Head trauma (adult): Difference between revisions

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==Diagnosis==
== Background ==
*Classification based on GCS
**14-15: Mild
**9-13: Moderate
**3-8: Severe
*B/l pinpoint pupils suggests opiate use or pontine lesion
*Pretreatment w/ lidocaine has not been shown to improve outcomes


CT Guidelines
== Clinical Decision Rules ==
=== NEXUS-II ===
*Consider no head CT if all of the following are negative:
**Abnormal alertness, behavior
**Suspected skull fracture
**Recurrent vomiting
**�Age ≥65
**Coagulopathy
**Focal neuro deficit
**Scalp hematoma


Inclusion = 'minor head trauma'
== Diagnosis ==
*Monitor for increased ICP
**HA, N/V, sz, lethargy, HTN, bradycardia, agonal respirations
*Monitor for herniation
**Ipsilateral fixed and dilated pupil
**Contralateral motor paralysis
===Skull Fracture===
*All skull fx require head CT
*ABX indicated for:
**Open fx
**Depressed fx
**Involves sinus
**Leads to pneumocephalus
*Vancomycin 1gm IV AND CTX 2gm IV
===Cerebral Contusion / Intracerebral Hemorrhage===
*Often a/w SAH
*ICH can occur days after trauma often at site of resolving contusions
**More common in pts w/ coagulopathy
===Subarachnoid Hemorrhage===
*Most common CT abnormality in moderate-severe TBI
*+Meningeal signs
===Epidural Hematoma===
*Due to trauma to temporoparietal area w/ associated skull fx and meningeal artery damage
*Classic presentation of LOC > lucid interval > LOC only occurs in 20%
*Injury to brain is often absent so good recovery if hematoma evacuated in time
===Subdural Hematoma===
*Often a/w underlying parenchymal damage
*More common in elderly, alcoholics, children <2yr
*May be acute (rapid LOC) or chronic (AMS w/ gradual decrease in consciousness)
 
== DDx ==
#DAI
#Contusion/intracerebral hematoma
#Epidural
#Subdural
#Traumatic SAH
#Concussion
 
==Treatment==
===Prevent further brain injury===
#Head of bed @ 30 degrees
#Prevent:
##Hypotension
##Hypoxia
##Anemia
##Hyperthermia
##Coagulopathy
 
===Increased ICP===
#Ensure adequate sedation (prevent gag reflex)
#IVF to goal MAP >80 (maintains cerebral perfusion)
#Mannitol
##Consider as long as pt is not hypotensive
##Reduces ICP w/in 30min; duration of action of 6-8hr
##Bolus 0.25-1 gm/kg
##Monitor I+O to maintain euvolemia
#Hyperventilation
##No longer recommended as prophylactic intervention
###Hyperventilation to PaCO2 <25 never indicated
##Brief course only recommended if impending herniation (i.e., Cushing reflex)
####Maintain PaCO2 30-35
#Seizure
##Treat immediately
##Seizure prophylaxis reduces sz but does not improve long-term outcome


AMERICAN HEAD CT RULE
*Minor head trauma = brief LOC after event, then GCS of 15


*CT indicated for:
#Short term memory deficit (more than amnesia to the event; i.e. persistent anterograde amnesia)
#Evidence of trauma above clavicles
#Headache
#Vomiting
#Age > 60yrs
#Drug or EtOH intoxication (clinical impression, not by labs)
#Seizure post trauma


*Coagulopathy (including coumadin)


CANADIAN HEAD CT RULE
*Minor head trauma = witnessed LOC, definite amnesia, witnessed disorientation w/ GCS 13-15


*CT indicated for:
#GCS <15 2hrs post accident
#Suspected open/depressed skull fx
#Any sign of basal skull fracture (hemotympanum, racoon eyes, CSF otorrhea/ rhinnorrhea, Battle's sign)
#Vomiting >2 episodes
#Age >=65
#Amnesia >30 mins pror to impact
#Dangerous mechanism (struck by MVA, ejected from MV, fall from height > 3ft or 5 stairs)


