Management of traumatic brain injury DUSTY RICHARDSON, MD

Agenda

u Discuss injury types ranging from concussion to severe traumatic brain injury

u Review components of the neurologic examination

u Review management strategies for patients with TBI

Concussion

u  Any traumatic alteration of consciousness

u  Usually results in a rapid onset of altered neurologic function, but symptoms may develop and evolve over minutes to hours following the initial insult

u  Neuropathologic changes may occur, but routine imaging studies are negative

Concussion

u 80-90% of concussions have symptoms that resolve within 7-10 days

u Headache

u Cognitive

u Emotional lability, irritability

u Amnesia, loss of consciousness

u Balance disturbances

u Insomnia

u  Initial investigation

u  Should be performed by a health care professional in a setting which is appropriate for assessment

u  Thorough Medical and Neurologic examination

u  Specific attention should be paid to evaluating the cervical spine

u  Important to assess whether the patient appears stable, declining, or improving

u  Patients should not be left alone for several hours following the injury

u  Determination whether the patient should undergo neuroimaging made at this time

Concussion

http://physicians.cattonline.com/scat/

Management of concussion

u  Physical and cognitive rest

u  Generally 24-48h

u  Stepwise return to activity

u  Rest for 24 hours

u  Light activity

u  Light exercise

u  Moderate to Heavy exercise

Return to play u  For athletes who have suffered a concussion, they should not be

allowed to return to play on the same day

u  Each of the following stages should be given 24 hours

Other pioneering work in concussion

u Balance systems

u APO-E4

u fMRI

u DTI

u EEG

u Biomarkers

When the injury gets worse

u  Now you’ve found something on a CT of the head

Intracranial hemorrhage

u CTIDES

u  Cerebral contusion

u  Traumatic subarachnoid hemorrhage

u  Intraventricular hemorrhage

u  Diffuse Axonal Injury

u  Epidural Hematoma

u  Subdural Hematoma

Severe Traumatic Injury

u  What the patient really needs…

Acute traumatic brain injury—initial management

u  ATLS protocol

u  A->B->C

u  Remember to perform a brief neurologic examination if time and circumstances permit

GCS

GCS 14-15 = mild injury

GCS 13 or less = moderate or severe injury

CT head and cervical spine

Observation versus head CT, NEXUS criteria for cervical spine management

NEXUS—Allows for clearance of the cervical spine without imaging

u  Focal neurologic deficit

u Midline spinal tenderness

u Distracting injury

u  Intoxication

u Altered level of consciousness

Goal: Prevent secondary injury

Brain Swelling

Brain swelling leads to decreased blood supply to the brain

What does the neurosurgeon want to know when you call?

1. Findings on CT scan 2. Neurologic examination 3.  Hemodynamics and ability to

transfer

Neurologic examination: GCS

Eye opening u  1 = None

u  2 = To Pain

u  3 = To verbal command

u  4 = Spontaneous

Verbal response u  1 = None

u  2 = Incomprehensible groaning

u  3 = Non-contextual speech

u  4 = Confusion

u  5 = Oriented and conversant

Motor response u  1 = None

u  2 = Extensor posturing

u  3 = Flexor posturing

u  4 = Withdrawal from pain

u  5 = Localizing movements

u  6 = Following commands

Acute care management of traumatic brain injury: what you can do without a neurosurgeon

u  Positioning

u  Keep the head of the bed elevated--use reverse trendelenberg positioning when spine fractures have not been ruled out

u  Hyperventilation—OK to use in the short term PCO2 25-35

u  Ensure neutral cervical spine positioning

u  Mannitol 1g/kg up to 100 g

u  Hypertonic Saline 23.4% 15-30cc slow infusion (10-15 minutes)

u  Antiepileptic medications (Phenytoin or Levetiracetam)

u  Sedation

u  Paralytics

Stepwise protocol for management of

intracranial hypertension

Intubation

Intensive Care Management of Brain Injury

u  Guiding Principle: Preserve viable brain tissue

u  Prevent secondary brain injury

u  Management of Intracranial Pressure and perfusion to the brain

u  Intracranial pressure monitoring

u  Patients who remain a GCS of 8 or less after resuscitation and who have a brain injury meet criteria for intracranial pressure monitoring

u  EVD or Fiber optic monitor (bolt)

The neurosurgical arsenal

26 YO woman in a team roping accident. Never regained consciousness

u  Patient arrives to your facility in a cervical collar, intubated by the flight team en route

u  Vital signs are stable

u  Neurologic exam demonstrates anisocoria L (8mm and fixed) >R (3 mm and reactive), no movement in the extremities and the presence of an endotracheal tube

u  What’s the GCS?

u  3T

u  Next step?

