Head Injury Management Guidelines For St Mary s Major Trauma Centre

Head Injury Management Guidelines For St Mary s Major Trauma Centre Table of Contents Introduction... 2 Referral Process, Admission and Resuscitation... 2 The Trauma Tree Pathway:... 2 Neurosurgery Registrar Presence at Trauma Calls... 3 Times to CT and theatre... 3 Acute Head Injuries Outside of the Trauma Tree Pathway... 3 Chronic Subdurals and Non Urgent Head Injuries:... 3 Non- Trauma Neurosurgery Cases within St Mary s:... 4 Documentation of Referrals... 4 Documentation in Notes... 4 Emergency Head Injury Management in Resus... 5 Use of Mannitol / Hypertonic Saline... 5 Warfarin Reversal... 5 Imaging... 6 Emergency Head Injury Management in Theatres... 6 Specific surgical principals:... 7 Emergency Head Injury Management on ITU... 7 Emergency Head Injury Management on the Major Trauma Ward... 8 Documentation:... 8 General Information:... 8 DVT prevention:... 8 Seizures prevention:... 8 Discharge / Follow Up:... 8 Audit and M&M:... 9 Paediatrics:... 9 Trials... 9 Initial version written 16/02/2011 Updated 12/04/2013 Up- to- date version: http://www.londonneuro.com/smh.html 1

Introduction This document outlines the main principals of care that we should provide for patients suffering Traumatic Brain Injury (TBI). The principals of assessment and management are the same as the guidelines produced by NICE (which can be found here: http://www.nice.org.uk/cg56. IN addition, patients will be dealt with as defined in the MTC Operational Policy and Clinical Pathways documents. This document highlights specifically some of the local issues. All decisions to admit, not admit, to operate or not to operate and most management decisions should be made by the Consultant in charge of the patients care or the Consultant on call. If there are any doubts then please contact the relevant Consultant. Referral Process, Admission and Resuscitation The majority of patients will be admitted via the standard trauma tree pathway as described below (the trauma tree for London s Ambulance Service is in Appendix 1.1 and explains why most head injured patients will come directly to us). However, we also provide care for the trauma patients that come outside of this pathway as explained. The Trauma Tree Pathway: This mechanism has been set out in great detail by the London Trauma Office (LTO). In brief, based on mechanism of injury, London Ambulance Crews will triage patients to the most appropriate centre hence they may bypass local units to bring a head injury directly to St Mary s. They are then trauma called. 2

In some circumstances, the Ambulance crew may take them direct to a local hospital who then refer them to the Trauma team leader at St Marys. He/She will normally inform the Neurosurgeon that a head injury is expected. If possible, please call back the original referrer and obtain more information and images through IEP. If the call comes directly to Neurosurgery, then it is essential that the Consultant and the trauma team leader are both informed. All transfers of acutely unwell TBI patients are time critical and hence this must be stated at the time of transport request. On arrival the patient should be re- trauma called and treated as if they have come directly to St Mary s ED. Neurosurgery Registrar Presence at Trauma Calls It is a requirement that a Neurosurgical registrar is present at all trauma calls (and it is a requirement to sign in). We have agreed that if there is no head / spinal injury, the neurosurgery registrar is to be released as soon as possible. The resus process follows standard ATLS principals. If a CT scan demonstrates head / spinal injury then it is a LTO requirement that the Trauma Team leader informs the Neurosurgery Consultant on call within 90 minutes and this is documented in the notes. If the Trauma team Leader does not speak to the Consultant, then the registrar must do (and document it). This later communication is more common and is more appropriate. Either way, a discussion with the Neurosurgery Consultant should be documented within 90 minutes of arrival. Times to CT and theatre LTO expect us to achieve times to CT scan of < 30 minutes and times to theatre of <1 hour. These are difficult to achieve hence rapid diagnosis and communication is required. The patient is then transferred to theatres / ITU / the MTU as clinically indicated. Acute Head Injuries Outside of the Trauma Tree Pathway It is common practice for neurosurgeons to receive referrals directly, especially if the mechanism of injury has not been appreciated. Under such circumstances the trauma pathway may should still be activated by informing the TTL. The TTL may not call a trauma call if the patient is clearly well. Chronic Subdurals and Non Urgent Head Injuries: St Mary s has a limited capacity as a Major Trauma Centre and therefore non- urgent cases, in most circumstances, should be admitted to Charing Cross Hospital. Such cases should always be discussed with the Consultant on Call (he/ she is on call for both sites). It is important to be helpful to try to coordinate a response to try to make life easier for the referring hospital. If the patient is to be admitted to St Marys the trauma team leader and the trauma consultant of the week should be informed. 3

