Dr. Gibbs

Impact 
- Head injury is the #1 killer  the trauma patient


To scan or not to scan?

Cost Issues
  - Head CT = $2700

Occult Injury Issues

• In large populations of blunt trauma patients with a GCS of 15, > 5% of these patients will have + CT.

• <1% will need neurosurgical intervention.

If GCS = 14, 10-20% + head CT
If GCS 13 = 20-30% + head CT

So, if GCS is not 15... risk increases substantially.


2 classes of head trauma patients:  

1. GCS 15, no evidence of fracture, no deficit, no symptoms, alert = Imaging CONTROVERSY
2. GCS < 15, suspected skull fracture, neurologic deficit, not acting right, persistent symptoms - No Controversy -- IMAGE
   

New Orleans Head CT rule - goal was to identify all patients with abnormal scan.

• Scan if: HA, persistent amnesia, vomiting, intoxication, seizure, age > 60, physical trauma above the clavicle
  
• 100% sensitivty for abnormal scan
  

Canadian Head CT rule - looking for clinically significant findings - more specific

• San if: Abnormal GCS 2 hrs after injury, open depressed skull fracture, basilar skull fx findings, vomiting > 2 episodes, >65
• Minor criteria - doesn't madate imaging - dangerous mechanism, amnesia > 30 min before impact
  

Use with caution in drunk folks!


Anticoagulation is the Enemy! 

IMAGE ALL ANTICOAGULATED HEAD TRAUMA
-- Much higher mortality in anticoagulated patients when compared to age matched controls

Plavix vs Coumadin?
-- Observational study of adult ED patients with blunt head trauma on coumadin vs plavix
    -- higher risk of immediate bleed in plavix
    -- important - 60% of people with bleeds had GCS 15 and 70% had no LOC

Delayed Bleeds?
-- Risk of delayed bleed relatively small;
-- People with negative head CT who are THERAPEUTICALLY anticoagulated can be DC'ed home
-- People who are supra-therapeutic likely need observation.


Blood in the Brain is Bad.

Airway management - want to minimize increased ICP
    RSI
                > Lidocaine - theoretically is supposed to attenuate cough reflex but hasn't been proven to change outcomes
                > Sucyincholine - can use without concern of worsening ICP from fasiculations
                > Ketamine - is ok to use in ICP - good literature that ketamine can help with ICP and avoids risk of hypotension that can occur with etomidate  (don't use if has history of obstructive hydrocephalus) - use 1-2mg/kg

    Ventilator settings - RR of 12

    Mannitol: 1g/kg (0.5g/kg - 1.5g/kg) - some evidence higher doses are more effective.


The Primary damage has been done... your job is to Prevent Secondary Injury

• Avoid Hypoxia, aggressive resuscitation - AVOID HYPOTENSION

              > Single episode of hypotension or hypoxia is related to doubling of mortality

• Resuscitation - ID bleeding sources immediately, maintain CNS perfusion, Definitive hemorrhage control
• ICP management - mannitol - only if BP can tolerate it; Hypertonic saline - no randomized trials yet, less likely to cause hypotension;
• Hyperventilation - reduces ICP by causing cerebral vasoconstriction - but this can lead to hypoperfusion > ONLY USE IF PATIENT HAS
  

             IMPENDING HERNIATION (and briefly in conjunction with other measures); endpoint 30 mm Hg

         d. Steroids, narcan, hypothermia - none has been proven to work

* No fantastic evidence in people on ASA with head trauma*

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