-6.70)who had a CT - OR for ICI 2.78 (95% CI 1.15-6.70) NB: the only patient missed was a 2yo with an epidural NB: the only patient missed was a 2yo with an epidural

requiring no interventionrequiring no intervention

265 patients (43%) asymptomatic with no 265 patients (43%) asymptomatic with no significant scalp hematomasignificant scalp hematoma No clinically significant injuryNo clinically significant injury 95% CI 0-1.2%95% CI 0-1.2%

Clinically significant (95%) predictors of ICIClinically significant (95%) predictors of ICIHx of lethargyHx of lethargyIrritabilityIrritabilityDepressed mentalstatusDepressed mentalstatusBulging fontanelleBulging fontanelleAbnormal vital signsAbnormal vital signs

Not found to be significantNot found to be significantLOCLOCseizuresseizuresvomitingvomiting

Blunt pediatric head trauma Blunt pediatric head trauma requiring neurosurgical intervention: requiring neurosurgical intervention:

How subtle can it be?How subtle can it be?Brown L, et al. AJEM 2003Brown L, et al. AJEM 2003

Retrospectively reviewed all children Retrospectively reviewed all children <10y.o. with blunt head trauma who <10y.o. with blunt head trauma who went for neurosurgical intervention went for neurosurgical intervention between 1985-2001.between 1985-2001.

110 patients met inclusion criteria110 patients met inclusion criteria

Variables assessedVariables assessed

LOCLOC Altered mental Altered mental

statusstatus SeizuresSeizures VomitingVomiting Focal neurologic Focal neurologic

findingsfindings Scalp hematomaScalp hematoma Scalp lacerationScalp laceration Facial lacerationFacial laceration

Pupillary changesPupillary changes Vital signs Vital signs

abnormal abnormal consistent with consistent with high ICPhigh ICP

HA (kids >2)HA (kids >2) Bulging fontanelle, Bulging fontanelle,

irritability, apnea, irritability, apnea, retinal retinal hemorrhages hemorrhages (kids<2)(kids<2)

ResultsResults

All children had at least 2 SSx of head injuryAll children had at least 2 SSx of head injury

ALOC most common finding (>80%)ALOC most common finding (>80%)

““Emergency physicians should feel Emergency physicians should feel confident that standard history and confident that standard history and physical examination skills are adequate physical examination skills are adequate to identify head-injured children who to identify head-injured children who require neurosurgical procedures.”require neurosurgical procedures.”

A Decision Rule for Identifying Children at Low A Decision Rule for Identifying Children at Low Risk for Brain Injuries After Blunt Head TraumaRisk for Brain Injuries After Blunt Head Trauma

Palchak M, et al. Annals of EM 2003:42(4)Palchak M, et al. Annals of EM 2003:42(4)

Prospective Prospective observational observational studystudy

2043 enrolled2043 enrolled 1271 underwent 1271 underwent

CTCT

Evaluated clinical Evaluated clinical predictors for predictors for outcomes ofoutcomes of1.1. Brain injury on CTBrain injury on CT

2.2. Need acute interventionNeed acute intervention Neurosurgical Neurosurgical

procedureprocedure Antiepileptic Antiepileptic

medications > 1 weekmedications > 1 week Persistent neurological Persistent neurological

deficitsdeficits Hospitalization at least Hospitalization at least

2 nights2 nights

ResultsResults

Significant predictorsSignificant predictors GCS<15GCS<15 Clinical skull fractureClinical skull fracture VomitingVomiting Scalp hematoma if <2yoScalp hematoma if <2yo HeadacheHeadache

Can safely omit CT in absence of all Can safely omit CT in absence of all significant predictorssignificant predictors

Identified 97/98 (99% CI 94-100) Identified 97/98 (99% CI 94-100) patient with head injury on CTpatient with head injury on CTThe only patient not identified was The only patient not identified was

discharged home from ED without discharged home from ED without complicationscomplications

Identified 105/105 (100% CI 97-100%) Identified 105/105 (100% CI 97-100%) of patients requiring acute interventionsof patients requiring acute interventions

NPV 100% (CI 99.7-100)NPV 100% (CI 99.7-100)

ConclusionsConclusions

Application of rule would have eliminated Application of rule would have eliminated ¼ CT scans ordered¼ CT scans ordered

Included all severity of injuriesIncluded all severity of injuries May be underpowered to make judgements May be underpowered to make judgements

about minor head traumaabout minor head trauma

Are the confidence intervals acceptable?Are the confidence intervals acceptable?

Will this reduce use of scanning here?Will this reduce use of scanning here?

