Sports Related Severe TBI

Sports-Related SevereTraumatic Brain Injury:Management by the Emergency Medicine Specialist: 

Sports-Related Severe Traumatic Brain Injury: Management by the Emergency Medicine Specialist

Edward P. Sloan, MD, MPHAssociate ProfessorDept of Emergency Medicine: 

Edward P. Sloan, MD, MPH Associate Professor Dept of Emergency Medicine University of Illinois College of Medicine Chicago, IL

Attending Physician Emergency Medicine: 

Attending Physician Emergency Medicine University of Illinois Hospital Our Lady of the Resurrection Medical Center Chicago, IL

FERNE: 

FERNE Foundation for the Education and Research of Neurological Emergencies www.FERNE.org

IBIAInternational Brain Injury Association : 

IBIA International Brain Injury Association 5th World Congress On Brain Injury Stockholm, Sweden

OverviewGlobal Objectives: 

Overview Global Objectives Understand disease state (TBI) Utilize best management strategies Have many options available Optimize patient outcome Maximize resource use Make our practice enjoyable

OverviewSession Objectives: 

Overview Session Objectives Consider the frequency of this event Look at pathophysiology TBI Examine how we evaluate TBI Look at specific therapies Consider prognostic findings

OverviewSession Specifics: 

Overview Session Specifics Present a representative case Address clinically relevant therapies Utilize the medical literature Review what are optimal strategies Summarize what we know Be clear on our approach

Methodology: 

Methodology

Methodology Literature Search: 

Methodology Literature Search MEDLINE, PubMed TBI AND Guidelines TBI AND Diagnosis AND E.D. TBI AND Therapy AND E.D.

Methodology Internet Sources: 

Methodology Internet Sources www.cochrane.org/ www.update-software.com/Cochrane/default.HTM/ www.neurosurgery.org/aans/ www.braintrauma.org/ www.ferne.org/ www.google.com/

Methodology Source Documents: 

Methodology Source Documents Cochrane Review abstracts Guidelines for Rx Severe Head Injury J Neurotrauma, Vol 15:11 November 1996 Guidelines for Prehospital RX TBI Brain Trauma Foundation (BTF) 1999 Rx and Prognosis of Severe TBI BTF website, Feb 2000

Methodology Source Documents: 

Methodology Source Documents Emergency Medicine Reports December 3, and December 17, 2001 Guidelines for Rx of Adults with TBI J of Neurosurgical Sciences Vol 44:1 March 2000 Three articles Initial assessment, medical, surgical Rx

TBI Overview: 

TBI Overview

EpidemiologyTBI Incidence: 

Epidemiology TBI Incidence 1.6 million head injuries per year 800,000 receive ED, outpatient care 270,000 hospital admissions 52,000 deaths 90,000 permanent neuro disabilities

EpidemiologyTBI and Mortality: 

Epidemiology TBI and Mortality 52% of all trauma deaths due to TBI CNS: more lethal than other body sites ASCOT: ISS with CNS weighting Morbidity data: key CNS role also

PathophysiologyDamage Types: 

Pathophysiology Damage Types Primary damage: Surface contusions Lacerations Diffuse axonal injury Secondary Damage: Hemorrhage Swelling, ICP andamp; hypoxic effects, infection

PathophysiologyBrain Edema and ICP: 

Pathophysiology Brain Edema and ICP Brain edema: Vasogenic, hydrostatic, osmotic effects Cytotoxic effects Interstitial edema Normal intracranial pressure CPP = MAP – ICP 80 = 90 – 10 (mm Hg)

PathophysiologySBP, ICP, and Low CPP : 

Pathophysiology SBP, ICP, and Low CPP CPP = MAP – ICP Increased intracranial pressure 60 = 80 – 20 (mm Hg) Low systolic BP 60 = 70 – 10 (mm Hg) Both elevated ICP and low SBP 50 = 70 – 20 (mm Hg)

PathophysiologyElevated ICP : 

Pathophysiology Elevated ICP ICP andlt; 15 mm Hg is normal Altered mental status patients: 40% will have increased ICP CBF is disturbed above 40 mm Hg ICP andgt; 60 mm Hg is lethal Begin therapy with ICP above 20

PathophysiologyCytotoxic Effects: 

Pathophysiology Cytotoxic Effects Secondary auto-destruction Delayed O2 radical formation Intracellular calcium shifts Glutamate, NMDA effects Ongoing cell death

Health Care CostsTBI Effects: 

Health Care Costs TBI Effects Leading cause of death andamp; disability Loss of life Loss of productivity Significant health care costs Annual cost: $40 billion

A Sports-Related Severe TBI Case: 

A Sports-Related Severe TBI Case

The Disease StateA Sports Severe TBI Case : 

The Disease State A Sports Severe TBI Case What likely diagnoses? What diagnostic tests in the ED? What acute therapies? What disposition? What expected outcome?

