Initial Treatment and Prognosis of an Elderly Male with a Traumatic Head Injury. By: Adam Warelis. Home for the Summer Project June/July 2016

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1 By: Adam Warelis Home for the Summer Project June/July 2016 Portage la Prairie, Manitoba Supervisor: Dr. Michelle Bailes

2 Abstract A 68 year old man presented with a traumatic head injury after a fall from standing. A PubMed search to answer the question, In an elderly male, what is the prognosis and palliative treatment of a traumatic closed head injury? yielded various case reports and studies. These reports described the increasing frequency of traumatic head injuries in the elderly and how with aggressive treatment, morbidity and mortality have been shown to decrease. The presenting patient deteriorated after their initial injury and after consultation with neurosurgery, a palliative course was set. However, with supportive treatment in the intensive care unit the patient rebounded beyond initial prognoses with improvements being seen daily. Case History The patient is a 68-year-old First Nations male. He is a homeless member of the community who has frequented the emergency department with regularity. Past medical history includes hypertension, diabetes mellitus with a right Charcot foot and known alcohol abuse. The patient presented to the emergency department at 16:27 on May 30, 2016 by ground ambulance with a laceration to the head after a fall from standing. No seizures were witnessed and the patient was deemed to be intoxicated. On triage examination the patient had vitals of: BP 145/68, pulse of 75, respiratory rate of 20 and an oxygen saturation of 96% on room air. The patient had a laceration to the head, a left blown pupil unreactive to light, a perforated left tympanic membrane with blood present in the canal, and a left sided facial droop that was noted as being part of a past orbital facial fracture. The patient was incontinent and a foley catheter was inserted. The musculoskeletal exam was normal aside from the preexisting Charcot foot. Respiratory and cardiac exams were normal aside from hypertension. Initial management included the ordering of a CT head, an EKG and blood work. Initial review of the CT head in the emergency department lead to an interpretation of a large area of parenchymal contusion and and hematoma to the right temporal lobe with local mass effect along with a small sub arachnoid hematoma. The EKG done at 16:18 revealed sinus rhythm with a right bundle branch block and occasional premature ventricular contraction, no ischemia or pathologic abnormalities were seen. Blood work revealed a hemoglobin of 100 ( ) with a MCV of 90 (80-98) and MCH of 29.4 (26-34), RBC of 3.4 ( ), and a serum glucose of 5.3. Urea and creatinine were within normal limits. Troponin was within normal limits. The INR was within normal limits, PT was 13.2 ( ). The ethanol blood level was 44 (toxic) (>33 mmol/l). At 20:15 the patient deteriorated to a GCS of 4 and was intubated by 20:30. The patient was then transferred by ground ambulance at 21:10 to Health Sciences Center for evaluation and neurosurgery consultation. 2

3 Upon arrival and consultation with neurosurgery the patient had a GCS of 7 (E1, V1, M5), corneal reflexes present bilaterally with a left pupil of 4 mm and a right pupil of 2 mm, neither reactive to light. The CT/CTA done revealed no aneurysm but a right temporal intracranial hemorrhage 9x6cm in area with uncal herniation. The neurosurgeon determined there was severe irreversible brain/brainstem injury and there would be no meaningful neurological recovery regardless of treatment or surgery. The patient was transferred back to Portage General Hospital intensive care unit for palliative treatment and comfort care at 03:00 May 31, 2016 (the same night as initial injury) by ground ambulance and arrived at 06:15 with a GCS of 6, still intubated. In the days that followed, the patient remained intubated with GCS variation from 6 to 9. Despite slight clinical improvement day to day, the family was cautioned of poor prognosis. The family decided to maintain a resuscitation order. On June 8 th, 2018, 9 days after initial presentation and deterioration, the patient improved and was extubated with a nasogastric tube inserted for nutrition. On June 9 th, the patient continued to improve and was transferred from the ICU to a medical ward, his communication and verbalization improving by the day. By June 16 th the patient was eating purred honey thick meals, communicating in comprehensible sentences. The following weeks included improved strength and ambulation in the wheelchair along with progress in standing while working with physiotherapy. It is important to note this is the second time in the last year that the patient has sustained a traumatic head injury from falling and was transported to Winnipeg for treatment. The past event in September 2015 yielded a similar injury to the left side of the brain and was severe enough to warrant admittance to the medical unit at Health Sciences Center for observation and rehabilitation. The detriments from the past injury were not as severe or debilitating as this injury and the patient had regained the majority of his functional status. Literature Review The clinical question is, In an elderly male, what is the prognosis and potential palliative treatment of a traumatic closed head injury? The PubMed MeSH terms used to answer said clinical question include, Intracranial Hemorrhage, Traumatic, hematoma, subdural and palliative medicine. Further application of filters such as publications in the last 10 years and an age filter of 65+ years also helped to refine the search for related articles. According to literature, traumatic brain injury in the elderly (defined as 65+ years old) is a neglected disease worldwide. The most common causes being falls and motor vehicle accidents with the most common injury being subdural hematomas. With comorbidities found in 40% of the elderly population, increased prevalence of treatments such as anticoagulation and anti platelet therapy will further complicate outcomes. Although elderly patients have far worse outcomes when compared to the young, certain younger elderly patients (aged years old) could have comparable outcomes for mild to moderate head injury compared to younger demographics, especially when intensive care unit treatment can be applied. Surgical intervention such as subdural hematoma evacuation has been shown to be beneficial in the 3