SEVERE HEAD INJURYSEVERE HEAD INJURY

Head Injury:Head Injury:HistoryHistory

Key Historic InfoKey Historic InfoMVCMVC fallfall

height, landing position, assault weaponheight, landing position, assault weaponLOCLOCamnesiaamnesiaSz (Hx of Sz)Sz (Hx of Sz)vitals and GCS on scene and transportvitals and GCS on scene and transportAMPLEAMPLEcurrent complaintscurrent complaints

Head Injury: Head Injury: Physical ExamPhysical Exam

Key Clinical InfoKey Clinical Info ABCs --high incidence ABCs --high incidence

of polytraumaof polytrauma GCSGCS Head and neckHead and neck

?basal skull#?basal skull# pupilspupils

size, reactivity, size, reactivity, asymmetryasymmetry

motor exammotor exam symmetry, abnormal symmetry, abnormal

posturing, strength.posturing, strength. Cranial nervesCranial nerves

gag, corneal ref.gag, corneal ref. DTRs and pathologic DTRs and pathologic

reflexesreflexes vitalsvitals ?herniation syndromes?herniation syndromes

Approx 60% TBI will have a Approx 60% TBI will have a second system injurysecond system injury

Up to 16% have associated Up to 16% have associated c-spine injuryc-spine injury

Head Injury:Head Injury:Glasgow Coma ScaleGlasgow Coma Scale

*GCS*GCSdeveloped for assessment at 6hrs post-developed for assessment at 6hrs post-

injuryinjuryisolated HI and hemodynamically stableisolated HI and hemodynamically stableuse at <6hrs is limiteduse at <6hrs is limited

hemodynamics, intubation, ETOH, hemodynamics, intubation, ETOH, sedation/paralysissedation/paralysis

does not assess brainstem functiondoes not assess brainstem function

SEVERE HISEVERE HI

Prevention of secondary injuryPrevention of secondary injury 1 episode of 1 episode of hypotensionhypotension (SBP<90) increased (SBP<90) increased

mortality by 150%.mortality by 150%. Hypoxia Hypoxia (paO2<60) also significantly increased (paO2<60) also significantly increased

mortality (but less than hypotension).mortality (but less than hypotension). Combined hypotension and hypoxia more Combined hypotension and hypoxia more

detrimental than either alone.detrimental than either alone.

Chestnut, RA. Analysis of the role of Secondary Brain Injury in determining the Chestnut, RA. Analysis of the role of Secondary Brain Injury in determining the outcome from severe head injury. outcome from severe head injury. J. Neurosurg J. Neurosurg 1990;72:360.1990;72:360.

Case 8Case 8 40 y.o. woman40 y.o. woman

Rollerblading without helmetRollerblading without helmet Hit occiput on cementHit occiput on cement GCS 12 at scene (E3 V3 M6)GCS 12 at scene (E3 V3 M6) Brought by EMS in full spinesBrought by EMS in full spines

In EDIn ED 90, 120/70, 16, 99% on 5L by np, 36.590, 120/70, 16, 99% on 5L by np, 36.5 PERLPERL Confused, combative, 4 limb spontaneous Confused, combative, 4 limb spontaneous

movement.movement. Large hematoma on occiputLarge hematoma on occiput

Management?Management?

Her CTHer CT

No surgical intervention indicated No surgical intervention indicated

She is admitted under neurosurgery for She is admitted under neurosurgery for observationobservation

The next morning she is found to be more The next morning she is found to be more drowsy than the night beforedrowsy than the night before GCS 9 (E2 V3 M4)GCS 9 (E2 V3 M4)

Now what would you like to do?Now what would you like to do?

Her new CTHer new CT

•Uneven inner surface

•Important in contrecoup injury

ICU calledICU calledGCS 9GCS 99>89>8No need to intubate or take to ICU right nowNo need to intubate or take to ICU right now““Just watch her on the ward. Call us if there’s Just watch her on the ward. Call us if there’s

any problems …”any problems …”

Patient perks up slightly during day (GCS Patient perks up slightly during day (GCS 10-11)10-11)

Deteriorates at bedtime (GCS 7)Deteriorates at bedtime (GCS 7)

What now?What now?

You decide to intubateYou decide to intubate

As you are bagging the patient you As you are bagging the patient you notice that their right pupil has notice that their right pupil has become quite dilated. It doesn’t become quite dilated. It doesn’t seem to react very well to light.seem to react very well to light.

What do you do?What do you do?

