1. Neurotrauma
James F. Holmes, MD, MPH Professor, Department of Emergency Medicine University of California at Davis - School of Medicine Director, EM Research Fellowship Director, Department of EM Journal Club Davis, California

2. Objectives Epidemiology Types of traumatic brain injuries (TBI)
Diagnosis of patients with TBI
Treatment of TBI

3. Essentials of TBI Most traumatic deaths secondary to TBI
Secondary brain injury may cause morbidity and mortality but is often preventable
Initial Resuscitation and care:
Maintain oxygenation
Appropriate ventilation
Maintain blood pressure (prevent hypotension)
Cranial CT scanning is the diagnostic test of choice 3

4. Pathophysiology Primary (initial) brain injury
Structural damage from the initial impact
Prevention strategies to minimize the number of patients sustaining head injuries
Example: motorcycle helmets

5. Pathophysiology Secondary brain injury
Tissue injury occurring after the initial injury
Usually in the initial 24 hours
Hypoxia
Mass effect
Limited blood flow
Infection
Hyperthermia
Treatment goal: prevent these types of insults with appropriate treatment 5

6. Pathophysiology CPP = MAP - ICP Intracranial pressure may be  with:
Cerebral perfusion pressure (CPP)
Goal is > 70mmHg
Mean Arterial Pressure (MAP)
Intracranial Pressure (ICP)
Intracranial pressure may be  with:
mass effect of a bleed
generalized brain edema
Cellular dysfunction occurs with decreased perfusion to the brain cells 6

7. Types of Injuries Skull Fracture Concussion Contusion
Intracranial hematoma
Epidural, Subdural, Epidural, Intracerebral
Diffuse axonal injury
Intraventricular and Subarrachnoid hemorrhages
Penetrating injury

8. Skull Fracture Multiple types: CT must be viewed on bone windows
Linear, depressed, and basilar
CT must be viewed on bone windows
Most important feature is injury occurring to the brain at the site of the skull fracture
Linear skull fracture:
If closed, can simply be observed

9. Skull Fracture Basilar skull fracture: Depressed skull fracture:
Most often involving the temporal bone
Clinical diagnosis (CT often fails to show fracture)
Raccoon’s (Panda’s) eyes, hemotympanum, Battle’s sign (mastoid ecchymosis), CSF rhinorrhea
Depressed skull fracture:
Surgical elevation:
if greater than width of skull or
> 5mm

13. Concussion
Brief change in brain function usually with loss of consciousness/amnesia
Head CT often normal
Post-concussive syndrome:
Headache, confusion, difficulty concentrating, memory problems, nausea
May last hours to months
Treatment
Simple observation
Limit activity that may reinjure patient’s head
Avoid “repeat concussion”

14. Cerebral Contusion Bruising to the brain
Most common traumatic finding on CT
Large contusions may have significant bleeding (hemorrhagic contusion or intracerebral hematoma), edema, or cause seizures
Location: Frontal and Temporal lobes
Due to irregularity of the skull base
Treatment: close observation

16. Epidural Hematoma (EDH)
Hemorrhage “above” the dura
Usually arterial (middle meningeal artery) but can also be from venous bleeding
CT: convex (lens shaped) area of blood
Bleeding restricted by the dura’s attachment to the skull
5-15% of patients with TBI on CT have an EDH

19. Epidural Hematoma (EDH)
Potentially rapidly expanding with mass effect and uncal herniation (fixed/dilated pupil)
“Awake and then die”
Most EDHs can be observed
EDHs with mass effect require surgical drainage

20. Subdural Hematoma (SDH)
Hemorrhage between the dura and the brain
More common than EDH
30% of patients with TBI have a SDH
CT: Crescent shaped area of blood
Can be acute, subacute or chronic
Subacute or chronic presents days/weeks after injury

21. Subdural Hematoma (SDH)
Elderly at  risk (less severe mechanisms)
Brain shrinks with age resulting in stretching of the bridging veins in the subdural space
May gradually enlarge (slower than EDH)
Surgical drainage for lesions resulting in masse effect and shift

