Edward Sloan, MD, MPH Traumatic Brain Injury: Specific Management Items of Note for the Emergency Physician

Edward Sloan, MD, MPH Edward P. Sloan, MD, MPH Associate Professor Dept of Emergency Medicine University of Illinois College of Medicine Chicago, IL

Edward Sloan, MD, MPH Attending Physician Emergency Medicine University of Illinois Hospital Our Lady of the Resurrection Medical Center Chicago, IL

Edward Sloan, MD, MPH Overview Global Objectives Understand disease state (TBI) Utilize best management strategies Have many options available Optimize patient outcome Maximize resource use Make our practice enjoyable

Edward Sloan, MD, MPH Overview Session Specifics Review Italian guidelines Discuss the EM Reports Examine the ACR head trauma criteria Summarize minor TBI practice parameters Detail trephination and antibiotic use Look at some head CTs Journal club articles

Edward Sloan, MD, MPH Methodology Literature Search Traumatic Brain Injury 21 guidelines provided Relevant US guides used

Edward Sloan, MD, MPH

Methodology Internet Sources

Edward Sloan, MD, MPH Methodology Source Documents Guidelines for Rx of Adults with TBI –J of Neurosurgical Sciences –Vol 44:1 March 2000 –Three articles –Initial assessment, medical, surgical Rx Emergency Medicine Reports –December 3, and December 17, 2001

Edward Sloan, MD, MPH Methodology Source Documents Roberts, Hedges: Clinical Procedures in Emergency Medicine, 2 nd Edition EM journal club articles –make a point –describe a clinical entity –have medicolegal import

Edward Sloan, MD, MPH Guidelines Italian Recommendations I: Initial Assessment RSI:Thiopental (ketamine or midazolam) Sux or vecuronium GCS:In comatose pts (eye=1, verbal=1,2) Motor component very important. Use best response from either side.

Edward Sloan, MD, MPH Guidelines Italian Recommendations I: CT Indications Loss of two points on GCS Rise in ICP above 25 mm Hg Decrease in CPP below 70 mm Hg > 15 min Decrease in O2 sat below 50% > 15 min

Edward Sloan, MD, MPH Guidelines Italian Recommendations II: Medical Therapy Inotropes once blood volume restored To maintain MAP above 90 mm Hg To achieve CPP > 70 mm Hg if ICP high Not in lieu of ICP management

Edward Sloan, MD, MPH Guidelines Italian Recommendations III: Surgical Therapy Absolute: –Focal lesion, midline shift > 5 mm –Space occupying lesion > 25 cc Relative: –ICP > 20 mm Hg or CPP < 70 mm Hg –Optimal medical ICP management Case-specific criteria also

Edward Sloan, MD, MPH Literature EM Reports: TBI, Subdural I: Emergency Rx, Imaging Pathophysiology Neurologic exam CT indications MRI: DAI, subcortical injury, brainstem Angiography: Penetrating TBI, vascular occlusion, dissection, aneurysm

Edward Sloan, MD, MPH Literature EM Reports: TBI, Subdural II: Emergency Rx of Severe TBI Severe TBI Rx, including ICP Rx Cranial decompression indications Monitoring indications Moderate TBI Rx, outcome Minor TBI, and post-concussion syndrome

Edward Sloan, MD, MPH ACR Guidelines Appropriateness Criteria Imaging in head trauma Classified by clinical condition Provides summary by imaging modality CT: screening tool in mild TBI to determine who may benefit from observation Skull xrays: calvarial fractures, penetrating injuries, and foreign bodies

Edward Sloan, MD, MPH EAST Guidelines Mild TBI Management Transient neuro deficit, no acute pathology CT is gold standard Normal CT: 0-3% deterioration (GCS 13-14) Neuropsychological testing at 1-2 months Most pts recover within one month Limited data on those who do not recover

Edward Sloan, MD, MPH Neurology Guidelines Concussion in Sports Grade 1: Transient sx for < 15 minutes –May return if sx resolve within 15 minutes Grade 2: Transient sx for > 15 minutes –No return to contest –CT if sx persist Grade 3: Any LOC noted –ED eval if sx persist or more than brief LOC

Edward Sloan, MD, MPH Emergent Cranial Decompression Indications Hippocrates utilized trephination To evacuate extradural hematomas To reverse signs of tentorial herniation Rapid, progressive neurologic deterioration Coma, fixed, dilated pupil, hemiplegia and presumed skull fx on side of pupil Likely intracranial hematoma on same side

Edward Sloan, MD, MPH Emergent Cranial Decompression Procedure 4 cm vertical incision External auditory canal is key landmark –Three cm superior to zygoma –Two cm anterior to ear

Edward Sloan, MD, MPH Emergent Cranial Decompression Procedure Drill a hole, enlarge with a Burr Careful as the inner table is perforated Epidural: clotted, unless bleeding persists Middle meningeal artery is deep to clot Be prepared to replace blood loss Bilateral fixed pupils, or no clot, repeat on contra-lateral side

