g02 head injury
TRANSCRIPT
Assessment, Management and Decision Making in the
Treatment of Polytrauma Patients with Head Injuries
Roman A. Hayda, MD
Epidemiologic Aspects
• 80,000 survivors of head injury annually• 40-60% of head injured patients have
extremity injury• 32,000-48,000 head injury survivors with
orthopaedic injuries annually
Overview• 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
Evaluation
• ATLS—ABC’s• History
– loss of consciousness• Physical exam
– Glasgow Coma Scale• Radiographic studies
– CT Scan
Evaluation
• Must exclude head injury by evaluation if – history of loss of consciousness– significant amnesia– confusion, combativeness*– neurologic deficits on exam of cranial nerves or
extremities
* Cannot be simply attributed to drug or alcohol use
Physical Exam
• Exam of head and cranial nerves for lateralizing signs– dilated or sluggish pupil(s)
• Extremities– unilateral weakness– posturing
• decorticate (flexor)• decerebrate (extensor)
Glasgow Coma Scale• Eye opening
– Spontaneous 4– To speech 3– To pain 2– None 1
• Motor response – Obeys commands 6– Purposeful response to pain 5– Withdrawal to pain 4– Flexion response to pain 3– Extension response to pain 2– None 1
• Verbal response– Oriented 5– Confused 4– Inappropriate 3– Incomprehensible 2– None 1
Glasgow Coma Scale
• Sum scores (3-15)– <9 considered severe– 9-11 moderate– 13-15 mild*
• Modifiers—xT– 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
Radiographic Studies
• CT scan– required in ALL cases except when LOC is brief AND that patient can be observed and 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
Factors Influencing Prognosis• Age
– 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• Hypotension--50% increase in mortality with single episode
of hypotension• Hypoxia• Delay in treatment
– prolonged transport– surgical delay when lateralizing signs present
Treatment
• Initial– Intubation if unresponsive or combative to give
controlled ventilation– pharmacologic paralysis (after exam is
completed)– Blood pressure and O2 saturation monitoring
• keep systolic > 90 mm Hg• 100% O2 saturation
ICP Monitoring
• Indications– severe head injury (GCS < 9)
• abnormal head CT or• normal CT and at least two of the following
– age over 40– uni- or bilateral flexor or extensor posturing– history of systolic BP < 90 mm Hg
– when unable to follow serial neurologic exams– i.e. for operative or lengthy diagnostic procedures
ICU Management Goals
• Mean arterial pressure 90-110 mm Hg
• O2 saturation 100%• ICP < 20 mm Hg• Cerebral Perfusion
Pressure (CPP=MAP-ICP) >70 mm Hg
• PaCO2= 35±2 mm Hg• HCT~ 30-33%• CVP= 8-14 mm Hg• avoid dextrose IV• maintain euthermia or
mild hypothermia
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
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• Serum markers under investigation (s-
100B) has an accuracy of 83% (Woertgen, J Trauma, 1999)
Prognosis of the SeverelyHead 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
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
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
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
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
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
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
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)
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
Fracture Care
• Management decisions made in conjunction with trauma/neurosurgical team
• 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
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
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
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
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 is not significantly affected
Complications
• Heterotopic Ossification– up to 89-100% incidence
periarticular injury with head injury
• Contractures• Malunion
Recurrent elbow dislocation secondary to extensor posturing and heterotopic ossification
Heterotopic Ossification• Associated with ventilator dependency• Avoid periarticular procedures• Use approaches/techniques less associated
with H.O.• Prophylaxis
– XRT– Indocin
• Excision
Contractures
• Occurs due to spasticity/posturing• Effects
– Inhibits restoration of function– Complicates nursing care– Predisposes to decubitus ulcers
Contractures
• Treatment: – Prevention
• splinting/positioning• early physical and occupational therapy
– Established• serial casting• manipulation• surgery• nerve blocks
Associated Injuries
• Normal methods of clinical and radiologic assessment may not apply in the head injured patient– C spine injury– Occult fractures and injury
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%<96.8%9-121.4%13-15
IncidenceGCS
C Spine Injury
• Minimum requirement– Cervical collar– Plain films (3 views)– CT of at least C1 and C2
• Adjuncts– CT of entire cervical spine– MRI– “Dynamic” flexion extension radiographs in the
obtunded patient
Occult Injuries
• Fractures, dislocations and peripheral nerve injuries may be “missed”– Up to 11% of orthopaedic injuries may be
“missed”– Peripheral nerve injuries are particularly
common (as high as 34%)– Occult fractures in children with head injury are
also common (37-82%)
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 injury @ 72 hrs
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
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