Head Injury Flashcards
GENERAL APPROACH to severe TBI:
Trauma call (if GCS <14)
Neurosurg
Sit up 30deg
Cspine protection
Assess:
- Obs; ?Cushings
- GCS
- Palpable #, boggy haematoma, BOS signs
- Pupils
- Limbs, focal neuro
Avoid NP airway
Consider early intubation if GCS 8 or below
—> Protect airway AND neuroprotection with metabolic control
Head injury RSI:
- Manual in-line
- Ketamine and Roc/sux
- Can consider Lignocaine spray preTx
- Prop/Midaz infusion (anticonvulsant)
Avoid albumin (raises ICP in following days)
If stable: CTB/ cspine
If coning:
- Urgent ICP management
- +- burrholes
SECONDARY NEUROPROTECTION TARGETS
Seizure prophylaxis
—> props/ Midaz infusion is usually enough
—> OR, Keppra/ phenytoin
Refer for EVD, Codmans, craniectomy etc.
Neuroprotective targets for prevention of 2o injury:
If Codmans
ICP <20
CPP 60-70 mmHg
In absence of ICP measurement
MAP 80
Normoxia PaO2 60
Low normal PCO2 35-40
Normoglycaemia BSL <10
Normonatraemia Na 135-145
Normothermia Temp <37.5
—> no evidence for theraPx hypoT
Urgent ICP management:
Want to drop ICP without dropping CCP!
- Sit up 30deg
- Control pain
- Deepen sedation
—> bolus of fentanyl or Midaz etc. - Avoid propofol bolus as will compromise CPP - Paralyse
- Hyperventilate to CO2 25-35
- Osmotherapy
—> Hypertonic saline 3% 3ml/kg over 10mins SUPERIOR
—> (Mannitol 20% 1g/kg)
—> LP drainage
—> EVD
—> Craniectomy
Emergency decompressive craniostomy (‘burr hole’):
INDICATION
- GCS <8
- CT showing epidural/subdural with midline shift
- Unequal pupils (blown and fixed on ipsilateral side/ coning
- Timely NSx not available
PROCEDURE:
- Intubate
- Characterise location/ depth of haematoma on CT
- Shave
- Prep and drape
- Incise down and through periosteum
- Using cranial drill with self-limiting ‘clutch’ mechanism, firm pressure down and perpendicular until stops
- If subdural, open dura
- Allow free drainage of blood (avoid suction)
- Control scalp bleed (cautery, clamp)
- Transfer to definitive NSx care
EXTRADURAL
- Uncommon
- Usually associated with skull #
—> Typically temporal bone # and middle meningeal artery - ARTERIAL bleed, so rapidly expanding with mass effect +
- Classic: brief LOC —> lucid interval —> progressive ALOC
CT
-Lens shape
-Often skull #
-CANNOT CROSS SUTURES
—> Emergent craniectomy
SUBDURAL
- Common
-
Often delayed presentation
—> easy to miss on scan after 1-2 weeks!
—> “chronic” at 2 weeks - VENOUS bleed, slower
- Bridging veins- at risk in atrophy (elderly, alcoholic)
CT:
-Banana shape
-CROSSES SUTURES
—> Often conservative Mx.
SUBARACHNOID (traumatic)
- Mass effect uncommon
- More associated with DAI
- Also, vasospasm and secondary injury in 2-3 days
- May be ARTERIAL OR VENOUS
CT
- Blood in sulci
- May collect in basal cisterns, Sylvian fissure
- +- ventricular extension
—> Usually conservative neuroprotective and spasm Mx
Better prognosis than aneurysmal SAH, less vasospasm
TBI grading:
GCS score
13 - 15 = mild
9 - 12 = mod
8 or less = severe
CEREBRAL (parenchyma lol) CONTUSIONS
- Most common CT finding in TBI
- Varied appearance and location
- Oedema —> haemorrhage
- Incl. Contracoup
—> Conservative
DAI:
Rotational/ shear
Persisting coma/ deficits despite normal imaging
CT often normal
May see:
- Diffuse oedema
- ‘Tight’
- Loss of grey/white diff
- 2 or more small focal haemorrhages
—> MRI more sensitive
DDx: Contusions tend to be grouped, with focal surrounding oedema. Better GCS.
Antibiotics in penetrating head injury:
Cephazolin 2g (30mg/kg) IV
Complications of skull fracture:
- If depressed, compression
- Vessel injury (Incl. Middle meningeal —> extradural)
- If open, meningoencephalitis
- Pneumocephalus: *issue if PPV, air transport
- BASE OF SKULL:
—> CSF leak
—> CN VII/ VIII (facial paralysis, hearing loss)
—> NP tube malposition
—> Cavernous sinus thrombosis
—> Carotid-cavernous fistula
—> Pituitary injury
Options for closure of scalp wound:
Staples
Hair apposition + glue
Suture
–> Close aponeurosis and skin layers
–> If gaping/ under tension, horizontal mattress
SCALP- layers
Skin, CT, aponeurosis (galea), loose areolar fat, periosteum
Utility of the PECARN rule:
Decide neuroimage vs not
Most helpful when teasing out MILD TBI presentation
Best-performing tool (better than NEXUS II, CHALICE, CATCH )
Largest sample size
Results in fewer CT scans (+sedation!), without compromising identification of significant TBI.
DOESN’T apply in comorbidities: eg. ITP, brain tumour,
____________
RED (5% risk)- scan
YELLOW (1% risk)- observe OR scan
—> Judgement call. <3mo, parental preference, trajectory during observation, comorbs etc.
GREEN (0.02% risk)- discharge
What is the % chance of a clinically significant TBI in paeds (PECARN CATEGORIES):
Of all kids with MINOR HI, risk is <1%
GREEN (no risk factors) = 0.02%
—> Less than risk of cancer from the CTB!
YELLOW (some risk factors) = 1%
RED (high risk factors) = 5%
—> Much higher than the cancer risk
Major limitations of Canadian Head CT rule:
For adults with minor, closed HI.
Outperforms other tools
(NEXUSII, New Orleans)
BUT
- Excludes anticoagulants and antiplatelets
- Excludes new focal neurology