Mannitol / lasix attempted as temporizing Mannitol / lasix attempted as temporizing measuremeasure

Patient taken to ICU and intubatedPatient taken to ICU and intubated

Taken to OR for craniotomy / frontal Taken to OR for craniotomy / frontal lobectomylobectomy

Patient died 2 days laterPatient died 2 days later

Osmotic agentOsmotic agentReduces cerebral swelling (decreases Reduces cerebral swelling (decreases

ICP)ICP)Intravascular volume expander Intravascular volume expander

(increases MAP)(increases MAP)Reduces blood viscosityReduces blood viscosityNet effect = Increased CBFNet effect = Increased CBF

MannitolMannitol

PitfallsPitfalls ARF in large dosesARF in large doses HyperkalemiaHyperkalemia Paradoxically may cause increased bleeding Paradoxically may cause increased bleeding

into traumatic lesion by decompression of into traumatic lesion by decompression of tamponadetamponade

Causes BBB failure in large doses. Can Causes BBB failure in large doses. Can accumulate in brain tissue and cause reverse accumulate in brain tissue and cause reverse osmotic shift (rebound osmotic shift (rebound ICP)ICP)

Hypovolemic hypotension secondary to Hypovolemic hypotension secondary to diuresisdiuresis

Evidence???Evidence???

Only one placebo controlled trialOnly one placebo controlled trial Sayre M, Sayre M, et alet al. Out-of-hospital administration of mannitol . Out-of-hospital administration of mannitol

to head-injured patients does not change systolic BP. to head-injured patients does not change systolic BP. Acad Emerg Med 1996;3:840-48.Acad Emerg Med 1996;3:840-48.

Prehospital mannitol vs placeboPrehospital mannitol vs placeboMannitol associated with increased risk Mannitol associated with increased risk

of death (RR 1.59 CI 0.44-5.79)of death (RR 1.59 CI 0.44-5.79)

IndicationsIndicationsSigns of herniation syndromeSigns of herniation syndromeProgressive neurological deteriorationProgressive neurological deterioration

UsageUsageOnly in monitored settingOnly in monitored settingSmall boluses better than infusionSmall boluses better than infusion0.25-1 g/kg0.25-1 g/kgOnset within minutes, lasts 6-8 hoursOnset within minutes, lasts 6-8 hoursOsmolarity should be kept <320Osmolarity should be kept <320Colloids / blood prn hypotensionColloids / blood prn hypotension

Guidelines for the management of Guidelines for the management of severe traumatic brain injurysevere traumatic brain injury

Brain Trauma Foundation (2000)Brain Trauma Foundation (2000)

MannitolMannitol StandardsStandards

Insufficient data to support treatment standardsInsufficient data to support treatment standards GuidelinesGuidelines

Mannitol is effective for control of raised ICP after severe Mannitol is effective for control of raised ICP after severe head injury. Effective doses range from 0.25-1g/kghead injury. Effective doses range from 0.25-1g/kg

OptionsOptions Indications for mannitol prior to ICP monitoring are signs Indications for mannitol prior to ICP monitoring are signs

of transtentorial herniation or progressive neurological of transtentorial herniation or progressive neurological deterioration not attributable to extracranial deterioration not attributable to extracranial explanations. Hypovolemia should be avoided by fluid explanations. Hypovolemia should be avoided by fluid replacementreplacement

Serum osmolality should be kept below 320mOsm to Serum osmolality should be kept below 320mOsm to prevent renal failureprevent renal failure

Euvolemia should be maintained by fluid replacementEuvolemia should be maintained by fluid replacement Intermittent boluses may be more effective than Intermittent boluses may be more effective than

continuous infusion.continuous infusion.

HyperventilationHyperventilation

Hypocapnia (PCO2 30-35)Hypocapnia (PCO2 30-35) cerebral vasoconstrictioncerebral vasoconstriction

temporarily reduces ICP (~25%)temporarily reduces ICP (~25%)Also decreases CPPAlso decreases CPP

Rapid onset ~30 sec, peak ~ 8 minRapid onset ~30 sec, peak ~ 8 min

PCO2 <25 or prolonged hyperventilation PCO2 <25 or prolonged hyperventilation can cause ischemic injury, alkalosis, can cause ischemic injury, alkalosis, hypokalemiahypokalemia

Indications & usageIndications & usageOnly for brief periods during Only for brief periods during

resuscitationresuscitationOnly for patients with acute neurological Only for patients with acute neurological

deteriorationdeteriorationFull monitoring (including ICP if possible)Full monitoring (including ICP if possible)Method of last resortMethod of last resortDo not use if CPP >70Do not use if CPP >70

HyperventilationHyperventilation StandardsStandards

In absence of raised ICP, chronic prolonged In absence of raised ICP, chronic prolonged hyperventilation therapy (pCO2<25) should be avoided hyperventilation therapy (pCO2<25) should be avoided after severe TBIafter severe TBI

GuidelinesGuidelinesUse of prophylactic hyperventilation (pCO2<35) during Use of prophylactic hyperventilation (pCO2<35) during

first 24 hours after severe TBI should be avoided b/c it first 24 hours after severe TBI should be avoided b/c it can compromise cerebral perfusion while CBF reducedcan compromise cerebral perfusion while CBF reduced