26. Intracerebral Hematoma
Similar to cerebral contusions
More severe type injury
Bleeding within the brain itself
Frontal and temporal lobes
Close observation for progression of bleeding
May cause mass effect that results in herniation

28. Intraventricular Hemorrhage (IVH)
Collection of blood in the ventricles
Isolated IVH usually not problematic and requires no specific treatment

30. Subarrachnoid Hemorrhage (SAH)
SAH and contusion are most common injuries on CT after blunt trauma
CT: blood in the sulci and basal cisterns
Often associated with intracranial hematomas
Must consider that the SAH caused the trauma (spontaneous bleed and then fall)
Complications:
Arterial vasospasm: 2-3 days after injury

32. Diffuse Axonal Injury (DAI)
Shearing and rotational forces disrupt the axonal network
Mechanism: rapid acceleration/deceleration injury
Imaging
Not well visualized by CT
MRI can better define the extent of injury
No specific therapy
Likely results in the persistent neurologic deficits in patients with normal CT scans but substantial injury

33. Penetrating Injury
Primarily gunshot wounds (GSWs) but also from stab wounds (SWs)
Higher rate in urban areas
Injuries that cross the midline have very poor outcomes
Periorbital/nasal region  risk of infection

36. Epidemiology of Head Injury
Varies by country, but in general:
Most common in males (ages years)
Highest rates of TBI on CT in:
elderly (>65 years)
young (<10 years)
Mechanisms of injury:
Motor vehicle crash (including pedestrian/bike)
Falls (especially the young and elderly)
Assaults
Alcohol frequently involved

37. Classification of Neurotrauma
Multiple different classification schemes
Minimal
GCS = 15, No loss of consciousness
Normal alertness, memory and neuro exam
No evidence of skull fracture
Mild
Brief loss of consciousness, amnesia
GCS = 14
Impaired alertness, memory

38. Classification of Neurotrauma
Moderate or potentially severe
Prolonged (>5 minutes) loss of consciousness
GCS 9-13
Focal neurological deficit
Post-traumatic seizure
Intracranial lesion on CT scan
Palpable depressed skull fracture
Severe:
GCS < 8
Requires airway control

39. Prehospital Care Initial GCS score Spine immobilization
Airway management for moderate/severe head injury
Bag valve mask with oxygen to assist with ventilation
Endotracheal intubation not shown to help
Suggests harm in multiple studies

40. History Mechanism of injury Prehospital care Medical history Allergies
any seizure after the event?
Prehospital care
Medications given (and times)
Spine immobilization
Medical history
Allergies
Medications
Especially anticoagulant medications
Tetanus

41. Primary Survey Standard ATLS (A, B, C, D, E)
Assign a GCS score to the patient
May use AVPU scale
Alert
Verbal stimuli
Painful stimuli
Unresponsive
Cervical spine protection
Movement in all extremities if patient to be paralyzed for airway management

42. Primary Survey: Airway Managment
Most common reason for intubation in trauma
Rapid Sequence Intubation is standard in USA
Premedications
Lidocaine: 1-2mg/kg IV 3-4 minutes prior, potentially protects the rise in ICP with intubation
Sedatives
Etomidate: 0.3mg/kg, no effects on blood pressure
Benzodiazepines/Thiopental: volume status must be normal
Paralytics
Succinylcholine: 1-1.5mg/kg, paralysis for 5 minutes
Rocuronium: 1 mg/kg, paralysis for minutes

43. Glasgow Coma Scale (GCS) score
Standard GCS
Pediatric GCS
Eye Opening
Spontaneous
To Voice
To Pain
None
Spontaneous
To Voice
To Pain
None
Verbal Response
Oriented
Confused
Inappropriate words
Incomprehensible sounds
Coos/babbles
Irritable/cries
Cries to pain
Moans
Motor Response
Follows commands
Localizes pain
Withdraws to pain
Abnormal flexure posturing
Abnormal extension posturing 2
Spontaneous movement
Withdraws to touch
Abnormal extension posturing 2

