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Assessment, Management and Decision Making in the Treatment of Polytrauma Patients with Head Injuries Roman A. Hayda, MD Original Author March 2004; Revised.

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Presentation on theme: "Assessment, Management and Decision Making in the Treatment of Polytrauma Patients with Head Injuries Roman A. Hayda, MD Original Author March 2004; Revised."— Presentation transcript:

1 Assessment, Management and Decision Making in the Treatment of Polytrauma Patients with Head Injuries Roman A. Hayda, MD Original Author March 2004; Revised July 2006, November 2010

2 Epidemiologic Aspects 80,000 survivors of head injury annually 125,000 children <15yo head injured annually 40-60% of head injured patients have extremity injury 32,000-48,000 head injury survivors with orthopaedic injuries annually

3 Overview Pathophysiology Initial evaluation Prognosis Management of Head Injury Orthopaedic Issues –Operative vs. nonoperative treatment Timing of surgery methods – Fracture healing in head injury –Associated injuries –Complications

4 1 st hit 1 st hit: Head mechanical insult to brain tissue blunt or penetrating 1 st hit: body mechanical insult chest, abdomen extremities 2nd hit 2 nd hit: Head release of inflammatory mediators Hypoxia Acidosis Coagulopathy 2 nd hit: body systemic inflammation SURGERY

5 Evaluation ATLSABCs History –loss of consciousness Physical exam –Glasgow Coma Scale Radiographic studies –CT Scan

6 Evaluation Must exclude head injury by evaluation if –history of loss of consciousness –significant amnesia –confusion, combativeness Cannot be simply attributed to drug or alcohol use –neurologic deficits on exam of cranial nerves or extremities

7 Physical Exam Exam of head and cranial nerves for lateralizing signs –dilated or sluggish pupil(s) Extremities –unilateral weakness –posturing decorticate (flexor) decerebrate (extensor)

8 Glasgow Coma Scale Eye opening: 1-4 Motor response: 1-6 Verbal response: 1-5

9 Glasgow Coma Scale Eye opening –Spontaneous 4 –To speech 3 –To pain 2 –None1

10 Glasgow Coma Scale Motor response –Obeys commands6 –Purposeful response to pain5 –Withdrawal to pain4 –Flexion response to pain3 –Extension response to pain2 –None1

11 Glasgow Coma Scale Verbal response –Oriented 5 –Confused 4 –Inappropriate 3 –Incomprehensible2 –None1

12 Glasgow Coma Scale Sum scores (3-15) –<9 considered severe –9-12 moderate –13-15 mild* ModifiersxT– if intubated (Best score possible 11T) xTP – if intubated and paralyzed (Best score possible is 3TP) Done in the field but best in trauma bay following initial resuscitation

13 Radiographic Studies CT scan –required in ALL cases EXCEPT: LOC is brief AND patient can be serially examined –lesions focal--epidural, subdural hematoma, contusions diffuse--diffuse axonal injury Plain films –useful only to detect skull fracture but in the trauma setting wastes time Frontal Contusion

14 Treatment Initial –Intubation if unresponsive or combative to give controlled ventilation –pharmacologic paralysis after neurologic exam is completed –Blood pressure and O 2 saturation monitoring keep systolic > 90 mm Hg 100% O 2 saturation

15 ICP Monitoring Indications –severe head injury (GCS < 9) abnormal head CT or Coma >6 hrs –Intracranial hematoma requiring evacuation –Delayed neurologic deterioration from mild to moderate (GCS>9) to severe (GCS < 8) –Requirement for prolonged ventilation –Pulmonary injury, surgery etc.

16 ICU Management Goals O 2 saturation 100% Mean arterial pressure mm Hg ICP < 20 mm Hg Cerebral Perfusion Pressure (CPP=MAP-ICP) >70 mm Hg

17 ICU Adjuncts HCT~ 30-33% PaCO 2 = 35±2 mm Hg CVP= 8-14 mm Hg avoid dextrose IV maintain euthermia or mild hypothermia

18 Factors Influencing Prognosis Age –Younger pts have greatest potential for survival and recovery –61-75% mortality if over 65 –90% mortality in elderly with ICP >20 and coma for more than 3 days –100% mortality if GCS < 5, uni- or bilateral dilated pupils, and age over 75 Bottom line: survival and recovery not predictable except in old pts Treat presuming recovery

19 Factors Influencing Prognosis Hypotension--50% increase in mortality with single episode of hypotension Hypoxia Delay in treatment –prolonged transport –surgical delay when lateralizing signs present Potentially controllable!!