Sports Severe TBI CaseHistory: 

Sports Severe TBI Case History 21 year old male Snowmobiling in Colorado Swerves into a tree Headache, blood from the helmet Loss of consciousness for 10 minutes Dad has cell phone

Sports Severe TBI CaseHistory: 

Sports Severe TBI Case History 15 minutes wait for EMS Prehospital care: IV, O2, monitor Pt is immobilized 30 minute transport to nearest ED Pt responds only to painful stimuli

Sports Severe TBI Case Clinical Questions: 

Sports Severe TBI Case Clinical Questions How is severe TBI defined? Is MOI related to type of CNS injury? What physical exam elements are key? What are the components of the GCS? What findings suggest increased ICP? What findings suggest herniation?

Sports Severe TBI Case Airway Rx Questions: 

Sports Severe TBI Case Airway Rx Questions What are the indications for ET intubation? What is the accepted algorithm for rapid sequence induction? In what position should ETI be performed? What is the role of suspected c-spine injury in ETI with TBI?

Sports Severe TBI Case Therapy Questions: 

Sports Severe TBI Case Therapy Questions What are the indications for Fluids, hypertonic saline, blood? Hyperventilation? Mannitol? Barbiturates? Hypothermia? Steroids? Seizure prophylaxis?

Sports Severe TBI Case ICP Therapy Questions: 

Sports Severe TBI Case ICP Therapy Questions What is the accepted algorithm for the treatment of increased ICP? What is the role for ICP monitoring? When is a repeat CT indicated? When is surgical evacuation indicated?

Sports Severe TBI Case Outcome Questions: 

Sports Severe TBI Case Outcome Questions What resus findings predict outcome? What physical findings correlate? What CT findings predict outcome? What other factors predict outcome? How is poor outcome defined? How is outcome measured? When?

Sports Severe TBI Case Physical Exam: 

Sports Severe TBI Case Physical Exam 98.8 100/60 110 12 approx 70 kg Gen: ? Non-purposeful mvmt on cart Head: Large laceration, contusion over R temporal-parietal region Face: Several abrasions, contusions Eyes: 4 mm, equal, reactive, EOM OK

Sports Severe TBI Case Physical Exam: 

Sports Severe TBI Case Physical Exam Chest: BSBE, no crep pox 95% Cor: Tachycardia without murmur Abd: Soft, ? non-tender, no peritonitis Pelvis: Stable to compression Ext: No fracture evident, abrasions

Sports Severe TBI Case Neurologic Exam: 

Sports Severe TBI Case Neurologic Exam Motor: Withdraws to painful stimuli Sensory: No apparent anesthesia level Eyes: Open to painful stimuli Verbal: Moans to painful stimuli Reflex: No posturing, pathological reflex

Sports Severe TBI Case Provisional Diagnosis: 

Sports Severe TBI Case Provisional Diagnosis Severe TBI (GCS Score approx 8) R/o skull fracture R/o cerebral contusion R/o epidural hematoma

Sports Severe TBI Case Acute Management: 

Sports Severe TBI Case Acute Management IV NS 500 cc bolus, BVM O2 100% Rapid sequence induction Lidocaine 100 mg IVP Midazolam 4 mg IVP Succinylcholine 100 mg IVP Endotracheal intubation Ventilator: 100%, TV 600, IMV 14, PEEP 5

Sports Severe TBI Case Acute Diagnostic Tests: 

Sports Severe TBI Case Acute Diagnostic Tests XTL C-spine, chest, pelvis x-rays Non-contrast CT head Trauma labs, type and screen ABG after on ventilator for 10 min DPL prn for persistent hypotension

Sports Severe TBI Case Test Results: 

Sports Severe TBI Case Test Results No fractures on x-ray CT head: skull fracture, epidural ABG: 7.30 35 280 100% BD -3 Hb 11.4, other labs OK DPL not indicated

Slide39: 

Biconvex high-attenuation epidural hematoma R frontal

Slide40: 

Extends to level of lateral ventricle

Sports Severe TBI Case ED Diagnoses: 

Sports Severe TBI Case ED Diagnoses Linear skull fracture, non-depressed Epidural hematoma Severe TBI, GCS 8 Scalp laceration Multiple abrasions and contusions

Sports Severe TBI Case ED, Hospital Disposition: 

Sports Severe TBI Case ED, Hospital Disposition Helicopter transfer Neurosurgery consultation To OR: epidural hematoma evacuation Admitted to ICU, intubated 8 days Discharged to rehab facility: day 20

Severe TBI CasePatient Outcome: 

Severe TBI Case Patient Outcome Six month assessment Glasgow Outcome Scale Score Functions at home OK Just now beginning to drive Short work days Persistent headaches, amnesia

Brain Trauma FoundationTBI Guidelines: 

Brain Trauma Foundation TBI Guidelines

Guidelines Methods 1999, 2000 BTF Guidelines: 

Guidelines Methods 1999, 2000 BTF Guidelines IOM Clinical Practice Guidelines Develop practice parameters Class I: PRCTs: standards Class II: Prospective: guidelines Class III: Retro, opinions: options

Guidelines Methods 2000 BTF Guidelines: 