4 young elderly, however discerning mild to moderate brain injury is difficult and literature relating to this demographic is lacking. 1 Research has shown that aggressive treatment (transfer to major trauma center for evaluation) of elderly patients with survivable trauma of any kind leads to better outcomes then conservative treatment. However, under triaging of elderly patients to major trauma centers is widespread. Geriatric patients with sever head injuries are less likely to be transferred to a major trauma center when compared to younger populations. Protocol driven care of traumatic head injuries in the elderly can reduce mortality when following guidelines set out by organizations like the Brain Trauma Foundation or the American College of Surgeons Committee on Trauma. 2 The prognosis and long term care in patients with traumatic brain injuries can be challenging. Once stabilized after the initial injury, many of these patients have lost medical decision making capacity and thus working closely with a proxy such as family or otherwise is vital to continued care. One study found that although some patients with acute brain injuries regained capacity post injury, a sizeable portion of the affected patients studied did not regain said ability 6 months post injury. Clinically this translates into a long term care model that requires continuous decision making capacity reassessment and consultation with patient proxies 6 months post injury or more. 3 This detrimental of a head injury can cause a chronic disease state in the patient. Different trajectories of chronic disease have been well established in the past. The three well known trajectories include that of short period rapid decline, a chronic illness with exacerbations and prolonged dwindling. New research has suggested a new trajectory should be considered in the case of severe acute brain injuries. This trajectory includes the initial rapid decline in health post injury in which trust is gained with the proxy in crisis. This is followed by a period of patient stabilization where shared decision making occurs (often with the proxy). From there the trajectory either progresses to a chronic stage of survival and recovery that can span from months to years or proceed to end of life care. Clinically this means that the rapid decline in health cause by acute brain injuries can lead to difficult situations where shared decision making with a proxy is vital and often incorporated abruptly after injury onset. This relationship often spans long periods of time after the initial injury and care providers must lean on patient proxies to delineate how their loved one would want to proceed with treatment. 4 Discussion This case is of interest and note for a number of reasons. As stated above traumatic head injuries in the elderly aged 65 years and older is a growing medical problem that is often under triaged and treated worldwide 1. The ever growing comorbidities such as vascular pathology including stroke and acute coronary syndromes, decreased joint stability as the population ages and increased pharmacology with side effects all increase the risk of falls in an aging population. This combined with increased anticoagulation therapy among the population multiplies the risk of serious complications of a traumatic induced brain hemorrhage. The 4

5 frequency and risk associated with falls and head injuries in the elderly is growing and care providers must be aware. Another important concept covered in this case is the acuity and intensive care that the patient was given. Researched has shown that elderly patients are less likely to get fast and comprehensive care for what is first suspected to be mild and benign head injuries 2. The patient was transported to the local emergency department quickly and was triaged there with efficiency. All applicable tests were ordered including CT imaging as the neurological exam of the pupils and the mechanism of injury indicated the severity of the head trauma. Upon deterioration the patient was intubated and sent to a major trauma center for evaluation. After consultation the patient was transported back and maintained in an intensive care unit. All of these aggressive steps from complete initial triage and testing to comprehensive consultation and life support have shown to yield low mortality and morbidity in the young elderly (65-75 years old) despite increased comorbidities in this population 1. As the population ages and life expectancy increases, more aggressive treatment guidelines for increasingly older populations could become the standard of practice. The most important concept to take away from this case is the deterioration experienced by the patient and subsequent recovery made. Initially upon deterioration and consultation with neurosurgery, the case was deemed to be severe and a shortened palliative course was anticipated. As the case unfolded, analogous to the traumatic head injury trajectory as outlined above, the patient went through the acute phases, followed by proxy consultation and gradual clinical improvement 4. It is never easy to determine a prognosis in traumatic brain injuries, however as the medical team took the case step by step, the patient was able to recover slowly as necessary life supports were maintained at the wish of the patient s family. Although difficult to predict, not many would have anticipated such a recovery for a clinical case and head injury this severe. However, this case exemplifies that if prudent clinical actions are taken at each step in the patient s care, an initially poor prognosis can be given the chance to improve. Conclusion With longer life expectancy and increasing comorbidities as the population ages, traumatic brain injuries and subsequent treatment will increase. This case exemplifies the major impact possible from what many would consider a minor fall. The care team left no stone unturned in initial assessment and treatment of the elderly patient, sending them to the largest trauma center in the region for more intensive care. Even after a palliative course was set, intensive care treatment in conjunction with consultation of the patient s family enabled a better clinical outcome then was expected. Future areas of research could include evaluating the clinical length and course of elderly patients after a traumatic head injury or how invasive treatments such as craniotomies compare with conservative treatment like blood pressure management in patient outcome. Although traumatic head injuries in the elderly are on the rise, aggressive and intensive treatment yielding encouraging patient outcomes is possible. 5

6 Bibliography 1. Mak CHK, Wong SKH, Wong GK, et al. Traumatic Brain Injury in the Elderly: Is it as Bad as we Think? Curr Transl Geriatr Gerontol Reports. 2012;1(3): doi: /s Ross AGP. Prudent care of head trauma in the elderly: a case report. J Med Case Rep. 2014;8(1):448. doi: / Triebel KL, Martin RC, Novack TA, et al. Recovery over 6 months of medical decisionmaking capacity after traumatic brain injury. Arch Phys Med Rehabil. 2014;95(12): doi: /j.apmr Creutzfeldt CJ, Longstreth WT, Holloway RG. Predicting decline and survival in severe acute brain injury: the fourth trajectory. BMJ. 2015;351(aug06_4):h3904. doi: /bmj.h