OptionsOptionsHyperventilation may be necessary for brief periods of Hyperventilation may be necessary for brief periods of

neurologic deterioration, or longer periods of raised ICP neurologic deterioration, or longer periods of raised ICP refractory to sedation, paralysis, CSF drainage, and refractory to sedation, paralysis, CSF drainage, and osmotic diureticsosmotic diuretics

Guidelines for the management of severe Guidelines for the management of severe traumatic brain injury traumatic brain injury

Brain Trauma Foundation (2000)Brain Trauma Foundation (2000)

ICP MonitoringICP MonitoringStandardsStandards

Insufficient data to support standardsInsufficient data to support standardsGuidelinesGuidelines

Appropriate in patients with a severe head Appropriate in patients with a severe head injury (GCS 3-8) and abnormal CT scan injury (GCS 3-8) and abnormal CT scan (hematomas, contusions, edema, compressed (hematomas, contusions, edema, compressed basal cisterns)basal cisterns)

Appropriate in patients with severe head Appropriate in patients with severe head injury and normal CT scan if age >40, motor injury and normal CT scan if age >40, motor posturing, sBP <90posturing, sBP <90

Not routinely indicated in mild or moderate Not routinely indicated in mild or moderate head injuryhead injury

Guidelines for the management of severe Guidelines for the management of severe traumatic brain injury traumatic brain injury

Brain Trauma Foundation (2000)Brain Trauma Foundation (2000)

Hypertonic saline (HTS)Hypertonic saline (HTS)mechanisms of actionmechanisms of action

Draws water from brain tissue via Draws water from brain tissue via osmotic gradientosmotic gradient

Restores BP & cardiac output with less Restores BP & cardiac output with less volume and lower capillary hydrostatic volume and lower capillary hydrostatic pressurepressure

positive inotropic effectpositive inotropic effectDoes not impair renal function (vs Does not impair renal function (vs

mannitol)mannitol)

Increasing ICP: What’s new …Increasing ICP: What’s new …

Shackford S, et al. Hypertonic Saline Resuscitation Shackford S, et al. Hypertonic Saline Resuscitation of Patients with Head Injury: A Prospective, RCT. of Patients with Head Injury: A Prospective, RCT.

Trauma 1998;44(1):50-58.Trauma 1998;44(1):50-58.

RCTRCT N=34N=34 ComparedCompared

Hypertonic (1.6% HTS for resus, NS Hypertonic (1.6% HTS for resus, NS maintenance)maintenance)

Hypotonic (RL for resus, ½ NS maintenance)Hypotonic (RL for resus, ½ NS maintenance) HTS group had significantly lower GCS & HTS group had significantly lower GCS &

higher ICP to begin withhigher ICP to begin with No significant differences in No significant differences in ICP between ICP between

groupsgroups Underpowered (calculated N=320 for Underpowered (calculated N=320 for

significance) and inconclusivesignificance) and inconclusive

Qureshi A, et al. Use of hypertonic (3%) saline/acetate Qureshi A, et al. Use of hypertonic (3%) saline/acetate infusion in the treatment of cerebral edema: Effect on infusion in the treatment of cerebral edema: Effect on

intracranial pressure and lateral displacement of the brain. intracranial pressure and lateral displacement of the brain. Crit Care Med 1998; 26(3):440-46.Crit Care Med 1998; 26(3):440-46.

retrospective chart reviewretrospective chart reviewN=27N=27studied effect of infusion of 3% studied effect of infusion of 3%

NaCl/Na-acetate infusion (target Na NaCl/Na-acetate infusion (target Na 145-155) on ICP145-155) on ICP

Observed reduction of ICP correlated Observed reduction of ICP correlated to Na level in head trauma patients to Na level in head trauma patients (R(R22=.91, p=0.03)=.91, p=0.03)

Qureshi A, et al. Use of hypertonic saline/acetate infusion in Qureshi A, et al. Use of hypertonic saline/acetate infusion in treatment of cerebral edema in patients with head trauma: treatment of cerebral edema in patients with head trauma:

experience at a single center. Trauma 1999;47(4) 659experience at a single center. Trauma 1999;47(4) 659

retrospective review of 36 patients treated retrospective review of 36 patients treated with 2-3% HTS infusions vs 46 patients with 2-3% HTS infusions vs 46 patients treated with NStreated with NS

HTS associated with higher likelihood or HTS associated with higher likelihood or requiring barbituate coma to control ICP requiring barbituate coma to control ICP (p=0.04)(p=0.04)

HTS associated with higher in-hospital HTS associated with higher in-hospital mortality (OR 3.1; CI 1.1-10.2)mortality (OR 3.1; CI 1.1-10.2)

suggested further research into HTS suggested further research into HTS boluses and short infusionsboluses and short infusions

Hypertonic Saline & Hypertonic Saline & PediatricsPediatrics

RCT of 32 kids with GCS <8RCT of 32 kids with GCS <81.7% HTS vs RL for maintenance fluid1.7% HTS vs RL for maintenance fluidstatistically significant inverse statistically significant inverse

relationship between ICP and Na in both relationship between ICP and Na in both groupsgroups

RL group had more ARDS (p=0.1), RL group had more ARDS (p=0.1), complications (p=0.09), longer ICU complications (p=0.09), longer ICU times (p=0.1), longer ventilation time times (p=0.1), longer ventilation time (p=0.1)(p=0.1)

No difference in survival or duration of No difference in survival or duration of hospital stayhospital stay

Simma et al. A prospective, randomized, and controlled study of fluid management in children with severe head injury: Lactated Ringers vs

hypertonic saline.Crit Care Med 1998:26(7) 1265-70.

