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Updated: Feb 4 2019

Neuro Trauma

Images hematoma 2.jpg
  • Snapshot
    • A 38-year-old male presents to the ED after a motorcycle accident where he was flung from his seat and hit his head on a nearby pole. He was not wearing a helmet. Miraculously, paramedics found him early without any other injuries, albeit unconscious. He is on a backboard, bag-mask ventilated with an oropharyngeal airway and a C-spine collar as he enters the trauma bay. His blood pressure is 140/80 mmHg, pulse is 100/min, respirations are 22/min, and SaO2 of 95% on room air. Glasgow Coma Scale score is 3, with the left pupil that is 3 mm more dilated than his right. He is endotracheally intubated, sedated with propofol, the head of his bed is risen to 30°, and hyperventilated to 30 breaths/min while mannitol infusions are prepared. Immediate head CT reveals a left subdural hematoma with midline shift. ABG reveals pH 7.45, pCO2 32 mmHg. The patient is wheeled to the OR for emergent craniotomy.
  • Introduction
    • Almost 2/3 of trauma admissions have head injuries
      • falls and motor vehicle collisions are leading mechanisms
    • Neurotrauma includes injuries to skull, facial, scalp, brain, and spinal cord
      • skull
        • basal skull fracture
          • hemotympanum, CSF rhinorrhea/otorrhea, Battle's sign , Raccoon eyes
          • clinical diagnosis is best because of poor visualization on CT
        • vault fracture
          • non-depressed
            • typically over temporal bone (i.e., middle meningeal)
            • most common cause of epidural hematoma
          • depressed
            • either skin closed or open with lacerated dura
      • facial
        • high risk of cranial nerve injury, infection, and airway compromise
      • scalp
        • lacerations can result in significant hemorrhage
      • brain
        • focal
          • contusion
            • most common brain lesion due to trauma
          • intracranial hemorrhage
            • can be due to coalescing of multiple contusions
            • includes epidural , subdural , intraparenchymal
        • diffuse
          • concussion/mild traumatic brain injury (TBI)
            • highest rates in children < 4y, teenagers, and elderly > 65y
          • diffuse axonal injury
      • spinal cord (SCI)
        • complete/incomplete transection
        • cord edema
        • spinal/neurogenic shock
        • whiplash-associated disorders
          • pericordal soft tissue injury around cervical spine due to extreme movement of neck
        • vertebral fracture
  • Presentation
    • Clarify mechanism of injury and mental status before arrival to ED
      • transient altered mental status may include loss of consciousness (LOC)
        • consider TBI/concussion with following:
          • LOC < 30 minutes
          • post-trauma amnesia < 24 hours
          • initial GCS score between 13-15
        • if LOC/amnesia greater than indicated times, consider diffuse axonal injury
      • assume cord injury with significant falls > 10 feet, deceleration injuries, blunt trauma
        • normal neuro exam does not rule out SCI
        • SCI may be present even with normal C-spine radiograph
    • Vital signs
      • evidence of shock (hypotension/tachycardia despite fluid resuscitation)
      • evidence of increasing intracranial pressure
        • Cushing's triad: hypertension, bradycardia, irregular respirations
          • rare - if all three present, suggests poor prognosis
    • Physical exam
      • Glasgow Coma Scale score
        • changes in score more important than absolute score
          • change by > 3 points suggests severe injury
        • pupils
          • size, anisocoria, and response to light help prognose herniation injury
      • neurological exam
        • lateralizing cranial nerve and extremity motor/sensory deficits also guide severity of injury
  • Evaluation
    • Primary and seconary survey with resuscitation
    • Investigations
      • labs: CBC, electrolytes, BUN/Cr, glucose, PT/INR and PTT, toxicology screen
      • imaging: noncontrast CT and C-spine radiography (AP, lateral, odontoid)
        • lateral C-spine radiograph is most important
        • thoracolumbar/pelvic radiographs with AP and lateral views based on mechanism
        • MRI if soft tissue injury is suspected
    • Spinal immobilization (C-spine collar)
      • must be maintained until spinal injury has been ruled out by following criteria:
        • alert and oriented to person, place, time, and event (AOx4)
        • no evidence of intoxication
        • no posterior midline cervical tenderness
        • no focal neurological deficits
        • no other painful injuries
      • if any criterion abnormal but imaging is normal, consider flexion/extension rdaiography and/or MRI
        • if normal, C-spine is cleared
        • if abnormal, C-spine collar remains and neurosurgery/orthopedics consult
  • Management
    • Acute neurotrauma
      • in addition to primary survey and resuscitation, emphasis on maintaining adequate cerebral perfusion pressure (CPP) in the emergent setting
        • remember, CPP = mean arterial pressure (MAP) - intracranial pressure (ICP)
        • hypoxia, hypercapnia, and ischemia can all lead to cerebral edema, and thus cause elevation in ICP → decrease in CPP
          • decreasing CPP can also result in seizures
      • medical management if evidence of increased ICP
        • raise head of bed to 30°
        • intubate with 100% O2
        • hyperventilate to pCO2 goal of 30-35 mmHg
        • sedate with propofol, morphine, vecuronium if anxious or agitated
        • mannitol bolus
        • seizure prophylaxis with levitiracetam (1st line) or phenytoin (2nd line)
      • early neurosurgical consult
    • Spinal cord injury
      • best next step: immobilize C-spine with collar and body with restraints
      • intubate with evidence of impending respiratory failure
      • treat neurogenic shock if present with fluid resucitation and vasopressors as needed
      • insert NG and Foley catheter
      • methylprednisolone only if SCI is isolated and nonpenetrating
        • otherwise not recommended
      • early neurosurgical/orthopedics consult for potential decompression
    • Mild TBI/concussion
      • admit if GCS score < 15, seizures, or severe bleeding present despite normal CT
      • admit if abnormal CT
      • observe and discharge with clear instructions
        • if cause is athletic, follow CDC 5-step Return to Play guidelines
    • Other considerations
      • Cushing's ulcer prophylaxis with H2 antagonists or proton pump inhibitor
      • DVT prophylaxis
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