20 Outcome Glasgow Outcome Score: –1-dead –2-vegetative –3-cannot self care –4-deficits but able to self care –5-return to preinjury level of function

21 Outcome Prediction Glasgow scale (post resuscitation) 44-66% accuracy in determining ultimate outcome –39% with an initial GCS of < 5 made functional recovery CT based scoring (Marshall Computed Tomographic score) only 71% accurate

22 Outcome Prediction Serum markers (S-100B) –Accuracy of 83% (Woertgen, J Trauma, 1999) –Good sensitivity in moderate to severe injury even with extracranial injury (Savola, J Trauma, 2004) –May be elevated in 29% fx pts without head injury (Unden, J Trauma, 2005) Clinical utility not defined

23 Prognosis Significant 1 yr Disability even in mild injury –Glasgow cohort: 742 pts with 71% follow-up Rate of combined severe and moderate disability similar among groups (48%, 45% and 48%) Age >40, previous head injury, comorbidities increased disability (Thornhill, BMJ, 2000) Dead or vegetative Severe disability Moderate disability Good recovery Mild (GCS 13-15) 8%20%28%45% Mod (GCS 9-12) 16%22%24%38% Severe (GCS <9) 38%29%19%14%

24 Prognosis of the Severely Head Injured Patient Gordon (J Neurosurg Anes 95) – 1,294 pts with severe injury(GCS <9) at 10 year follow-up 55% good recovery 19% significant disability 7% vegetative 19% mortality Sakas (J Neurosurg 95) –40 pts with fixed and dilated pupils 55% younger than 20 years made independent functional recovery 25% mild to moderate functional disability 43% mortality

25 Orthopaedic Issues in the Head Injured Patient Role in resuscitation –pelvic ring injury –open injuries –long bone fractures Treatment methods and timing Associated injuries Complications

26 Initial Surgery in the Head Injured is Damage Control Surgery

27 Damage Control Orthopaedics Goal –Limit ongoing hemorrhage, hypotension, and release of inflammatory factors –Limit stress on injured brain –Initial surgery <1-2 hrs limit surgical blood loss

28 Damage Control Orthopaedics Methods –Initial focus on stabilization External fixation Limited debridement Limited or no internal fixation or definitive care –Delayed definitive fixation (5-7 days)

29 Resuscitation: Role of Orthopaedics Goal: limit ongoing hemorrhage and hypotension –pelvic ring injury-- external fixation reduced mortality from 43% to 7% (Reimer, J Trauma, 93) –open injury--limit bleeding –long bone fracture--controversial

30 Long Bone Fracture in the Head Injured Patient Early fixation (<24 hours) well accepted in the polytrauma patient In the head injured patient early fixation may be associated with –hypotension– elevated ICP –blood loss/coagulopathy –hypoxia Advocates of early and delayed treatment

31 Early Osteosynthesis Hofman (J Trauma 91): –58 patients with a GCS < 7 –lower mortality and higher GOS with operative treatment within 24 hours Poole ( J Trauma 92): –114 patients with head injury –delayed fixation did not protect the injured brain McKee (J Trauma 97): – 46 head injured with femur fractures matched with 99 patients without fracture –no difference in neurologic outcome or mortality

32 Early Osteosynthesis Bone (J Trauma 94): –in 22 patients (age <50) with a GCS 4-5 –13.6% (early fixation) vs 51.3% (delayed fixation) mortality rates Starr (J Orthop Trauma 98): –32 pts with head injury –14 early, 14 delayed, 4 nonoperative –delayed fixation associated with 45X greater pulmonary complications but did not affect neurologic complications

33 Early Osteosynthesis Kalb (Surgery 98): –123 patients, head AIS > 2, 84 early, 39 late fixation –early group had increased fluid requirement but no other difference in mortality or complication –emphasized the role of appropriate monitoring Scalea (J Trauma 99): –171 patients, mean GCS 9, 147 early, 24 late fixation –early fixation no effect on length of stay, mortality, CNS complications

34 Delayed Osteosynthesis Reynolds (Annals of Surg 95): –Mortality 2/105 patients, both early rodding (<24 hrs) –one due to neurologic and the other pulmonary deterioration Jaicks (J Trauma 97): –33 patients with head AIS > 2; 19 early fixation 14 late –early group required more fluid in 48 hrs (14 vs 8.7 l); more intraoperative hypotension (16% vs 7%); lower discharge GCS (13.5 vs 15)

35 Delayed Osteosythesis Townsend (J Trauma 98): –61 patients with GCS < 8; –hypotension 8 X more likely if operated < 2 hrs and 2 X more likely when operated within 24 hrs –no difference noted in GOS

36 Advances in Care of Head Injured ICP monitoring Evolution of anesthetic agents Improvement in neuroanesthetic techniques Allow for safer surgery in the head injured

37 Fracture Care Ultimate neurologic outcome continues to be difficult to predict –Presume recovery –Avoid treatments that may compromise neurologic outcome All interventions must strive to reduce musculoskeletal complications inherent in the head injured patient Management decisions made in conjunction with trauma/neurosurgical team