Peterson B, et al. Prolonged hypernatremia controls Peterson B, et al. Prolonged hypernatremia controls elevated intracranial pressure in head-injured pediatric elevated intracranial pressure in head-injured pediatric

patients. Crit Care Med 2000;28(4):1136-43.patients. Crit Care Med 2000;28(4):1136-43.

retrospective chart reviewretrospective chart reviewN=68N=68studied ability of 3% HTS infusion to studied ability of 3% HTS infusion to

reduce ICP to <20 mmHgreduce ICP to <20 mmHgHTS controlled ICP in most casesHTS controlled ICP in most cases

so same group decided to study this so same group decided to study this prospectively ….prospectively ….

Khanna S, et al. Use of hypertonic saline in the Khanna S, et al. Use of hypertonic saline in the treatment of severe refractory posttraumatic treatment of severe refractory posttraumatic

intracranial hypertension in pediatric traumatic brain intracranial hypertension in pediatric traumatic brain injury. Crit Care Med 2000;28(4):1144-51.injury. Crit Care Med 2000;28(4):1144-51.

Prospectively evaluated effect of prolonged 3% Prospectively evaluated effect of prolonged 3% HTS infusion on refractory elevations in ICPHTS infusion on refractory elevations in ICP

N=10N=10 significant reductions in ICP, and increased CPPsignificant reductions in ICP, and increased CPP avg highest Na 171, osm 365avg highest Na 171, osm 365 two patients developed ARFtwo patients developed ARF

one septicone septicone MOSFone MOSFboth recovered completelyboth recovered completely

concluded HTS is well tolerated and effective in concluded HTS is well tolerated and effective in controlling refractory ICP in pediatricscontrolling refractory ICP in pediatrics

Mannitol vs HTSMannitol vs HTSVialet R, et al. Isovolume hypertonic solutes in the treatment of refractory posttraumatic Vialet R, et al. Isovolume hypertonic solutes in the treatment of refractory posttraumatic

intracranial hypertension: 2ml/kg 7.5% saline is more effective than 2ml/kg 20% mannitol. Crit intracranial hypertension: 2ml/kg 7.5% saline is more effective than 2ml/kg 20% mannitol. Crit Care Med 2003. 31(6).Care Med 2003. 31(6).

Prospective RCTProspective RCTN=20N=207.5% HTS (2400 mOsm) vs 20% 7.5% HTS (2400 mOsm) vs 20%

mannitol (1160 mOsm)mannitol (1160 mOsm)Received 2cc/kg of solution for raised Received 2cc/kg of solution for raised

ICP refractory to sedation, ICP refractory to sedation, hemodynamic optimization, CSF hemodynamic optimization, CSF drainagedrainage

ResultsResultsHTSHTS

Significant reduction in raised ICP events Significant reduction in raised ICP events and timeand time

Significant reduction in failure rate Significant reduction in failure rate (persistant elevated ICP despite 2 infusions)(persistant elevated ICP despite 2 infusions)

ConclusionConclusionHTS is safe and more effective than HTS is safe and more effective than

mannitol in control of refractory ICPmannitol in control of refractory ICP

HTS - Take home pointsHTS - Take home pointsAcceptable as first or second line therapy to Acceptable as first or second line therapy to

treat elevated ICP in pediatric TBItreat elevated ICP in pediatric TBIIn adults use is only supported for treatment In adults use is only supported for treatment

of refractory intracranial hypertensionof refractory intracranial hypertensionMore research needed on concentrations More research needed on concentrations

and dosingand dosingno evidence of significant harm, may be no evidence of significant harm, may be

helpfulhelpful

You’re not going to use this in emerg … yetYou’re not going to use this in emerg … yet

ControversiesControversiesHypothermiaHypothermia

Mild hypothermia (32-34Mild hypothermia (32-3400)) neuroprotective in animal modelsneuroprotective in animal models in mechanistic models in mechanistic models

decreases excitatory amino acids in peritrauma decreases excitatory amino acids in peritrauma regionregion

decreases consumption of endogenous antioxidantsdecreases consumption of endogenous antioxidantsanti-inflammatory effectsanti-inflammatory effects

some evidence of protective effects in cardiac some evidence of protective effects in cardiac arrestarrest

Marion D, et al. Treatment of Traumatic Marion D, et al. Treatment of Traumatic Brain Injury With Moderate Hypothermia. Brain Injury With Moderate Hypothermia.