Non- Trauma Neurosurgery Cases within St Mary s: We have an ethical responsibility to provide acute neurosurgical care to Non- trauma cases while they await a bed at Charing Cross or other general neurosurgical facility. Such patients should be dealt with on an individual basis with close discussion between the Neurosurgery and ITU Consultant. As soon as a bed is available at Charing Cross Hospital they should be transferred. Documentation of Referrals All patients, whether admitted through St Mary s Emergency Department or from other hospitals should have their history and examination documented in our referral system. This is currently done electronically using www.neurorefer.co.uk. An alternative website can be found at www.acuterefer.com. If the referral comes from outside Imperial, then you can ask the referring hospital to fill in the online form. If from within our Emergency Department, this should be completed by the registrar attending the trauma call. This generates an email. It is vital that an email is also sent back acknowledging receipt and stating a plan. Documentation in Notes Brain Injuries commonly involve accidents or assaults and hence notes will often be scrutinised. Hence, it is more important than ever that good note keeping occurs. The following are essential: Name; Grade; Date; Time; Bleep No. Summary of History and Examination. Name of Consultant with whom discussed and a clear plan. 4

Emergency Head Injury Management in Resus Management should follow standard ATLS principles, however, two specific areas should be highlighted: Airway management: ATLS states that head injured patients of GCS <8 should be intubated. While true, many greater than GCS 8 will also need to be intubated for airway management during CT scanning. Physiological management: Optimising Intracranial Pressure and cerebral perfusion pressure is vital in resus. The following parameters should be controlled: Maintain Oxygenation (100% O2 or 15 l via non- rebreathe mask) EtCO2 = 4.5kPa Keep normothermic (or slightly cool) If intubated, ensure full paralysis and analgesia If spine cleared, keep head end elevated 30-45 degrees. If appropriate, and ICP monitor can be placed in resus. ICP can then also be optimised. Use of Mannitol / Hypertonic Saline These osmotic diuretics can be used when imminent herniation is demonstrated. Classically this involves a dilating pupil on the ipsilateral side to the injury. There are a number of studies that demonstrate mild benefit of hypertonic saline over mannitol, especially in the hypovolaemic patient and where a more prolonged effect is desired. A standard dose of hypertonic saline is 6mls/Kg of 5% to a max of 350mls. For mannitol, a standard dose is: 1 1.4g/Kg. (100g of 20% for a 70Kg man) Warfarin Reversal If a head injured patient has been on Warfarin, careful consideration should be given to reversing this. If there is any deterioration in conscious level there is no need to wait for a CT scan. If the patients is brought in by London HEMS, then a near patient INR will have usually been done and Octiplex already given. If not, then we should administer Octiplex. Details of how to obtain this are on the Code Red card within resus. If there are any delays, please inform the TTL or Neurosurgery Consultant on call. Note, if a full dose of Octiplex is given, there is no need to wait for an INR before starting surgery. 5

In less urgent cases FFP can be given but check INR pre- op when using this. Imaging A standard plain CT scans are usually adequate for most intracranial injuries. To avoid missing carotid or vertebral dissections, the Memphis modified criteria should be used to decide upon CTA: Screening protocol criteria Basilar skull fracture with involvement of the carotid canal Basilar skull fracture with involvement of petrous bone Cervical spine fracture Neurological exam not explained by brain imaging Horner s syndrome LeFort II or III fracture pattern Neck soft tissue injury (seatbelt sign or hanging or haematoma) MRI: We have pre- booked MRI slots each day. These are at: Monday: 10:00 Tuesday: 10:30 Wednesday: 14:00 Thursday: 14:15 Friday: 14:30 Saturday: 10:00-14:00 (give as much notice as possible) Outside of normal working hours, MRI is only possible at Charing Cross. Discuss this with the on call consultant before arranging. Emergency Head Injury Management in Theatres The following are golden rules for cases going to theatre: 6

1) The Consultant on Call is informed (if the 1 st on is not contactable, then contact the second on. Failing that, call Mark Wilson directly (07947 742234) 2) The patient is booked in and has a hospital number (for blood cross match purposes) 3) A WHO correct site surgery form is completed and the side of the patient marked 4) A Consent form is completed (usually Consent form 4) 5) Imaging must be displayed in theatres Additional Information: Between 8am and 5pm, a Consultant Neurosurgeon is always present in the building, though may allow the neurosurgery Registrar to operate without direct supervision if both are comfortable. If at any point a neurosurgery registrar feels they need additional support they should inform the Consultant immediately. Specific surgical principals: The type of surgery and decisions such as whether to leave bone flaps in our out is at the discretion of the consultant in charge of the case. There are however certain principals of neurotrauma care that should be targeted: 1. Rapid decompression of expanding extra- axial haematoma LTO require such cases to be in theatre within 1 hour of arrival. 2. Surgical decompression for refractory ICP should probably be within a trial (such as Rescue- ICP see trials below) 3. Ensure haemostais prior to closure Emergency Head Injury Management on ITU All neurotrauma patients must be seen everyday by a Neurosurgery / NeuroITU consultant and this must be documented. Separate ITU Head Injury Guidelines have been created by the intensivists. In brief, the principals of good ITU Care of Head Injured patients are: 1. All patients who have had a head injury who cannot be weaned from sedation and assessed should have ICP monitoring. 2. Stepwise increases in medical management should aim to maintain ICPs of < 25mmHg. 3. CPP targets are to be defined (if appropriate) by both the neurosurgeon and neurointensivist looking after the patient in question. Clear thought should be given when CPPs are targeted. ITU at St Mary s has an electronic documentation system. It is often difficult on the ward round to document things as you go along as there are usually to many people and too few computers. As such we recorded our notes and plan on the proforma sheet (appendix 3). In addition, it would be ideal to make an electronic note when able. Add hoc notes should be recorded electronically 7