38 Algorithm for Fracture care in Head injured Severe Head injury (GCS<9) or unstable pt DAMAGE CONTROL SURGERY Convert to definitive at 5+ days Mild head injury (GCS 13-15); stable pt Consider EARLY TOTAL CARE Intermediate head injury Determined by pt stability; complexity of surgery

39 Operative Fracture Care Surgery is often optimal form of fracture treatment in the head injured polytrauma patient Advantages –Alignment –Articular congruity –Early rehabilitation –Facilitated nursing care Galleazzi, ulna and olecranon fx with compartment syndrome

40 Operative Fracture Care Perform early surgery when appropriate –MUST minimize hypotension hypoxia elevated ICP –Consider temporary methods (external fixation) Fixation must be adequate –Patient may be non compliant –accelerated healing cannot be relied upon use appropriate monitors

41 Nonoperative Fracture Management Treatment of choice when –nonoperative means best treat that particular fracture –operative risks outweigh potential benefits Modalities –splint –brace –cast –traction Caveat –device must be removed periodically to inspect underlying skin for decubiti

42 Bone Healing in the Head Injured Patient Humoral osteogenic factors are released by the injured brain Exuberant callus MAY be seen Soft tissue ossification is common Ultimate union rate of fractures inconsistently affected

43 Fracture Healing with Head Injury Cadosch, JBJS-A, 2009 –Case matched series of 17 pts with avg GCS 5.6, treated with IM nail –Union 2X faster; 37-50%> callus; serum induced osteoblast proliferation Boes, JBJS-A, 2006 –Experimental model of 43 rats with IM nailed femur fx +/- head injury –More fx stiffness in head injury cohort –Serum of head injured rats promoted stem cell proliferation

44 Complications Heterotopic Ossification –up to % incidence periarticular injury with head injury Contractures Malunion Recurrent elbow dislocation secondary to extensor posturing and heterotopic ossification

45 Heterotopic Ossification Associated with ventilator dependency Use approaches/techniques less associated with H.O. Prophylaxis –XRT –Indocin Excision

46 Contractures Occurs due to spasticity/posturing Effects –Inhibits restoration of function –Complicates nursing care –Predisposes to decubitus ulcers

47 Contractures Treatment: –Prevention splinting/positioning early physical and occupational therapy –Established serial casting manipulation surgery nerve blocks

48 Associated Injuries Normal methods of clinical and radiologic assessment may not apply in the head injured patient –C spine injury –Occult fractures and injury

49 C Spine Injury Incidence increases with increasing severity of head injury Demetraiades, J Trauma, 00 Evaluation more difficult Optimal protocol for evaluation and management controversial 10.2%<9 6.8% %13-15 C spine injury Incidence GCS

50 C Spine Injury Minimum requirement –Cervical collar –CT entire C spine with reconstructions Adjuncts –MRI Difficult in vent patient May over call injury –Dynamic flexion extension radiographs in the obtunded patient Safety and reliability not established

51 Occult Injuries Fractures, dislocations and peripheral nerve injuries may be missed –Up to 11% of orthopaedic injuries may bemissed –Peripheral nerve injuries are particularly common (as high as 34%) –Occult fractures in children with head injury are also common (37-82%)

52 Occult Injuries Detailed physical exam with radiographs of any suspect area due to bruising, abrasion, deformity, loss of motion Consider EMG for unexplained neurologic deficits Bone scan advocated in children with severe head 72 hrs

53 Summary Orthopaedic injuries are common in head injured polytrauma patients Head injury outcome is difficult to predict Management requires multidisciplinary approach Operative management is safe and often improves functional outcome if secondary brain insults are avoided –Hypotension, hypoxia, increased ICP