NEJM 1997;336(8):540-6.NEJM 1997;336(8):540-6.

RCT of mild hypothermia (x24h) vs RCT of mild hypothermia (x24h) vs normothermia in severe TBI (GCS 3-normothermia in severe TBI (GCS 3-7)7)

N=87N=87 improvement in Glascow Outcome improvement in Glascow Outcome

Scores among GCS 5-7, but not 3-4Scores among GCS 5-7, but not 3-412 month RR of bad outcome 0.3 (CI 12 month RR of bad outcome 0.3 (CI

0.1-1.0)0.1-1.0)

Clifton G, et al. Lack of Effect of Induction Clifton G, et al. Lack of Effect of Induction of Hypothermia After Acute Brain Injury. of Hypothermia After Acute Brain Injury.

NEJM 2001;344(8):556-63.NEJM 2001;344(8):556-63.Randomized patients with GCS 3-7 to Randomized patients with GCS 3-7 to

mild hypothermia (x48 h) vs mild hypothermia (x48 h) vs normothermianormothermia

N=392; 11 centresN=392; 11 centressame rates of mortality & poor same rates of mortality & poor

neurological outcomeneurological outcomemore complications (sepsis, more complications (sepsis,

pneumonia, bleeding) in hypothermia pneumonia, bleeding) in hypothermia groupgroup

Criticized becauseCriticized becausehypothermia not achieved until 8.4 +/- 3 hypothermia not achieved until 8.4 +/- 3

hours post-injury (missed treatment hours post-injury (missed treatment window)window)

differences in fluid balance between differences in fluid balance between groupsgroups

differences in outcomes between centresdifferences in outcomes between centresUsed different protocol than 1997 studyUsed different protocol than 1997 study

Multiple RCT’s on hypothermia and TBI still Multiple RCT’s on hypothermia and TBI still ongoingongoing

Back to our patient…Back to our patient…Your medical student asks if you are Your medical student asks if you are

going to start her on seizure prophylaxisgoing to start her on seizure prophylaxis

BackgroundBackgroundPost-traumatic seizures are commonPost-traumatic seizures are common

2% of all comers2% of all comers12% of severe TBI12% of severe TBI

Seizures are physically and Seizures are physically and psychologically debilitating, can psychologically debilitating, can potentiate secondary brain injury, and potentiate secondary brain injury, and are costlyare costly

Prophylactic use of antiepileptics Prophylactic use of antiepileptics poses risk of adverse effectsposes risk of adverse effects

AAN. Practice parameter: Antiepileptic drug AAN. Practice parameter: Antiepileptic drug prophylaxis in severe traumatic brain injury. prophylaxis in severe traumatic brain injury.

Neurology 2003;60:10-16.Neurology 2003;60:10-16.

Reviewed evidence for seizure prophylaxis Reviewed evidence for seizure prophylaxis in preventing early (<7 days) and late in preventing early (<7 days) and late seizuresseizures

Severe TBI defined asSevere TBI defined as Prolonged LOC or amnesiaProlonged LOC or amnesia Intracranial hematomaIntracranial hematoma Depressed skull fractureDepressed skull fracture Brain contusionBrain contusion

125 prospective studies reviewed125 prospective studies reviewed

Does AED prophylaxis decrease risk of Does AED prophylaxis decrease risk of developing early seizures (within 7 days) in developing early seizures (within 7 days) in

patients with severe TBI?patients with severe TBI?

4 eligible studies4 eligible studies

2 class I studies of IV phenytoin2 class I studies of IV phenytoinOne statistically significantOne statistically significantOne not statistically significantOne not statistically significant

But very low incidence of seizures in placebo But very low incidence of seizures in placebo groupgroup

1 class II study of carbamazepine1 class II study of carbamazepine

1 class III study of phenytoin1 class III study of phenytoin

Combined resultsCombined resultsPooled class I evidencePooled class I evidenceRR of seizures 0.37 (CI 0.18-0.74)RR of seizures 0.37 (CI 0.18-0.74)

Adverse effectsAdverse effectsOne rash in phenytoin groupOne rash in phenytoin groupSimilar drop out rates for drug/placebo Similar drop out rates for drug/placebo

Does AED prophylaxis decrease the risk of Does AED prophylaxis decrease the risk of developing late (after 7 days) seizures in developing late (after 7 days) seizures in

patients with severe TBI?patients with severe TBI?