Emergency Head Injury Management on the Major Trauma Ward All patients must be seen everyday by a Consultant Neurosurgeon and this must be documented. Documentation: Each day a note should be made about the patients condition and a plan for the next 24 hours. This should ideally be documented on the proforma (appendix 1). This can also be downloaded from http://www.londonneuro.com/smh.html General Information: Head Injury Protocol: Please see Appendix 2 for clinical guidelines for Head Injury Management DVT prevention: DVT prophylaxis must always be considered. TEDS / Flowtrons should be provided (and checked) as standard. Tinzaparin is appropriate in many patients, but this must be checked with the neurosurgeon in charge of the case. In patients with acute bleeds, then Tinzaparin would not be appropriate. It is at the discretion of the Neurosurgery Consultant, evaluating each patient on an individual basis as to when the benefits of Tinzeparin outweigh the risks. Most cranial injuries can be started on Tinxaparin 72 hours post injury. Seizures prevention: Anyone who has a seizure should start antiepileptics Anyone else for whom a seizure would be detrimental or whos CT scan demonstrates a lesion which is highly likely to be eleptogenic (e.g. depressed skull fracture or temporal lobe haematoma) should be on phenytoin for 1 week. 15 mg/kg IV loading followed by 250-400mgod oral (titrate to levels). Discharge / Follow Up: All patients who are discharged following a head injury should be offered a follow- up appointment in Mark Wilson s clinic on Tuesday morning. Email sharon.hinds@imperial.nhs.uk to arrange. In addition, some patients (discuss with Consultant involved) should be followed up by David Sharp in his clinic. The forms to fax to arrange this are on the shared drive and on the shelves in the Trauma office. Alternatively download the pdf from http://www.londonneuro.com/smh.html 8

Audit and M&M: We have a Regular M&M meeting on the Second Thursday of each month directly after the Trauma meeting (2pm). Paediatrics: We have a duty to provide emergency care in life threatening (e.g. Extradural, imminent coning) to all patients including children and should undertake this as per SBNS guidelines. We should also be able to assess CT scans and wake children with no significant intracranial injury when appropriate. We should not however undertake care of more prolonged head injury management (e.g. contusions requiring ICP monitor) and these children should be refered to Great Ormond Street. At present, all children with head injuries requiring neurosurgical input should be discussed with GOSH. Separate guidelines specifically for the head injury management of children are available. Trials We are involved in a number of clinical trials at Imperial. These include: Rescue ICP (for refractory ICP) http://www.rescueicp.com Eurotherm (an ITU study) - http://www.eurotherm3235trial.eu And we are enrolling in Crash 3 - http://crash3.lshtm.ac.uk Clearly, the consultant in charge if the patients care should make the decision as to whether a patient is suitable for a specific trial. 9

Appendix 1: Date and Time: Admitting Consultant Summary Hospital No: Patient Name: Date of Admission Ward Round Consultants Day Neuro Vitals FiO2 PaO2/SaO2 Temperature GCS (EVM=Total) ICP Pupils Right Left EV D Day Limb Neuro RA LA RL LL CT Scan CSF C - Spine Cleared Maintain Collar T/Lsp Other Injuries CVS HR: BP: RS ABDO Bloods Hb Na+ WCC K+ Plts Ur INR/APPT Creat Phenytoin CRP Micro Other Notes Plan CHECK TED/Flotron s Fragmin Pabrinex /DTs Signature Print Bleep 10

Appendix 2 BASIC HEAD INJURY PROTOCOL Patient Admitted Standard ATLS Management Fulfils NICE criteria for Intubation Yes No Intubate Fulfils NICE criteria for CT Nil significant on CT Neuro- Obs as per NICE guidleines CT demonstrates intracranial pathology requiring immediate craniotomy CT demonstrates tight brain Theatre immediately Insert ICP monitor Post op Insert ICP monitor Follow High ICP protocol Home: Most patients with servere brain injuires will have comples discharge/rehab plans. For minor head injuries, discharge must be with head injury advice and with someone appropriate High ICP (>25) Low ICP (<25) Follow up: In Head Injury clinic (MW or DS) Document plan for length of sedation and plan if ICP increases 11