Head injuries. Severity of head injuries

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Georgia Terry
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1 Head injuries ED Teaching day 23 rd October Severity of head injuries Minor GCS Must not have any of the following: Amnesia 10min Neurological sign or symptom Skull fracture (clinically or radiologically) Abnormality on CT Moderate GCS 9-13 AND/OR one or more of the followings Difficult to assess (alcohol, drug, epilepsy, etc.) Relevant co-existent disorder or treatment e.g. clotting disorders, anticoagulants Skull fracture (radiological or clinical diagnosis) Severe GCS 9 AND/OR one or more of the followings Skull fracture with neurological sign Compound or depressed scull fracture Basal scull fracture Post traumatic epilepsy Drop of GCS 2 points Neurological disturbance lasting more than 6 hours Amnesia more than 10 minutes Any abnormality on the CT head scan 1

2 Glasgow Coma Scale Limitations of GCS Cooperation!!! 2

3 Emergency Department Guidelines HEAD INJURY CHILDREN Version 1.0 (March 2014) Review date: May 2015 Page 1 of 2 Textbook approach Acute subdural haematoma Chronic subdural haematoma Epidural haematoma Intracerebral bleeding Trauma related subarachnoidal bleeding Cerebral contusion Cerebral oedema Diffuse axonal lesion 3

4 Head injuries Primary head injury Secondary head injury Outcome The damage sustained at the moment of the injury as a result of the energy transferred to the brain. The damage occurs after the primary brain injury as a result of Hypoxia Hypotension Raised intracranial pressure (ICP) ABCD approach Primary survey Patient arrival 5 seconds round/handover PLAN A Change of plan - complete airway obstruction - Massive haemorrhage - Traumatic cardiac arrest A + C spine B C D ++ Assessment (LLF) Suction Manual airway manoeuvres + MILS Supraglottic airway technics (LMA, LT) Endotracheal intubation Needle/surgical cricothyroidotomy Assessment O2 Needle thoracotomy Chest drain Mechanical ventilation Assessment IV/IO access IV fluid Major bleeding protocol Neuro assessment Communication+ A M P L E 4

5 CPP CPP = MAP - ICP CPP cerebral perfusion pressure MAP mean arterial pressure ICP intracranial pressure Brain tissue perfusion and oxygenation CPP O2 Optimal vasoconstriction / vasodilation CO2!!! Glucose Electrolytes Temperature ph 5

6 Severe head injury management Manage as a general major trauma, other life threating injury usually needs to be the priority ICP MAP O2 CO2 + Free jugular flow (collar), Position (30 degree), adjust CO2 Consider reverse anticoagulants, (Mannisol, Furosemide, Barbiturate not as routine!) Maintain MAP over 90Hgmm / do not treat hypertension IV fluid, Aggressive management of shock / early bleeding control Early call for Major Bleeding protocol Airway! O2, Mechanical ventilation Keep CO kpa USE ETCO2 monitor Sedation and ventilation + CT head (and C spine) + Involve neurosurgeon ASAP Indications for intubation and ventilation Inability to maintain adequate airway or risk of aspiration (GCS 9) Inadequate ventilation Hypoxia PaO2 9 kpa on air or PaO2 13 kpa on high flow O2 Hypercapnia PaCO2 6 kpa Spontaneous hyperventilation PaCo2 3.5 kpa Rapidly deteriorating GCS Continuous or recurrent seizures Development of complications e.g. neurogenic pulmonary oedema, hyperthermia Urgent surgical treatment is needed 6

7 Ventilation targets Keep O2 sat over 94% (PaO2 over 10kPa) Adjust CO kpa and Keep Mean Airway Pressure as low as possible MAirwayP = ICP HOW? Mean Airway P PaO2 PaCO2 ICP RR (vasoconstricti on!) Tidal Volume --- FiO PEEP --- I:E ra o --- 7

8 Minor GCS Must not have any of the following: Amnesia 10min Neurological sign or symptom Skull fracture (clinically or radiologically) Abnormality on CT Disposition Moderate GCS 9-13 AND/OR one or more of the followings Difficult to assess (alcohol, drug, epilepsy, etc.) Relevant co-existent disorder or treatment e.g. clotting disorders, anticoagulants Skull fracture (radiological or clinical diagnosis) Severe GCS 9 AND/OR one or more of the followings Skull fracture with neurological sign Compound or depressed scull fracture Basal scull fracture Post traumatic epilepsy Drop of GCS 2 points Neurological disturbance lasting more than 6 hours Amnesia more than 10 minutes Any abnormality on the CT head scan? HOME BASED ON NEUROSURGICAL DISCUSSION Summary ABCD approach Other life-threating injury usually needs to be the priority Avoid hypoxia Avoid low CPP (low BP and high ICP) Call for help Trauma team Neurosurgeon 8

PRACTICE GUIDELINE. DEFINITIONS: Mild head injury: Glasgow Coma Scale* (GCS) score Moderate head injury: GCS 9-12 Severe head injury: GCS 3-8

PRACTICE GUIDELINE. DEFINITIONS: Mild head injury: Glasgow Coma Scale* (GCS) score Moderate head injury: GCS 9-12 Severe head injury: GCS 3-8 PRACTICE GUIDELINE Effective Date: 9-1-2012 Manual Reference: Deaconess Trauma Services TITLE: TRAUMATIC BRAIN INJURY GUIDELINE OBJECTIVE: To provide practice management guidelines for traumatic brain