8 eligible studies8 eligible studies2 class I studies of phenytoin2 class I studies of phenytoin3 class II studies3 class II studies

1 phenytoin study (large loss to follow-up)1 phenytoin study (large loss to follow-up)1 valproate study (large loss to follow-up)1 valproate study (large loss to follow-up)1 unspecified study (quasi-randomization)1 unspecified study (quasi-randomization)

3 class III studies3 class III studies

ResultsResultsClass I studiesClass I studies

Neither demonstrated statistical significanceNeither demonstrated statistical significanceClass II studiesClass II studies

0/3 demonstrated statistical significance0/3 demonstrated statistical significanceClass III studiesClass III studies

2 studies positive2 studies positive1 study no significant difference1 study no significant difference

Combined resultsCombined results Pooled results from class I and class II studies in Pooled results from class I and class II studies in

attempt to narrow CI’sattempt to narrow CI’s RR 1.05 (CI 0.82-1.35)RR 1.05 (CI 0.82-1.35)

Adverse effectsAdverse effects Higher incidence of rash in treatment group (6 vs Higher incidence of rash in treatment group (6 vs

1.2%)1.2%) 17.6% of phenytoin patients switched to 17.6% of phenytoin patients switched to

phenobarbital within 1 year in one class II studyphenobarbital within 1 year in one class II study Single episode of neutropenia in valproate groupSingle episode of neutropenia in valproate group Similar rates of discontinuationSimilar rates of discontinuation

Practice recommendationsPractice recommendationsFor adults with severe TBIFor adults with severe TBI

““Prophylactic treatment with Prophylactic treatment with phenytoin, beginning with IV loading phenytoin, beginning with IV loading dose, should be initiated as soon as dose, should be initiated as soon as possible after injury to decrease the possible after injury to decrease the risk of post-traumatic seizures risk of post-traumatic seizures occurring within the first 7 daysoccurring within the first 7 days” ” (Level A)(Level A)

Prophylaxis should not routinely be Prophylaxis should not routinely be used beyond 7 days to decrease the used beyond 7 days to decrease the risk of seizures (Level B)risk of seizures (Level B)

limitationslimitations

Does not addressDoes not addressNo proven difference in outcomes due to No proven difference in outcomes due to

prevention of early seizuresprevention of early seizuresPediatricsPediatricsMilder forms of head injuryMilder forms of head injuryThe utility of EEG in predicting seizure The utility of EEG in predicting seizure

riskrisk

Case 9Case 9

24 year old male24 year old malefound unconscious outside barfound unconscious outside bar+++EtOH+++EtOHUnclear if assaulted or fell and hit head or Unclear if assaulted or fell and hit head or

neitherneither

O/EO/EGCS 11 (E3 V3 M5)GCS 11 (E3 V3 M5)smells like EtOHsmells like EtOHblood coming from right earblood coming from right ear

His CTHis CT

Blood in ear canalBlood in ear canal hemotympanumhemotympanum rhinorrhearhinorrhea otorrheaotorrhea Battle’s sign Battle’s sign

(retroauricular (retroauricular hematoma)hematoma)

Raccoon sign Raccoon sign (periorbital (periorbital ecchymosis)ecchymosis)

Cranial nerve Cranial nerve deficitsdeficits facial paralysisfacial paralysis decreased auditory decreased auditory

acuityacuity dizzinessdizziness tinnitus, nystagmustinnitus, nystagmus

Basilar skull fractureBasilar skull fractureClinical FeaturesClinical Features

ManagementManagement

Admit for observation vs discharge?Admit for observation vs discharge? higher risk for development of late hematomashigher risk for development of late hematomas No good evidenceNo good evidence

Manage concurrent TBIManage concurrent TBI

How about antibiotics???How about antibiotics??? Now?Now? What if they come back in two days with fever?What if they come back in two days with fever?

Antibiotics in basilar skull Antibiotics in basilar skull fracture?fracture?

ForFor CSF exposed to pathogens CSF exposed to pathogens

in upper respiratory tractin upper respiratory tract reported risk of meningitis reported risk of meningitis

with BSF 9-50%with BSF 9-50% antibiotics are theoretically antibiotics are theoretically

beneficial in preventing beneficial in preventing meningitismeningitis

think rhinorrhea higher risk think rhinorrhea higher risk than otorrhea than otorrhea (communication of (communication of cribriform plate with CSF)cribriform plate with CSF)

AgainstAgainst antibiotics antibiotics

contribute to contribute to development of development of resistant organisms resistant organisms and more serious and more serious infectioninfection

no evidence for use no evidence for use of antibiotic of antibiotic prophylaxisprophylaxis

Villalobos T Villalobos T et alet al. Antibiotic prophylaxis after . Antibiotic prophylaxis after basilar skull fractures: A meta-analysis. Clinical basilar skull fractures: A meta-analysis. Clinical

Infectious Diseases 1998;27:364-9.Infectious Diseases 1998;27:364-9.

