Slide 1

Report
Emergency Neurotrauma
Head Injuries
in Emergency Medicine
Dr Brett Gerrard
Emergency Medicine Specialist
Middlemore Hospital
Overview
 What is neurotrauma?
 How do we classify injuries
 What goes wrong?
 Pathogenesis of brain injury
 How bad is it?
 Assessment of Head Injuries
 How do we fix it?
 Resuscitation in neurotrauma
Definition
 Approx 700 per 100 000 NZ population
 Responsible for the majority of trauma deaths
 Occurs on a continuum
 Classification can guide approach to investigation
and therapy
 Minimal
 Mild
 Moderate-Severe
Minimal Head Injuries
 No loss of consciousness
 Normal alertness and memory
 No neurological deficit
 GCS 15
 No signs of skull fracture
Mild Head Injuries
 Brief (<5min) loss of consciousness
 Amnesia (retrograde vs anterograde)
 GCS 14-15
 Impaired alertness
 No signs of skull fracture
Moderate or severe
Head injury
 Prolonged (>5min) loss of consciousness
 Persistant GCS <14
 Focal neurological deficit
 Seizure
 Signs of skull fracture
Pathogenesis of Brain Injury
 Primary (Immediate)
 Forces and disruptive mechanisms of original incident
 Secondary (2-24 hours post injury)
 Multiple factors
 Cerebral hypoxia due to impaired blood flow complicated
by
 Vasospasm
 Oedema
 Cellular dysfunction
 This is the injury that we can potentially prevent!
Classification of
Neurotrauma Injuries
1 Skull fractures
2 Concussion
3 Contusion
4 Diffuse axonal injury
5 Intracranial haematoma
6 Penetrating injury
Skull Fracture
 Increased risk of associated neurotrauma.
 Location of fracture important
 Base of skull
 Cribiform plate
 Depressed fractures
Concussion
 “Transient alteration in cerebral function, usually
associated with LOC and often followed by rapid or
complete resolution”
 Disturbance in RAS
 Symptoms include
 Headache
 Altered cognition
 Nausea
 Second Impact Syndrome
Contusion
 Bruising of the brain substance
 Usually due to blunt trauma
 Fractures are uncommon
 May lead to haematoma and oedema formation
 Most common in frontal and temporal lobes
Diffuse Axonal Injury
 Predominant mechanism of injury in neurotrauma
 Physical forces (shearing and rotational) disturb the
axonal network at a miscroscopic level
 Minimal changes may be evident on CT
 Clinical sequelae can range
 subtle neuropsychiatric changes
 Severe cognitive impairment
 Psychomotor retardation
Intracranial Haemorrhage
 Defined anatomically

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Subdural
Extradural
Intracerebral
Subarachnoid
Extradural
 Uncommon
 Usually associated with temporal
bone fracture
 Expanding haematoma strips dural
away from bone
 Increasing intracranial pressure and
uncal herniation
 Lenticular shape on CT
Subdural
 May be acute, subacute or
chronic
 Much higher risk in elderly
 Seen in non accidental shaking in
children
 Acute subdural high mortality
rate approx 50%
Intracerebral
 Most commonly frontal and parietal
lobes
 Clinical sequelae dependent on site
 May be primary or secondary due to
underlying contusion
 Symptoms and complicationsmay be
delayed
Subarachnoid
 Relatively common in severe head
trauma.
 May co-exist with other bleeding
sources
 Extention into the interventricular
spaces may lead to raised ICP.
 Subarachnoid blood can lead to
cerebral vasospasm and secondary
ischaemic brain injury
Penetrating Trauma
 Very high levels of morbidity and mortality
 High velocity
 Gunshot
 Impalement
 Low velocity
 Knife
 Crush
 Generally very dismal outlook although…
Assessment of Neurotrauma
 History
 Examination
 Investigations
History
 Detailed history can help attribute degree of risk
 High Risk mechanisms are utilised by several
clinical rules
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Pedestrian/cyclist struck by car
Fall from height of >1m or 5 stairs
Ejected from vehicle
Penetrating injury/blow to head with weapon
Suspicion of NAI
 Patient factors
 Risk factors for bleeding


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Co-morbidities
Drugs
Extremes of age
Difficulties in patient evaluation
 Was there loss of consciousness?
 How long?
 Any seizures?
 Can you remember what happened?
 Before? (Retrograde)
 After? (Anterograde)
 Any vomiting?
 How many times?
 Do you have a headache?
 Does it improve with medication?
Examination
 Integral part of primary and secondary survery

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ABC evaluation still remains priority
Remember risk of cervical spine injuries
Facial injuries
Assessment of neurological disturbance

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AVPU (Paediatric scoring system)
GCS (Glasgow Coma Score)
Focal neurological signs
Early signs of raised intracranial pressure
 GCS slide
Signs of Skull Fracture
 Rhinorrhoea
 Haemotympanum
 Battles Sign
 Racoon Eyes
Investigations
“To CT or not to CT?”
 Minimal Head Injuries
 No imaging required
 Moderate-Severe Head Injuries
 Prolonged (>5min) loss of consciousness
 Persistant GCS <14
 Focal neurological deficit
 Seizure
 Signs of skull fracture
CT =Investigation of choice
 Mild Head Injuries……?
 Several clinically derived decision rules have been
developed
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New Orleans
CHIP
Canadian CT Head Rule
CATCH
 Why not just scan EVERYBODY??
Risks of CT
 Sedation/compliance
 Time
 Costs
 Ionizing radiation
Indications for Head CT in
Trauma
 A CT scan is indicated for an adult patient with a
head injury if they have one of the following:
1. A Dangerous Mechanism

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Pedestrian hit by a car
Fall from >1 metre (or 5 stairs)
Blow to head with weapon
Ejected from vehicle
Based on Canadian CT Head Rules
Stiel et al. Lancet. 2001 May 5;357(9266):1391-6
Initial Data approx 3100 patients GCS 13-15.
Indications for Head CT in
Trauma
 2. Patient History factors
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Age >65
On warfarin or dabigatran
Vomited 2 or more times
Knocked out for >5 min
Persistant retrograde amnesia >30min or persistant
anterograde amnesia
Based on Canadian CT Head Rules
Stiel et al. Lancet. 2001 May 5;357(9266):1391-6
Initial Data approx 3100 patients GCS 13-15.
Indications for Head CT in
Trauma
 3. Patient Exam findings
 GCS 13 or less on arrival
 Persistant GCS <15 after 2 hours
 Signs of a skull fracture
Based on Canadian CT Head Rules
Stiel et al. Lancet. 2001 May 5;357(9266):1391-6
Initial Data approx 3100 patients GCS 13-15.
Paediatric Head Injury
Issues
 Differences in mechanism
 Differences in anatomy
 Signs may be subtle
 More prone to cerebral oedema
 Difficult in assessing GCS
 Potential for non accidental injury
 Radiation exposure

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