54 References Bayir H, Clark RS, Kochanek PM. Promising strategies to minimize secondary brain injury after head trauma. Crit Care Med. 2003;31:S112–S117. Bandari M, Guyatt GH, Khera V, et al. Operative management of lower extremity fractures in patients with head injuries. Clin Orthop Relat Res. 2003;407:187–198. Boes M, Kain M, Kakar S, et al. Osteogenic Effects Of Traumatic Brain Injury On Experimental Fracture-Healing. JBJS-A. 88: , Bone J, K McNamara, B Shine, J Border: Mortality in multiple trauma patients with fractures J Trauma, 37, , 1994 Brohi K Healy M, Fotheringham T, et al.Helical Computed Tomographic Scanning for the Evaluation of the Cervical Spine in the Unconscious, Intubated Trauma Patient. J Trauma. 2005;58:897–901. Cadosch D, Gautschi O, Thyer M, et al. Humoral Factors Enhance Fracture-Healing and Callus Formation in Patients with Traumatic Brain Injury. JBJS-A. 91: , 2009 Demetraiades D, K Charalambides, S Chahwan et al: Nonskeletal cervical spine injuries: Epidemiology and Diagnostic pitfalls. J Trauma, 48 (4): , Davis DP, Serrano JA, Vilke GM, et al. The predictive value of field versus arrival Glasgow Coma Scale score and TRISS calculations in moderate-to-severe traumatic brain injury. J Trauma. 2006;60:985–990. Flierl MA, Stonebak JW, Beauchamp KM, et al. Femur Saft Fixation in Head Injured Patients: When is the right time? J Orthop Trauma. 24: Garland D, M Rhoades. Orthopaedic Management of Brain Injured Adults, CORR 131: , 1978 Grossman R, C Loftus: Principles of Neurosurgery, 2nd ed, New York: Lippincott-Raven, Hariri R, A Firuk, S Shepard: Traumatic brain injury, hemorrhagic shock, and fluid resuscitation: effects on intracranial pressure and brain compliance J Neurosurg 79: Hofman P, Goris J. Timing of Osteosynthesis of Major Fractures in Patients with Severe Brain Injury, J Trauma, vol 31(2): Jaicks R, S Cohn, B Moller: Early fracture fixation may be deleterious after head injury J Trauma, vol 42 (1): 1-6) 1997 Jeremitsky E, Omert L, Dunham CM, et al. Harbingers of poor outcome the day after severe brain injury: hypothermia, hypoxia, and hypoperfusion. J Trauma. 2003;54:312–319. Kalb D, A Ney, J Rodriguez, et al: Assessment of the relationship between timing of fixation of the fracture and secondary brain injury in patients with multiple trauma Surgery vol 124 (4) , Kushwaha V, D Garland. Extremity fracture in the patient with traumatic brain injury JAAOS, 6(5): , Li J, Guo Z, Han J, et al. Expression of vascular endothelial growth factor in bony callus of patients with fracture combined with head injury versus simple fracture patients and its clinical significance. J Clin Rehab Tissue Eng Res. 13: , Marion D Head Injury in: The Trauma Manual, Peitzman A, M Rhoades, C Schwab, D Yealy eds, New York: Lippincott-Raven, Masson F, Thicoipe M, Aye P, et al. Epidemiology of severe brain injuries:a prospective population-based study. J Trauma. 2001;51:481–489.

55 Moore E, K Mattox, D Feliciano: Trauma, 2nd ed, Norwalk, CT: Appleton and Lange, Moppett IK. Traumatic Brain Injury: assess, resuscitation and early management. Br J Anaesth 99: Morshed S, Miclau T 3rd, Bembom O, et al. Delayed internal fixation of femoral shaft fracture reduces mortality among patients with multisystem trauma. J Bone Joint Surg Am. 2009;91:3–13. Nau T, Aldrian S, Koenig F, et al. Fixation of femoral fractures in multipleinjury patients with combined chest and head injuries. ANZ J Surg. 2003; 73:1018–1021. Poole GV, J Miller, S Agnew, J Griswold: Lower extremity fracture Fixation in Head injured Patients J Trauma, 32(5) , Reimer BL, Butterfield S. Diamond DL, et al., Acute mortality associated with injuries to the pelvic ring: The role of early patient mobilization and external fixation, J Trauma 35 (1993), 671–677. Reynolds MA, J Richardson, D Spain, et al: Is the timing of fracture fixation important for the patient with multiple trauma Annals of Surgery, 222(4): , Savola O, Pyhtinen J, Leino T, Siitonen S, Niemelä O, Hillbom M. Effects of Head and Extracranial Injuries on Serum Protein S100B Levels in Trauma Patients. J Trauma, 5: , 2004 Scalea T, J Scott, R Brumback, et al: Early fracture fixation may be just fine after head injury: No difference in central nervous system outcomes J Trauma vol 46 (5): , Starr A, J Hunt, D Chason, C Reinert: Treatment of femur fracture with associated head injury J Orthop Trauma, vol 12 (1): 38-45, Thornhill S, Teasdale G, Murray GD, et al. Disability in young people and adults one year after head injury: prospective cohort study BMJ 2000; 320 : 1631 Townend W,Muller K,Waterloo K, Ingebrigtsen T, Lecky F. Validation Of Serum S-100b As A Predictive Marker For Mild Head Injury Outcome. Emerg Med Journal. 24:381, May Townsend R, T Lheureau, J Protetch et al: Timing fracture repair in patients with sever brain injury J Trauma 44: , 1998 Undén J, Bellner J, Eneroth M, et al. Raised Serum S100B Levels after Acute Bone Fractures without Cerebral Injury J Trauma 58: Woertgen C, R Rothoerl, C Metz, A Brawanski: Comparison of clinical, radiologic, and serum markers as prognostic factors after severe head injury, J Trauma, vol 47 (6): , 1999ICL, 49, 2000

56 Return to General/Principles Index OTA about Questions/Comments If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an to


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