Edward Sloan, MD, MPH Prophylactic Antibiotics Skull Fx, Penetrating TBI Sanford, ePocrates: no recommendations EM study guide: ask neurosurgeon Prophylaxis controversial Skull fracture and fever: –Pneumococcus within 72 hours –Staph aureus and gram negs after 72 hours –Vancomycin, 3 rd gen ceph (ceftazadime)

Edward Sloan, MD, MPH Radiology Cases Searching for Teaching Files Google: Radiology Teaching Files Many universities post files Two examples of content Easy to use in the E.D. Radiology of Emergency Medicine

Edward Sloan, MD, MPH

Biconvex high-attenuation epidural hematoma R frontal

Edward Sloan, MD, MPH Extends to level of lateral ventricle

Edward Sloan, MD, MPH Extends to level of roof of orbit R

Edward Sloan, MD, MPH No fx evident here

Edward Sloan, MD, MPH Skull fx evident at R orbit

Edward Sloan, MD, MPH Associated STS

Edward Sloan, MD, MPH

R Subdural hematoma frontal lobe CSF leakage

Edward Sloan, MD, MPH R to L midline shift with subfalcine herniation

Edward Sloan, MD, MPH R to L midline shift with R uncal herniation

Edward Sloan, MD, MPH

R base hyperdense subdural hematoma

Edward Sloan, MD, MPH Extension to anterior interhemispheric fissure

Edward Sloan, MD, MPH R lateral ventricle body swelling

Edward Sloan, MD, MPH Swelling L parietal region, no fracture evident

Edward Sloan, MD, MPH Radiology Cases How to Obtain Images Get the image on the screen Hit the print screen button Go to PowerPoint Edit: Office Clipboard Double click on R to paste Resize to fit, add text box as needed

Edward Sloan, MD, MPH Journal Club Articles BTF Guidelines Basis for lecture on TBI Rx Explains guideline development Guides acute ED therapies Brain Trauma Foundation: J Neurotrauma, 1996; 13: Brain Trauma Foundation : J Neurotrauma, 1996; 13:

Edward Sloan, MD, MPH Journal Club Articles Skull X-ray Indications Multi-disciplinary study Provided key recommendations Changed clinical practice Skull xrays: occult penetrating trauma Masters SJ: N Engl J Med, 1987; 316: The Selection of Patients for X-Ray Examinations: Skull X-Ray Examination for Trauma

Edward Sloan, MD, MPH Journal Club Articles Hypertonic Saline in TBI J Trauma literature review Proven mechanism for benefit Conflicting clinical data Restores MAP without edema, inc ICP Doyle JA: J Trauma, 2001; 50:

Edward Sloan, MD, MPH Journal Club Articles PEG-SOD in TBI JAMA article SOD: oxygen radical scavenger EM physicians involved No benefit, control group did well Young B: JAMA, 1996; 276(7):

Edward Sloan, MD, MPH Journal Club Articles CT in Mild TBI J Trauma article Is CT of all mild TBI pts cost-effective? CT is cost effective, no need to admit Normal CT and neuro exam: home Shackford SR: J Trauma, 1992; 33(3):

Edward Sloan, MD, MPH Journal Club Articles CT in TBI & Hypotension Annals EM article CT prior to laparotomy? If stable after initial resus, OK to CT Average delay of 68 minutes Winchell RJ: Ann Emerg Med, 1995; 25(6):

Edward Sloan, MD, MPH Journal Club Articles EtOH and Minor TBI Acad EM article CT in intoxicated minor TBI pts? 8% Positive CT, 2% craniotomy rate May need to CT with mild TBI and EtOH Cook LS: Acad Emerg Med, 1994; 1(3):

Edward Sloan, MD, MPH Journal Club Articles Pts Who Talk & Deteriorate Annals EM article Can speak and then coma within 48 hrs 75% intracranial hematoma rate Deterioration: bad prognosis Need to achieve early decompression Rockswold GL: Ann Emerg Med, 1993; 22(6):

Edward Sloan, MD, MPH Conclusions TBI Rx in the ED GCS motor key in coma RSI with Thiopental/sux Clear CT, surgery indications Inotrope, PRN if volume OK MRI, angio less needed

Edward Sloan, MD, MPH Conclusions TBI Rx in the ED CT is best screening tool Mild TBI: 1 month recovery Concussion: LOC is key Trephination: epidural Rx Drill on side of blown pupil Anbx: prophylaxis unclear

Edward Sloan, MD, MPH Conclusions TBI Journal Club BTF guidelines key Skull xray: penetrating trauma HTN saline unclear CT even if hypotension prior EtOH: CT liberally Talk & deteriorate: evacuate

Edward Sloan, MD, MPH Conclusions Internet Medical Information Guidelines.gov Google: radiology teaching file PrintScreen, paste to PowerPoint FERNE.org

Edward Sloan, MD, MPH Recommendations TBI Rx in the ED Liberal CT use Follow guidelines Surf the web Maximize patient outcome (312)