==DDx==


#DAI
== See Also ==
#Contusion
 
#Epidural
[[Glasgow Coma Scale (GCS)]] [[Head Trauma (Minor) (Peds)]]
#Subdural
#Traumatic SAH
#Intracerebral
#Concussion


==Treatment==
== Source ==
#Head of bed @ 30 degrees
#Seizure prophylaxis
#Maintain CO2 30-35 if suspect herniation
#maintain CPP (MAP-ICP) 40-65
#Prevent:
##Hypotension
##Hypoxia
##Anemia
##Hyperthermia
##Coagulopathy


==See Also==
*Annals 2/09, Stein
[[Head Trauma (Minor) (Peds)]]
*Tintinalli
==Source==
*(NEJM 7/00, Haydel)
*(Lancet 5/01, Stiell)


[[Category:Trauma]]
[[Category:Trauma]]

Revision as of 21:43, 10 July 2011

Background

  • Classification based on GCS
    • 14-15: Mild
    • 9-13: Moderate
    • 3-8: Severe
  • B/l pinpoint pupils suggests opiate use or pontine lesion
  • Pretreatment w/ lidocaine has not been shown to improve outcomes

Clinical Decision Rules

NEXUS-II

  • Consider no head CT if all of the following are negative:
    • Abnormal alertness, behavior
    • Suspected skull fracture
    • Recurrent vomiting
    • �Age ≥65
    • Coagulopathy
    • Focal neuro deficit
    • Scalp hematoma

Diagnosis

  • Monitor for increased ICP
    • HA, N/V, sz, lethargy, HTN, bradycardia, agonal respirations
  • Monitor for herniation
    • Ipsilateral fixed and dilated pupil
    • Contralateral motor paralysis

Skull Fracture

  • All skull fx require head CT
  • ABX indicated for:
    • Open fx
    • Depressed fx
    • Involves sinus
    • Leads to pneumocephalus
  • Vancomycin 1gm IV AND CTX 2gm IV

Cerebral Contusion / Intracerebral Hemorrhage

  • Often a/w SAH
  • ICH can occur days after trauma often at site of resolving contusions
    • More common in pts w/ coagulopathy

Subarachnoid Hemorrhage

  • Most common CT abnormality in moderate-severe TBI
  • +Meningeal signs

Epidural Hematoma

  • Due to trauma to temporoparietal area w/ associated skull fx and meningeal artery damage
  • Classic presentation of LOC > lucid interval > LOC only occurs in 20%
  • Injury to brain is often absent so good recovery if hematoma evacuated in time

Subdural Hematoma

  • Often a/w underlying parenchymal damage
  • More common in elderly, alcoholics, children <2yr
  • May be acute (rapid LOC) or chronic (AMS w/ gradual decrease in consciousness)

DDx

  1. DAI
  2. Contusion/intracerebral hematoma
  3. Epidural
  4. Subdural
  5. Traumatic SAH
  6. Concussion

Treatment

Prevent further brain injury

  1. Head of bed @ 30 degrees
  2. Prevent:
    1. Hypotension
    2. Hypoxia
    3. Anemia
    4. Hyperthermia
    5. Coagulopathy

Increased ICP

  1. Ensure adequate sedation (prevent gag reflex)
  2. IVF to goal MAP >80 (maintains cerebral perfusion)
  3. Mannitol
    1. Consider as long as pt is not hypotensive
    2. Reduces ICP w/in 30min; duration of action of 6-8hr
    3. Bolus 0.25-1 gm/kg
    4. Monitor I+O to maintain euvolemia
  4. Hyperventilation
    1. No longer recommended as prophylactic intervention
      1. Hyperventilation to PaCO2 <25 never indicated
    2. Brief course only recommended if impending herniation (i.e., Cushing reflex)
        1. Maintain PaCO2 30-35
  5. Seizure
    1. Treat immediately
    2. Seizure prophylaxis reduces sz but does not improve long-term outcome




See Also

Glasgow Coma Scale (GCS) Head Trauma (Minor) (Peds)

Source

  • Annals 2/09, Stein
  • Tintinalli
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