Next steps

u  Cervical collar?

u  CT cervical spine is negative

u  Should you investigate for blunt carotid/vertebral injury?

u  Do you have the capabilities to handle the injury if you find it?

u  When do we administer IV contrast?

u  MRI?

70 YO man struck by a car at 40 mph

u  Patient was GCS 3 at the scene

u  Intubated and mechanically ventilated upon arrival to Billings Clinic

u  Workup included CT head, CT cervical spine, CT C/A/P with contrast, CT maxillofacial, CT angiogram of the head and neck, CT T/L spines

u  Open Tib/Fib fracture on the left

u  Left shoulder dislocation

u  Open elbow fracture

u  Multiple skull and facial fractures

u  Hemodynamically stable, no injury to internal organs

What next?

Conclusions

u  Concussion is a traumatic alteration of consciousness

u  People who are suspected to have a concussion should not return to play on the day of the injury, should be evaluated by a medical professional, and should ideally undergo a graduated return to activity prior to returning to play

u  Management of acute traumatic brain injury in the field and emergency department should follow ATLS guidelines

u  Obtain a neurologic examination

u  Empiric management of presumed intracranial hypertension can be enacted in the absence of neurosurgical care with close attention paid to the clinical scenario

References

u  Martins, R. S., Siqueira, M. G., Santos, M. T. S., Zanon-Collange, N., & Moraes, O. J. S. (2003). Prognostic factors and treatment of penetrating gunshot wounds to the head. Surgical Neurology, 60(2), 98–104. doi:10.1016/S0090-3019(03)00302-1

u  Rosenfeld, J. V., Bell, R. S., & Armonda, R. (2014). Current Concepts in Penetrating and Blast Injury to the Central Nervous System. World Journal of Surgery. doi:10.1007/s00268-014-2874-7

u  McCrory P, Meeuwisse WH, Aubry M, Cantu RC, Dvořák J, Echemendia RJ, Engebretsen L, Johnston K, Kutcher JS, Raftery M, Sills A, Benson BW, Davis G a., Ellenbogen R, Guskiewicz KM, Herring S a., Iverson GL, Jordan BD, Kissick J, McCrea M, McIntosh AS, Maddocks D, Makdissi M, Purcell L, Putukian M, Schneider K, Tator CH, Turner M. Consensus statement on concussion in sport: The 4th international conference on concussion in sport, Zurich, November 2012. J. Athl. Train. 48: 554–575, 2013.

u  Anthony Marmarou, Ph.D., Randy L. Anderson, Ph.D., John D. Ward, M.D., Sung C. Choi, Ph.D., and Harold F. Young, M.D. Howard M. Eisenberg, M.D. Mary A. Foulkes, Ph.D. Lawrence F. Marshall, M.D. John A. Jane, M.D. Impact of ICP instability and hypotension on outcome in patients with severe head trauma. Special Supplements Nov 1991 / Vol. 75 / No. 1s, Pages S59-S66

u  Chesnut, R. M., Temkin, N., Carney, N., Dikmen, S., Rondina, C., Videtta, W., … Hendrix, T. (2012). A trial of intracranial-pressure monitoring in traumatic brain injury. The New England Journal of Medicine, 367(26), 2471–81. doi:10.1056/NEJMoa1207363

u  Marmarou, A., Anderson, R. L., Ward, J. D., Choi, S. C., Young, H. F., Eisenberg, H. M., … Jane, J. A. (1991). Impact of ICP instability and hypotension on outcome in patients with severe head trauma. J Neurosurg, 75(Supplement), S59–S66.

u  Bratton, S. L., Chestnut, R. M., Ghajar, J., McConnell Hammond, F. F., Harris, O. a, Hartl, R., … Wright, D. W. (2007). Guidelines for the management of severe traumatic brain injury. VI. Indications for intracranial pressure monitoring. Journal of Neurotrauma, 24 Suppl 1, S37–44. doi:10.1089/neu.2007.9990

u  Polin, R. S., Shaffrey, M. E., Bogaev, C. A., Tisdale, N., Germanson, T., Bocchicchio, B., & Jane, J. A. (1997). Decompressive bifrontal craniectomy in the treatment of severe refractory posttraumatic cerebral edema. Neurosurgery, 41(1), 84–92; discussion 92–94.

u  Talving, P., Karamanos, E., Teixeira, P. G., Skiada, D., Lam, L., Belzberg, H., … Demetriades, D. (2013). Intracranial pressure monitoring in severe head injury: compliance with Brain Trauma Foundation guidelines and effect on outcomes: a prospective study. Journal of Neurosurgery, 119(5), 1248–54. doi:10.3171/2013.7.JNS122255

Questions?