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Roman A. Hayda, MD Original Author March 2004; Revised July 2006, November 2010

Assessment, Management and Decision Making in the Treatment of Polytrauma Patients with Head Injuries. Roman A. Hayda, MD Original Author March 2004; Revised July 2006, November 2010. Epidemiologic Aspects. 80,000 survivors of head injury annually 125,000 children <15yo head injured annually

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Roman A. Hayda, MD Original Author March 2004; Revised July 2006, November 2010

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  1. Assessment, Management and Decision Making in the Treatment of Polytrauma Patients with Head Injuries Roman A. Hayda, MD Original Author March 2004; Revised July 2006, November 2010

  2. Epidemiologic Aspects • 80,000 survivors of head injury annually • 125,000 children <15yo head injured annually • 40-60% of head injured patients have extremity injury • 32,000-48,000 head injury survivors with orthopaedic injuries annually

  3. Overview • Pathophysiology • 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

  4. 2nd hit 1st hit • 1st hit: Head • mechanical insult to brain tissue • blunt or penetrating • 2nd hit: Head • release of inflammatory mediators • Hypoxia • Acidosis • Coagulopathy • 1st hit: body • mechanical insult • chest, abdomen • extremities • 2nd hit: body • systemic inflammation • SURGERY

  5. Evaluation • ATLS—ABC’s • History • loss of consciousness • Physical exam • Glasgow Coma Scale • Radiographic studies • CT Scan

  6. Evaluation • Must exclude head injury by evaluation if • history of loss of consciousness • significant amnesia • confusion, combativeness • Cannot be simply attributed to drug or alcohol use • neurologic deficits on exam of cranial nerves or extremities

  7. Physical Exam • Exam of head and cranial nerves for lateralizing signs • dilated or sluggish pupil(s) • Extremities • unilateral weakness • posturing • decorticate (flexor) • decerebrate (extensor)

  8. Eye opening: 1-4 Motor response: 1-6 Verbal response: 1-5 Glasgow Coma Scale

  9. Eye opening Spontaneous 4 To speech 3 To pain 2 None 1 Glasgow Coma Scale

  10. 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 Glasgow Coma Scale

  11. Verbal response Oriented 5 Confused 4 Inappropriate 3 Incomprehensible 2 None 1 Glasgow Coma Scale

  12. Glasgow Coma Scale • Sum scores (3-15) • <9 considered severe • 9-12 moderate • 13-15 mild* • Modifiers—xT–ifintubated (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

  13. Radiographic Studies Frontal Contusion • CT scan • required in ALL cases EXCEPT: • LOC is brief AND • patient can be 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

  14. Treatment • Initial • Intubation if unresponsive or combative to give controlled ventilation • pharmacologic paralysis • after neurologic exam is completed • Blood pressure and O2 saturation monitoring • keep systolic > 90 mm Hg • 100% O2 saturation

  15. ICP Monitoring • Indications • severe head injury (GCS < 9) • abnormal head CT or • Coma >6 hrs • Intracranial hematoma requiring evacuation • Delayed neurologic deterioration from mild to moderate (GCS>9) to severe (GCS < 8) • Requirement for prolonged ventilation • Pulmonary injury, surgery etc.

  16. O2 saturation 100% Mean arterial pressure 90-110 mm Hg ICP < 20 mm Hg Cerebral Perfusion Pressure (CPP=MAP-ICP) >70 mm Hg ICU Management Goals

  17. HCT~ 30-33% PaCO2= 35±2 mm Hg CVP= 8-14 mm Hg avoid dextrose IV maintain euthermia or mild hypothermia ICU Adjuncts

  18. Factors Influencing Prognosis • Age • Younger pts have greatest potential for survival and recovery • 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 • Bottom line: survival and recovery not predictable except in old pts • Treat presuming recovery

  19. Factors Influencing Prognosis • Hypotension--50% increase in mortality with single episode of hypotension • Hypoxia • Delay in treatment • prolonged transport • surgical delay when lateralizing signs present Potentially controllable!!

  20. 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

  21. 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

  22. Outcome Prediction • Serum markers (S-100B) • Accuracy of 83% (Woertgen, J Trauma, 1999) • Good sensitivity in moderate to severe injury even with extracranial injury (Savola, J Trauma, 2004) • May be elevated in 29% fx pts without head injury (Unden, J Trauma, 2005) Clinical utility not defined

  23. Prognosis • Significant disability @ 1 yr • Disability even in “mild” injury • Glasgow cohort: 742 pts with 71% follow-up • Rate of combined severe and moderate disability similar among groups (48%, 45% and 48%) • Age >40, previous head injury, comorbidities increased disability (Thornhill, BMJ, 2000)

  24. 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

  25. 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

  26. Initial Surgery in the Head Injured is Damage Control Surgery

  27. Damage Control Orthopaedics • Goal • Limit ongoing hemorrhage, hypotension, and release of inflammatory factors • Limit stress on injured brain • Initial surgery • <1-2 hrs • limit surgical blood loss

  28. Damage Control Orthopaedics • Methods • Initial focus on stabilization • External fixation • Limited debridement • Limited or no internal fixation or definitive care • Delayed definitive fixation (5-7 days)

  29. 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

  30. 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

  31. 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

  32. 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

  33. 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

  34. 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)

  35. 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

  36. Advances in Care of Head Injured • ICP monitoring • Evolution of anesthetic agents • Improvement in neuroanesthetic techniques Allow for safer surgery in the head injured

  37. Fracture Care • 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 • Management decisions made in conjunction with trauma/neurosurgical team

  38. Algorithm for Fracture care in Head injured • Severe Head injury (GCS<9) or unstable pt DAMAGE CONTROL SURGERY Convert to definitive at 5+ days • Mild head injury (GCS 13-15); stable pt Consider EARLY TOTAL CARE • Intermediate head injury Determined by pt stability; complexity of surgery

  39. 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

  40. 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

  41. 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

  42. 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 inconsistently affected

  43. Fracture Healing with Head Injury • Cadosch, JBJS-A, 2009 • Case matched series of 17 pts with avg GCS 5.6, treated with IM nail • Union 2X faster; 37-50%> callus; serum induced osteoblast proliferation • Boes, JBJS-A, 2006 • Experimental model of 43 rats with IM nailed femur fx +/- head injury • More fx stiffness in head injury cohort • Serum of head injured rats promoted stem cell proliferation

  44. 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

  45. Heterotopic Ossification • Associated with ventilator dependency • Use approaches/techniques less associated with H.O. • Prophylaxis • XRT • Indocin • Excision

  46. Contractures • Occurs due to spasticity/posturing • Effects • Inhibits restoration of function • Complicates nursing care • Predisposes to decubitus ulcers

  47. Contractures • Treatment: • Prevention • splinting/positioning • early physical and occupational therapy • Established • serial casting • manipulation • surgery • nerve blocks

  48. Associated Injuries • Normal methods of clinical and radiologic assessment may not apply in the head injured patient • C spine injury • Occult fractures and injury

  49. 13-15 1.4% 9-12 6.8% <9 10.2% 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 C spine injury Incidence GCS

  50. C Spine Injury • Minimum requirement • Cervical collar • CT entire C spine with reconstructions • Adjuncts • MRI • Difficult in vent patient • May over call injury • “Dynamic” flexion extension radiographs in the obtunded patient • Safety and reliability not established

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