Management of Closed Head Injuries in an Austere Environment

1. Management of Closed Head Injuries in an Austere Environment 1LT Greg Nix, APA-C //UNCLASSIFIED//

2. Overview • Pathophysiology of an injured brain • Intracranial Pressure • TBI • Mild/Mod/Severe • Skull Fx • Brain Bleeds • Diffuse Axonal Inj. • Eval & Tx • Evacuation suggestions //UNCLASSIFIED//

3. Pathophysiology of Brain Inj. -Terms: • CPP Cerebral Perfusion Pressure • CBF Cerebral Blood Flow • Auto regulation • MAP Mean Arterial Pressure • ICP Intracranial Pressure //UNCLASSIFIED//

4. Intracranial Pressure • Pressure changes • Increase • Decrease • Cushing's Reflex (triad) • HTN • Bradycardia • Irregular Respirations //UNCLASSIFIED//

5. Specific Injuries • TBI • Head trauma + AMS/LOC/PTA • Mild (Concussion) • Mod • Severe • Skull Fx • Brain Bleeds • Diffuse Axonal Injuries //UNCLASSIFIED//

6. TBI • Mild/Concussion • Classification: LOC < 30m, AMS < 1d, PTA < 1d • s/sx: • HA/Vis disturb/N/V/Irritability • GCS: 14-15 • Dx: • Physical exam & MACE • Tx: • Supportive, brain rest, monitor //UNCLASSIFIED//

7. TBI • Moderate • Classification: LOC 30m24hrs, AMS >1d, PTA 1-7d • s/sx: • HA/Vis disturb/N/V/Irritability • GCS: 9-13 • Dx: • AMS, PTA/RTA, MACE • Tx: • +/- Airway, Supportive, +/- Evac, Brain rest, non-operational //UNCLASSIFIED//

8. TBI • Severe • Classification: LOC > 24hrs, AMS > 24hrs, PTA > 7d • s/sx: • HA/Vis disturb/N/V/Irritability • GCS: <9 • Dx: • AMS, PTA/RTA, MACE • Tx: • RSI Airway, ASAP Evac, Brain rest, non-operational //UNCLASSIFIED//

9. Skull Fx • Linear & Comminuted • s/sx: • May be obvious or occult • Basilar • Ascending/Descending point of many vessels & nerves. • s/sx: • Raccoon eyes, Battle signs, CSF leak, CN def. • Tx: • Airway, Supportive, ASAP Evac //UNCLASSIFIED//

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11. Brain Bleeds • Cerebral Contusion • s/sx: • Exaggerated Concussion sx • Intracerebral Hemorrhage • Focal Neuro def. often present • Pt may have residual effects • Dx: • RTA/PTA without resolution • AMS • Tx: • +/- Airway, Supportive, ASAP evac //UNCLASSIFIED//

12. Brain Bleeds • Subarachnoid Hemorrhage (SAH) • s/sx: (often sudden/aneurysm) • Profound photophobia, HA, N/V • Textbook: “Worst HA of life” • Dx: • Abrupt onset of sx mod/severe TBI • Tx: • Control BP do not allow to exceed 140 Syst. • CCB & CT would be preferred but prob not avail. (Nimodipine to stop vasospasm. Vasospasm stops flow to brain) • Airway & Evac! //UNCLASSIFIED//

13. Brain Bleeds • Epidural Hematoma • s/sx: • MOI: blast/fall, sports, MVA • Probable skull fx • Middle Meningeal Artery! • HA, AMS, Sz • Dx: • S/sx, MOI, LOC with lucid interval • Tx: • EVAC! Be prepared for RSI! • Control Sz //UNCLASSIFIED//

14. Brain Bleeds • Subdural Hematoma (SDH) • s/sx: • LOC, AMS • Becomes sx within x14d • Dx: • Acceleration/Deceleration MOI • Increase of sx over period of time • Venous Hemorrhage • Tx: • Evac, CT • Beware of death within x14d; usually 72hrs. //UNCLASSIFIED//

15. Diffuse Axonal Injury (DAI) • s/sx: • Sudden LOC/Unresponsive • Shearing MOI • Dx: • MOI, Prolonged unresponsiveness • Tx: • Respectful care, Irreversible. //UNCLASSIFIED//