44. Secondary Survey Formal (repeat) GCS score Pupil examination
General neurological examination
Cranial nerves
Motor exam
Sensory exam
Reflexes

45. Secondary Survey Head examination:
Lacerations and possible skull fracture
Evaluation for Basilar skull fracture
Hemotympanum
Raccoon’s (panda’s) eyes
Battle’s sign – mastoid ecchymosis, often takes > 12 hours to develop
CSF from the nose:
Halo test: drop of fluid onto a towel, central spot bloody with surrounding tint (CSF)
CSF contains glucose, nasal secretions do not

46. Diagnostic Testing CT scan: Primary screening tool
Has decreased morbidity and mortality
Images viewed in bone and brain windows
Images rapidly obtained (<1 minute on fast CT scanners)
Exposes the patient to large amounts of radiation
Costly

47. Diagnostic Testing CT scan:
Alert patients with normal CT scans are at very low risk for neurologic deterioration
Safe to discharge home from the ED
CT limitations:
Ability to detect diffuse axonal injury
No information on blood flow to the brain

48. Diagnostic Testing Skull radiographs: May localize a foreign body
low utility and generally not performed in those at risk for brain injury
Consider in very young children (<1 year) who appear well but only have a hematoma to head

50. Diagnostic Testing MRI: Better than CT
May show diffuse axonal injury and injuries not identified by CT scan
Not used as a routine screening test
30 – 45 minutes to obtain images
Very costly and not always available

52. Evaluation – Mild Head Injury
Diagnostic evaluation with cranial CT imaging when appropriate
GCS with LOC:
TBI on CT in 4-15%
Neurosurgery 1-3%
Determining appropriate indications to obtain CT is difficult
GCS = 14: patient should get a CT scan
GCS = 15: not all patients need a CT scan
Several rules to help determine when CT should be performed have been published

53. GCS = 15: Indications for CT
Canadian Cranial CT Rule Stiell I, Lancet, 2001
New Orleans Rule Haydel, New England Journal Medicine, 2000
NEXUS Cranial CT Rule Mower W, Journal Trauma, 2005
NICE Head Injury Guidelines
These rules are designed to more appropriately utilize CT in those with GCS = 15 but these rules may actually increase CT use

54. Canadian Cranial CT Rule
High Risk (to identify those needing neurosurgery)
Failure to reach GCS=15 within 2 hours of injury
Open or basilar skull fracture
Vomiting more than once
Age > 65 years
Moderate Risk (to identify those with brain injury on CT)
Amnesia >30 minutes before accident
High risk mechanism: auto v. ped, ejection from a motor vehicle, fall over 3 feet/5 stairs

55. New Orleans Head CT Rule
Short-term memory deficits: 5/9 patients
Intoxication: 19/176 patients
Age > 60 years: 4/26 patients
Seizure: 2/16 patients
Headache: 4/81 patients
Vomiting: 1/15 patients
Above clavicle trauma: 1/197 patients

56. NEXUS Head CT Rule Age < 65
No evidence of skull fracture or scalp hematoma
No neurologic deficit
No abnormal alertness
No abnormal behavior
No coagulopathy
No persistent vomiting
If negative for all, then no need for CT

57. NICE Head Injury Guidelines for CT
GCS < 13 on initial assessment
GCS < 15 at 2 hours after the injury on assessment
Suspected open, depressed, or basilar skull fracture
Post-traumatic seizure
Focal neurological deficit
More than one episode of vomiting in adults
Coagulopathy
Amnesia for events > 30 minutes before impact
Age > 65 years with loss of consciousness or amnesia
Dangerous mechanism of injury (pedestrian struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 m or five stairs) with loss of consciousness or amnesia

58. GCS = 15: Indications for CT
Risk factors for injury on CT from these prior studies include:
Elderly: > 60 or 65 years of age
Vomiting
Altered Mental status/abnormal neurologic exam
Skull fracture: depressed, basilar, linear
LOC with symptoms (headache, nausea, etc)
Post-traumatic seizure
Coagulopathy (on blood thinning medications)

