Head trauma (main): Difference between revisions

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{{Adult top}} [[head trauma (peds)]]
==Background==
==Background==
*Main goals in management:
**Prevent intracranial hypertension
**Prevent secondary brain insults
**Maintain CPP > 70 mmHg
**Optimize cerebral oxygenation and blood flow
*Severe TBI defined as head trauma and GCS 3-8<ref>Teasdale G, Jennett B: Assessment of coma and impaired consciousness: A practical scale. Lancet. 1974, 2: 81-84.</ref>
[[File:TBI GCS.jpg|thumb]]
[[File:TBI GCS.jpg|thumb]]
*Also known as Traumatic Brain Injury (TBI): Impairment in brain function from a mechanical force
{{TBI pathophysiology}}


==Clinical Features==
==Clinical Features==
{{GCS table}}
*Adult patient with blunt head trauma


==Differential Diagnosis==
==Differential Diagnosis==
{{Intracranial hemorrhage DDX}}
{{Head trauma DDX}}
 
{{Maxillofacial trauma DDX}}
 
{{Blunt neck trauma DDX}}
{{Blunt neck trauma DDX}}
===Other===
*[[Concussion]]
*[[Severe traumatic brain injury]]


==Evaluation==
==Evaluation==
{{Head trauma workup}}
{{GCS table}}
*Pertinent labs
**Immediate blood glucose level
**Serial ABGs with focus on PaO2, PaCO2, acid-base status
**Hb assessment with consideration for transfusion with Hb < 7 mg/dL
**PT/INR/PTT
**Electrolytes
***Hyponatremia, hypomagnesemia, hypophosphatemia lower seizure threshold
===Monitoring===
*Core temperature, Foley with bladder probe
*ICP monitoring
*Jugular venous oxygen saturation (SjvO2) by retrograde catherization of right IVJ associated with improved outcomes<ref>Cruz J: The first decade of continuous monitoring of jugular bulb oxyhemoglobin saturation: management strategies and clinical outcome. Crit Care Med. 1998, 26: 344-351.</ref>
**Normal range 55-70%
**Sustained desaturation < 50% requires aggressive treatment<ref>Robertson CS, Cormio M: Cerebral metabolic management. New Horiz. 1995, 3: 410-422.</ref>
*Transcranial doppler around thinner walls of skull (insonation windows)<ref>de Freitas GR, Andre C: Sensitivity of transcranial Doppler for confirming brain death: A prospective study of 270 cases. Acta Neurol Scand. 2006, 113: 426-432.</ref><ref>Dosemeci L, Dora B, Yilmaz M, et al: Utility of transcranial Doppler ultrasonography for confirmatory diagnosis of brain death: Two sides of the coin. Transplantation. 2004, 77: 71-75.</ref>
**Temporal region above zygomatic arch, through eyes, below jaw, behind occiput
**Sensitivity for brain death is ~75%, specificity 98%


==Management==
===Workup===
*Monitor for increased ICP
''Workup is dependent on [[GCS]] severity, see:''
*Monitor for herniation
*[[Mild traumatic brain injury]] ([[GCS]] 14-15)
*Maintain PaO2 > 60 mmHg
**[[Clinical decision rules for head CT in trauma]]
*Prevent hyperthermia
*[[Moderate-to-severe traumatic brain injury]]  ([[GCS]] <14)
*Prevent hypotension
*Correct coagulopathy (FFP, vitamin K, PCC, desmopressin)
*[[Tranexemic acid]]
*Surgical intervention


{{Increased ICP treatment}}
==Management & Disposition==
''Dependent on underlying diagnosis, see:''
*[[Intracranial hemorrhage]]
*[[Moderate-to-severe traumatic brain injury]]
**[[Elevated intracranial pressure]]
*[[Mild traumatic brain injury]]
*[[Post-concussive syndrome]]


==See Also==
==See Also==

Revision as of 23:12, 28 November 2019

This page is for adult patients. For pediatric patients, see: head trauma (peds)

Background

TBI GCS.jpg
  • Also known as Traumatic Brain Injury (TBI): Impairment in brain function from a mechanical force

TBI Pathophysiology

Primary injury

Secondary injury

Brain swelling causes increased ICP which compresses the tissue causing ischemia with direct compression of the vasculature causing brain tissue herniation and brain death

  • Leads to expansion of the original injury (predominantly metabolic insult)
    • Calcium and sodium shifts
    • Mitochondrial damage
    • Production of free radicals
  • Ultimately leads to damage to axonal integrity and axonal transport
    • Enzyme activity leads to apoptosis
  • Microscopic structural injury is often unidentifiable on CT or MRI

Cerebral Blood Flow and Autoregulation

  • vasoconstriction
    • HTN, Hypocarbia, alkalosis
  • No good way to measure cerebral blood flow
    • Use CPP as surrogate
      • CPP is amount of pressure needed to perfuse the brain
      • CPP=MAP-ICP
        • When ICP elevates, CPP decreases
        • Normal ICP
          • 15 in adults
          • <10 to 15 in children
          • 1.5 to 6.0 in infants
  • Autoregulation allows the body to control the cerebral blood flow
    • Autoregulatory mechanism is damaged in most TBI patients

Clinical Features

  • Adult patient with blunt head trauma

Differential Diagnosis

Head trauma

Neck Trauma

Evaluation

Adult GCS

Eye Opening Verbal Motor
6: Obeys commands
5: Oriented 5: Localizes to pain
4: Spontaneously opens 4: Confused speech 4: Withdraws from pain (normal flexion)
3: Opens to command 3:Inappropriate words 3: Decorticate posturing (abnormal flexion)
2: Opens to pain 2: Incomprehensible sounds 2: Decerebrate posturing (extension)
1: Does not open 1: No response 1: No response
  • 14-15: Mild
  • 9-13: Moderate
  • 3-8: Severe

Workup

Workup is dependent on GCS severity, see:

Management & Disposition

Dependent on underlying diagnosis, see:

See Also

References