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17. Pt Eval/Exam • Eval • Determine MOI, Level of consciousness • PE & HEENT • MACE/AVPU/GCS • Cognition • Coordination • CN II-XII exam • Look for focal deficits //UNCLASSIFIED//

18. Pt Eval/Exam • Ultrasound of Ocular nerve sheath • Place tegaderms over pt’s eyes • Visualize the Optic nerve • Approx x3mm from the globe, the nerve should be 5mm in width • 3x5 • >5mm = increased ICP • Watch if tx are efficacious!!!!! //UNCLASSIFIED//

19. Interventions • Packaging • Trendelenburg 30-45* • Increases venous flow • non-constricting C-spine protection • Temp • Increased ICP pts tend to have elevated temps • Increased metabolic needs!!! • Keep pt cool • Fluids • Isotonic vs. Hypotonic //UNCLASSIFIED//

20. Interventions • Diuretics • Mannitol • Decreases ICP via Increasing Outflow and stimulating Autoregulation • 1g/kg • Use Foley to measure pt’s outflow… • Replace fluids to avoid HoTN(hypotension) • Best used for HTN pts with increased ICP //UNCLASSIFIED//

21. Interventions • Diuretics • Hypertonic Saline 3% • Increases CO2 • Increases Na+ gradient • Decreases ICP by pulling fluid • Admin 250mg over 10min • Best utilized in nml/HoTN pts //UNCLASSIFIED//

22. Interventions • RSI: • Succinylcholine • Etomidate/Ketamine/Propofol • Steroid use • No longer used • Especially not used with hemorrhage • CO2 • Watch End-tidal carefully • 33-38 ideal //UNCLASSIFIED//

23. Interventions • Hyperventilation? • No longer advocated due to ischemia • Still acceptable with s/sx of Herniation. • Life > perm. Adverse effects • Pain Control • Fentanyl/Ketamine • Helps prevent excess metabolic needs //UNCLASSIFIED//

24. To Evac, or Not to Evac? • PECARN/New Orleans Trial //UNCLASSIFIED//

25. Case Study • GSWface • Massive post. Neck bleed • Unresponsive • Anisocoric • No Resp. drive • Tachycardic //UNCLASSIFIED//

26. References • Auerbach, Paul S., Howard J. Donner, and Eric A. Weiss. "Head Injury." Field Guide to Wilderness Medicine. 4th ed. St. Louis: Mosby, 1999. 139-44. Print. • Lenhart, Martha K., Eric Savitsky, and Brian Eastridge. "Traumatic Brain Injury Management." Combat Casualty Care: Lessons Learned from OEF and OIF. N.p.: n.p., n.d. 33-378. Print. • "Medicolegal Visuals." Medical Illustrator Medical Illustration Scientific Illustration. N.p., n.d. Web. 20 Feb. 2015. • "Minor Head Trauma in Infants and Children: Evaluation." Minor Head Trauma in Infants and Children: Evaluation. UpToDate.com, 17 Oct. 2014. Web. 20 Feb. 2015. • Papadakis, Maxine A., Stephen J. McPhee, and Michael W. Rabow. Current Medical Diagnosis & Treatment 2014. 2014 ed. N.p.: n.p., n.d. Print. • "Pictures." TeachMeAnatomy. N.p., n.d. Web. 20 Feb. 2015. • "Subarachnoid Hemorrhage vs. Subdural Hematoma." Galleryhip.com Images of Hemorrhage Types. N.p., n.d. Web. 20 Feb. 015. • Swisher, Linda, and Kevin T. Patton. Study and Review Guide to Accompany Anatomy & Physiology, 7th Edition: Kevin T. Patton, Gary A. Thibodeau. 7th ed. St. Louis, MO: Mosby Elsevier, 2010. Print. • Tintinalli, Judith E., Gabor D. Kelen, and J. Stephan. Stapczynski. "Ch. 255 HEAD INJURY." Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York: McGraw-Hill, Medical Pub. Division, 2004. 1557-569. Print. • "Welcome - EMCrit CME Site." EMCrit CME Site. N.p., n.d. Web. 21 Feb. 2015. //UNCLASSIFIED//

27. QUESTIONS? //UNCLASSIFIED//