traumatic brain injury: specific management items of note for the emergency physician

Edward Sloan, MD, MPH

Traumatic Brain Injury:Specific Management Items

of Note for theEmergency Physician

http://www.ferne.org/


Edward P. Sloan, MD, MPH

Associate ProfessorDept of Emergency Medicine

University of Illinois College of Medicine

Chicago, IL



Attending Physician Emergency Medicine

University of Illinois Hospital

Our Lady of the Resurrection

Medical Center

Chicago, IL



OverviewGlobal Objectives

• Understand disease state (TBI)

• Utilize best management strategies

• Have many options available

• Optimize patient outcome

• Maximize resource use

• Make our practice enjoyable



OverviewSession 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



Methodology Literature Search

• www.guidelines.gov

• Traumatic Brain Injury

• 21 guidelines provided

• Relevant US guides used



Methodology Internet Sources• www.guideline.gov/

• www.med.wayne.edu/diagRadiology/TF/

• www.brighamrad.harvard.edu/cases/

• www.ferne.org/

• www.google.com/



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



Methodology Source Documents• Roberts, Hedges: Clinical Procedures

in Emergency Medicine, 2nd Edition

• EM journal club articles–make a point–describe a clinical entity–have medicolegal import



GuidelinesItalian 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.




• 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




• 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




• 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



LiteratureEM Reports: TBI, Subdural

• I: Emergency Rx, Imaging • Pathophysiology• Neurologic exam • CT indications• MRI: DAI, subcortical injury, brainstem• Angiography: Penetrating TBI, vascular

occlusion, dissection, aneurysm



LiteratureEM 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



ACR GuidelinesAppropriateness 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



EAST GuidelinesMild 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



Neurology GuidelinesConcussion 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



Emergent Cranial DecompressionIndications• 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



Emergent Cranial DecompressionProcedure• 4 cm vertical incision

• External auditory canal is key landmark–Three cm superior to zygoma

–Two cm anterior to ear



Emergent Cranial DecompressionProcedure• 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



Prophylactic AntibioticsSkull 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, 3rd gen ceph (ceftazadime)



Radiology CasesSearching 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



Biconvex high-attenuation

epidural hematoma

R frontal



Extends to level

of lateral ventricle



Extends to level

of roof of orbit R



No fx evident here



Skull fx evident

at R orbit



Associated STS



R Subdural hematoma

frontal lobe

CSF leakage



R to L midline shift with

subfalcine herniation



R to L midline shift

with R uncal herniation



R base hyperdense

subdural hematoma



Extension to anterior

interhemispheric fissure



R lateral ventricle

body swelling



Swelling L parietal region,

no fracture evident



Radiology CasesHow 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



Journal Club ArticlesBTF Guidelines • Basis for lecture on TBI Rx• Explains guideline development• Guides acute ED therapies

• Brain Trauma Foundation: J Neurotrauma, 1996; 13: 643-645• Brain Trauma Foundation : J Neurotrauma, 1996; 13: 653-659



Journal Club ArticlesSkull 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: 84-91 • The Selection of Patients for X-Ray Examinations: Skull

X-Ray Examination for Trauma



Journal Club ArticlesHypertonic 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: 367-383



Journal Club ArticlesPEG-SOD in TBI

• JAMA article

• SOD: oxygen radical scavenger

• EM physicians involved

• No benefit, control group did well

• Young B: JAMA, 1996; 276(7): 538-543



Journal Club ArticlesCT 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): 385-394



Journal Club ArticlesCT 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): 737-742



Journal Club ArticlesEtOH 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): 227-234



Journal Club ArticlesPts 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):1004-100



ConclusionsTBI 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



ConclusionsTBI 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



ConclusionsTBI Journal Club• BTF guidelines key

• Skull xray: penetrating trauma

• HTN saline unclear

• CT even if hypotension prior

• EtOH: CT liberally

• Talk & deteriorate: evacuate



ConclusionsInternet Medical Information• Guidelines.gov

• Google: radiology teaching file

• PrintScreen, paste to PowerPoint

• FERNE.org



RecommendationsTBI Rx in the ED• Liberal CT use• Follow guidelines• Surf the web• Maximize patient outcome

[email protected](312) 413-7490
