non accidental head injury - how to improve outcome
DESCRIPTION
Presentation at Paed Neuro Update 2014TRANSCRIPT
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EssenDals
• Non Accidental Head Injury is not only another type of traumaDc head injury but THE most severe form of traumaDc head injury
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Disclosure
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OUTCOME
1/3 die 1/3 no sequelae 1/3 permanent neurological damage Poorer than accidental impact injury (translational forces)
Haviland et al Arch Dis Child 1997;77:504-507
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The pyramid and iceberg of disease
1 Diseased, diagnosed & controlled
2 Diagnosed, uncontrolled
3 Undiagnosed or wrongly diagnosed disease
4 Risk factors for disease
5 Free of risk factors
Diagnosed disease
Undiagnosed or wrongly diagnosed disease
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Causes begin to exert their influence here
Disease and first manifestation can be diagnosed here, eg.
Time
Infancy childhood adolescence adulthood old age
Full health
Death
Recurrence and death
NATURAL HISTORY AND OUTCOMES
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SUBDURAL HEMATOMA
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EPIDURAL HEMATOMA
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SUBDURAL vs EPIDURAL HEMATOMA
• EPIDURAL – Requires linear
force – Associated with
skull fracture and torn artery. Brain often uninjured
– “Lucid” interval common
– Common in accidental trauma
• SUBDURAL – Requires significant
rotational forces – Associated with brain
injury and torn bridging veins
– Neurologic symptoms from the start
– Common in infants with abusive head trauma
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COUP -‐ CONTRA COUP INJURY
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Cerebral Contusion Most common Focal brain Injury
Sites Impact site/ under skull #
Anteroinferior frontal
Anterior Temporal Occipital Regions
Petechial hemorrahges coalesce Intracerebral Hematomas later on.
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We are not alone • 1783 Monro & Kellie
define closed box concept • 1866 Lyden measures ICP
via trephine • 1866 Knoll produces
graphic CSF pressure trace
• 1870s Duret observes deleterious effects of injecDng fluid in to dogs skulls
• 1891 Quinke introduces LP allowing CSF sampling & measurement
• 1900 Cushing describes the classic Triad seen with
severely elevated ICP • systolic hypertension with widened pulse pressure
• bradycardia • respiratory irregulariDes
• 1960 Lundberg introduced long term conDnuous ICP
monitoring via an indwelling intraventricular
catheter.
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PLAN A , PLAN B , PLAN C
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50% are unconscious immediately. Focal deficits common
Hemiparesis – 50%
Pupillary abnormality-‐ 28-‐78%
Seizures – 6-‐22%
Rx-‐ larger-‐ urgent removal
Small -‐
Small with mass effect/ significant change in conscious/ focal deficits
Removed
Small with significant brain injuries + mass effect out of proporDon to size of clot
Non operaDve approach
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DAI
Hallmark of severe traumaDc Brain Injury
DifferenDal Movement of Adjacent regions of Brain during acceleraDon and DeceleraDon.
DAI is major cause of prolonged COMA ader TBI, probably due to disrupDon of Ascending ReDcular connecDons to Cortex.
Angular forces > Oblique/ Sagital Forces
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The shorn Axons retract and are evident histologically as RETRACTION BALLS.
Located predominantly in
1. CORPUS CALLOSUM 2. PERIVENTRICULAR WHITE MATTER 3. BASAL GANGLIA 4. BRAIN STEM
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Pathophysiology of Brain Injury
Brain Injury
Primary Secondary
1.Delayed cell death 2.Intracranial hypertension and mass effect
3.Ischemia systemic hypoxia,hypercarbia and
hypotension
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Primary Brain Injury
Primary
Focal @SITE
Contra-‐coup
Diffuse DAI
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PredicDng outcomes
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OXYGENATION
• Early episodes of hypoxemia greatly increases mortality and morbidity.
• Hypoxia is apnoea or cyanosis in the field or an oxygen saturaOon (SaO2) < 90%.
• IntubaOon of unconscious and unresponsive child improves outcome.
• General rule : intubate if apnea / cyanosis GCS 8 , airway compromise and signs of herniaOon
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Cerebral Perfusion
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ICP
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Haemoglobin
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Deep tendon and superficial reflexes
• DTR’s exaggerated ader trauma is due to corDcal disinhibiDon
• Decreased / absent ader Spinal cord injury • Asymmetric DTR’s unilateral brain/spine injury • Superficial lost/decreased in corDcospinal dysfuncDon and helpful in localizing lesions
• Plantar response
Normal reflex Intact descending corOcospinal inhibiOon
PosiDve Babinski Interrupted inhibiDon pathways
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Intracranial Hypertension
• Pathophysiology – ICP monitoring and control are the cornerstones of TBI management
– Normal ICP • Adults <10mmhg • Children 3-‐7mmhg • Infants 1.5-‐ 6mmhg
– When to treat? • Adults > 20 • Children >15 • Infants >10 { Arbitrary numbers most commonly used, pending outcome studies}
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Device / method Risk / benefit
1. Intraventricular catheter Adv-‐ drainage of CSF to reduce ICP DisAdv-‐ infecDon/ ventricular compression leads to inaccuracy
2. subdural/ subarachnoid bolts ( Philadelphia, Leeds, Richmond bolts)
Occlusion of port in device leads to inaccuracy
3. FiberopDc cath ( Camino labs) Improved fidelity & longevity Can be placed Intraparenchymal/ intraventricular/ subdural Used to drain CSF Accuracy maintained even with fully collapsed ventricles Single cath can be used as long as needed
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POST TRAUMATIC SEIZURES • Complicate 10% pediatric head injuries 1. Impact seizures follow minor injury ,
occur on impact 2. Early posvraumaDc seizures within min
to hours of injury.
1. No radiological intracranial injury noted in many cases
2. Do not portend later epilepsy
3. Most do not need Rx
4. Outcome good.
• Late seizure >24 hrs ader injury
– Visible intracranial injury.
– PenetraDng injuries/ depressed #/ SDH/ Lower GCS score
– Long term risk of epilespy high-‐ need Rx for 6-‐12 mo.
• Seizure prophylaxis Only during first week Or Dll
intracranial hypertension phase is passed.
Prolonged usage has cogniDve deficits on long term follow ups.
Phenytoin commonly used
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TAKE HOME MESSAGE Have a plan , a back-‐up plan and and anDcipate the curve ahead
Karak Highway
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Acknowledgments
Doctors and Nurses of HRPB IPOH