14 studies14 studies12 with extractable data12 with extractable data9 retrospective9 retrospective2 prospective RCT’s2 prospective RCT’s1 combined retrospective/prospective1 combined retrospective/prospective

1241 patients1241 patients719 antibiotics719 antibiotics522 no antibiotics522 no antibiotics

Antibiotics usedAntibiotics usedceftriaxoneceftriaxoneampicillin/sulfadiazineampicillin/sulfadiazinepenicillinpenicillinfirst and third generation cephalosporinsfirst and third generation cephalosporinschloramphenicolchloramphenicolgentamicingentamicinsulfonamidessulfonamides

Odds ratio of meningitisOdds ratio of meningitis(no Abx vs Abx)(no Abx vs Abx)

All 12 studies individuallyAll 12 studies individuallynone differed significantly from OR = 1none differed significantly from OR = 1OR 0 to infinityOR 0 to infinity

all 12 studies pooledall 12 studies pooledOR=1.15; CI 0.68-1.94l p=0.678OR=1.15; CI 0.68-1.94l p=0.678

9 retrospective studies pooled9 retrospective studies pooledOR = 1.17; CI 0.68-2.01; p=0.706OR = 1.17; CI 0.68-2.01; p=0.706

2 prospective studies pooled2 prospective studies pooledOR 0.68; CI 0.01-13.77; p=0.187OR 0.68; CI 0.01-13.77; p=0.187

Antibiotics with CSF leakageAntibiotics with CSF leakage

Data extractable from 9 studiesData extractable from 9 studies547 patients547 patients

297 received antibiotics297 received antibiotics29 developed meningitis29 developed meningitis

250 received no antibiotics250 received no antibiotics34 developed meningitis34 developed meningitis

Odds ratio of meningitis (no Abx vs Abx)Odds ratio of meningitis (no Abx vs Abx) Each study individuallyEach study individually

No OR’s significantly different than 1No OR’s significantly different than 1 All studies pooledAll studies pooled

OR 1.34; CI 0.75-2.41; p=0.358OR 1.34; CI 0.75-2.41; p=0.358

CSF Rhinorrhea vs OtorrheaCSF Rhinorrhea vs Otorrhea

Data from 6 studiesData from 6 studies 70 patients with rhinorrhea70 patients with rhinorrhea

4 patients developed meningitis4 patients developed meningitis 109 with otorrhea109 with otorrhea

3 patients developed meningitis3 patients developed meningitis No significant differences in any studyNo significant differences in any study Pooled data from 6 studiesPooled data from 6 studies

OR 1.74; CI 0.26-13.36; p=0.772OR 1.74; CI 0.26-13.36; p=0.772 NB: did not break down into Abx vs noneNB: did not break down into Abx vs none

What about kids?What about kids?

3 studies exclusively on pediatrics3 studies exclusively on pediatrics131 patients131 patients

57 received antibiotics57 received antibiotics2 developed meningitis2 developed meningitis

74 received no antibiotics74 received no antibiotics2 developed meningitis2 developed meningitis

OR not reported OR not reported NB: all patients developing meningitis NB: all patients developing meningitis

had CSF leakhad CSF leak

Choi D, Choi D, et alet al. Traumatic CSF leakage: risk factors . Traumatic CSF leakage: risk factors and the use of prophylactic antibiotics. Br J and the use of prophylactic antibiotics. Br J

Neurosurgery 1996;10(6):571-575.Neurosurgery 1996;10(6):571-575.

Retrospective study Retrospective study

293 patients with basilar skull 293 patients with basilar skull fracturefracture115 clinical CSF leak115 clinical CSF leak170 no clinical CSF leak170 no clinical CSF leak8 no documentation8 no documentation

Incidence of meningitis in all patients with Incidence of meningitis in all patients with fracture of the base of skull, regardless of the fracture of the base of skull, regardless of the presence or absence of clinical CSF leakagepresence or absence of clinical CSF leakage

Prophylactic antibiotics

No antibiotics

Meningitis 12 0

No meningitis 185 73

Significant p<0.05

Incidence of meningitis in those patients Incidence of meningitis in those patients with fractures of the base of skull and with fractures of the base of skull and

clinical evidence of CSF leakageclinical evidence of CSF leakage

Prophylacticantibiotics

No antibiotics

Meningitis 10 0

No meningitis 72 15

No significant difference p=0.170

The bottom lineThe bottom line

All studies are small and All studies are small and underpowered to detect a small underpowered to detect a small differencedifference

there is no evidence to support the there is no evidence to support the use of prophylactic antibiotics to use of prophylactic antibiotics to prevent meningitis is asymptomatic prevent meningitis is asymptomatic patient with basilar skull fracturepatient with basilar skull fracture

Use common sense if SSx of infection Use common sense if SSx of infection (both groups at risk for meningitis)(both groups at risk for meningitis)

the endthe end