59. GCS = 15: CT caveats If CT is not available, consider:
Transfer to center with CT capabilities
Observation in ED or prolonged observation in hospital depending on resources

60. Pediatric: Indications for CT
Children different than adults in many aspects
Indications for cranial CT in children different than adults
Risk of radiation from the CT scan is greatest in children
Recent large pediatric study to evaluate indications for cranial CT in children
42,412 children with GCS = 14-15
Kuppermann, Lancet; 2009; 374:1160

61. Suggested CT algorithm for patients
>2 years old with GCS after head trauma
GCS = 14 or other signs of altered mental status, or
Palpable skull fracture
Yes
CT recommended
14.0% of population
4.3% risk of clinically
important TBI No
Yes
Observation vs. CT: based on clinical factors
including:
Physician experience
Multiple versus isolated findings
Worsening symptoms or signs
after ED observation
Parental preference
History of LOC, or vomiting, or
Severe mechanism of injury, or
Severe Headache
27.7% of population
0.9% risk of Clinically important TBI No
58.3% of population
<0.05% risk of clinically important TBI
CT not recommended

62. Suggested CT algorithm for patients
<2 years old with GCS after head trauma
GCS = 14 or other signs of altered mental status, or
Palpable skull fracture
Yes
CT recommended
13.9% of population
4.4% risk of clinically
important TBI No
Yes
Observation vs. CT: based on clinical factors
including:
Physician experience
Multiple versus isolated findings
Worsening symptoms or signs
after ED observation
Age < 3 months
Parental preference
Occipital/parietal/temporal scalp hematoma, or
History of LOC > 5 sec, or
Severe mechanism of injury, or
Not acting normally per parent
32.6% of population
0.9% risk of Clinically important TBI No
53.5% of population
<0.02% risk of clinically important TBI
CT not recommended

63. Treatment of Mild Head Injury
Safe to discharge patients with normal cranial CT scans to home:
Adults (Livingston, Ann Surg 2000)
2,152 adults with normal CT
One patient had a craniotomy for skull fracture not noted on initial CT scan
NPV for craniotomy = 99.94%
Pediatrics (Holmes, AEM 2010)
13,543 children with normal CT
None underwent craniotomy
NPV for craniotomy = 100%

64. Treatment of Mild Head Injury
Appropriate discharge instructions
Warnings regarding concussion symptoms
Explanation of post-concussive symptoms
Exclusion from activity that may result in a repeat head injury (i.e. sports)
Headaches: paracetamol, aspirin
Nausea/Vomit: antiemetics

65. Moderate/Severe Head Injury

66. Initial Evaluation of Moderate/Severe Head Injury
A,B,C,D,E
Airway control for GCS < 8
Prevent hypotension and Hypoxia
Hypotension: triples risk of death
Hypoxia: doubles risk of death
Movement in all extremities prior to paralysis if possible
If comatose, assess brainstem function:
Corneal reflex: lightly touch cornea will result in blinking (Cranial Nerves V and VII)

67. Initial Evaluation of Moderate/Severe Head Injury
GCS ≤ 13
Immediate CT scan (if stable)
If no CT available, then consult with neurosurgeon and transfer to site with CT
Include cervical spine imaging: CT of the cervical spine recommended the lower the GCS score is

68. Treatment of Moderate/Severe Head Injury
Maintain CPP and the patient’s airway
treat hypoxia and hypotension immediately
Intracranial pressure monitoring in those with GCS < 8
Although no evidence outcome is improved
Can be performed in the ED but normally in the operating suite by a neurosurgeon
Elevate head of bed (30) if no cervical spine injury

69. Treatment of Moderate/Severe Head Injury
Mannitol
Increases mean arterial pressure and lowers ICP
Patient must be stable
Do not give if volume depleted as it may result in hypotension
Maintain volume status
Keep serum osmolarity < 320 mmol/L

70. Treatment of Moderate/Severe Head Injury
Mannitol
0.5 – 1 gram/kg IV bolus
Repeat boluses better than drip
Indications
increased ICP: once ICP monitor placed
Give in ED:
signs of transtentorial herniation
progressive neurological deterioration

71. Treatment of Moderate/Severe Head Injury
Anticonvulsants
Used for the first 7 days after injury in patients with high risk TBI:
GCS<10, CT with contusion, hematoma, or depressed skull fracture, Seizure
No evidence for anticonvulsants beyond 7 days
Phenytoin 15–18mg/kg IV
Carbamezapine and kepra also used
Acute seizure:
Standard therapy:
oxygen
Benzodiazepines, phenytoin, barbituates

72. Treatment of Moderate/Severe Head Injury
Sedation and Pain control
Intubated patients require sedation to prevent elevation of ICP (fighting the ventilator)
Sedation must be balanced with the need for repeat neurologic examinations to determine if brain injury is worsening
Pain control:
Fentanyl ideal narcotic in TBI patients
Sedation:
Propofol: used with increasing frequency in TBI patients
Benzodiazepines:
Barbiturates: high doses in those with uncontrollable ICP

73. Treatment of Moderate/Severe Head Injury
Surgical therapy
Craniotomy
Treatment of choice for correctable mass lesions
Better outcomes with no delays to surgery
Large hematomas (with shift), depressed skull fractures, penetrating injuries (debride the wound)
Intracranial pressure monitors/ventriculosotmy
Monitor pressure and drain CSF

74. Treatment of Moderate/Severe Head Injury
Emergency Burr Hole
Indicated in patients with rapid neurologic deterioration and an expanding hematoma and unable to get to a neurosurgeon
Other measures to reduce ICP should be attempted prior to this procedure
Burr hole performed on side of dilated pupil at the temporal bone
MD must be familiar with technique prior to attempting

75. Treatment of Moderate/Severe Head Injury
Hyperventilation
Previously a standard treatment in those with TBI
Now known to be harmful
Worse outcomes in those with prophylactic hyperventilation (Muizelaar, J Neurosurg 1991)
No prophylactic hyperventilation
Goal pCO2: ~ 35mmHg
Do not let pCO2 get below 30mmHg

76. Treatment of Moderate/Severe Head Injury
Hyperventilation
Do not hyperventilate during initial 24 hours after injury
Hyperventilate for brief periods when there is acute neurologic deterioration
Hyperventilate for  ICP that is refractory to sedation, paralysis, cerebral spinal fluid drainage, and osmotic diuretics
This is one of the last therapies

77. Treatment of Moderate/Severe Head Injury
Antibiotics
Basilar skull fracture – no evidence that prophylactic antibiotics are beneficial
Open fractures
Controversial, little evidence to support
Antibiotics to cover skin flora

78. Treatment of Moderate/Severe Head Injury
Corticosteroids
Believed to decrease cerebral edema
CRASH trial (Roberts, Lancet 2004; 364:1321)
10,008 adults in a randomized controlled trial
Increased risk of death with steroids
Relative risk = 1.18 (95% CI 1.09, 1.27)
No longer recommended in patients with traumatic brain injury

79. Treatment of Moderate/Severe Head Injury
Hypertonic saline
No benefit in 2 large randomized controlled trials
Hypothermia
Experimental in those with isolated head injury
No good clinical evidence that it is useful
Albumin
Unlikely to be beneficial and generally not recommended
Progesterone
Promising in several small studies
Wright, Ann Emerg Med 2007; 49:391
Large trial ongoing in the USA

80. Points to remember Avoid hypoxemia and hypotension in the TBI patient
Airway controlled if GCS ≤ 8
Avoid hyperventilation – keep pCO2 from mmHg
Mannitol for evidence of brain herniation or neurologic deterioration
Anticonvulsants for those at risk of post-traumatic seizures
Avoid delays to the OR for those patients needing craniotomy

81. Points to remember
Depressed mental status may be due to brain injury in the intoxicated patient
CT scanning is the screening test of choice but is not necessary in all patients with minor head injury
Patients with normal cranial CT scans are at low risk for deterioration and may be discharged from the ED if otherwise stable