Guidelines Methods 2000 BTF Guidelines Standard: high degree of clinical certainty Guidelines: moderate degree of certainty Options: clinical uncertainty

Guidelines Methods AMA Attributes for Guides: 

Guidelines Methods AMA Attributes for Guides I: By experts, with broad-based reps II: Describe methods, use best lit, reps III: Comprehensive, specific IV: Remain current via updates V: Wide dissemination

Treatment Trauma Systems: 

Treatment Trauma Systems Standards: None Guides: Regionalized trauma systems Option: Neurosurgeons need to have a responsive system in place Option: In rural setting, where no neurosurgeon: know how to Rx extra- cerebral hematoma in deteriorating pt

Treatment Initial Management: 

Treatment Initial Management Standards: None Guides: None Options: Directly address what we do

Treatment Initial Management Options: 

Treatment Initial Management Options Rapid physiologic resuscitation No intracranial HTN Rx unless herniation or rapid neurologic deterioration Rapid hyperventilation Mannitol if adequate volume established Sedation as desired Short-acting neuromuscular blockade prn

Treatment Resus: Blood Pressure: 

Treatment Resus: Blood Pressure Standards: None Guides: Achieve SBP andgt; 90 mm Hg Options: MAP andgt; 90 mm Hg CPP andgt; 70 mm Hg Use fluid infusion to achieve above

Treatment Resuscitation: Hypoxia: 

Treatment Resuscitation: Hypoxia Standards: None Guides: PaO2 andgt; 60 mmHg, O2 sat andgt; 90% Options: Endotracheal intubation for GCS andlt; 9 Unable to maintain airway Persistent hypoxia

Treatment Hyperventilation : 

Treatment Hyperventilation Standards: Normal ICP, avoid sustained pCO2 andlt; 25 mm Hg in severe TBI Guides: Avoid early prophylactic hyperventilation (pCO2 andlt; 35 mm Hg) Note: During first 24 hours, cerebral perfusion can be compromised due to low cerebral blood flow

Treatment Hyperventilation Options: 

Treatment Hyperventilation Options Option: Hyperventilation useful briefly Acute neurologic deterioration Longer use if intracranial HTN persists despite other medical therapies (sedation, paralysis, mannitol, CSF drainage) Option: Test for cerebral ischemia Jugular venous O2 sat, AV O2 sat diff If sustained pCO2 andlt; 30 mm Hg needed

Treatment Hyperventilation - CR: 

Treatment Hyperventilation - CR Rapidly lowers ICP via vasoconstriction, which reduces cerebral blood flow One RCT Considerable uncertainty Possible beneficial effect on mortality No proven neurologic outcome benefit

Treatment Mannitol: 

Treatment Mannitol Standards: None Guides: Controls increased ICP Severe TBI 0.25 to 1.0 gr/kg body weight

Treatment Mannitol Options: 

Treatment Mannitol Options Options: Use in herniation, rapid decline Avoid hypovolemia Keep serum osmolarity below 320mOsm to avoid renal failure Achieve euvolemia, use a foley Use intermittent boluses, may be better

TreatmentMannitol - CR: 

Treatment Mannitol - CR May reverse brain swelling, lower ICP Few eligible RCTs Considerable uncertainty May be superior: to pentobarbital for increased ICP in setting of measured increased ICP

Treatment High Dose Barbiturates: 

Treatment High Dose Barbiturates Standards: None Guides: Controls increased ICP May be useful when maximal therapies fail Includes both medical and surgical Rx Severe TBI, salvageable Hemodynamically stable

TreatmentBarbiturates - CR: 

Treatment Barbiturates - CR Lower ICP via lower cerebral metabolism Few eligible RCTs No evidence of improved outcome Noted hypotension in 1 of 4 patients May offset any beneficial ICP effects

Treatment Cerebral Perfusion Pressure: 

Treatment Cerebral Perfusion Pressure Standards: None Guides: None Guides: Maintain CPP at 70 mm Hg

TreatmentICP Rx Algorithm: 

Treatment ICP Rx Algorithm Insert ICP monitor, maintain CPP andgt; 70 Ventricular drainage Repeat CT Hyperventilate to pCO2 30-35 mm hg Mannitol 0.25 to 1.0 gr/kg Second tier Rx: barbitruates, pCO2 andlt; 30

Treatment ICP Monitoring: 

Treatment ICP Monitoring Standards: None Guides: Useful in severe TBI (GCS andlt; 9) Guides: Abnormal initial head CT Hematomas, contusions Edema, compressed basal cisterns All other recommendations are options

Treatment ICP Monitoring: Normal CT: 

Treatment ICP Monitoring: Normal CT Guides: ICP monitor with normal CT if two of three noted Age andgt; 40 years Persistent BP andlt; 90 mm Hg Motor posturing

Treatment ICP Monitoring Not Indicated: 

Treatment ICP Monitoring Not Indicated Guides: Not useful with GCS andgt; 8 May be useful if traumatic mass lesion if evident on head CT

Treatment ICP Monitoring Technology: 

Treatment ICP Monitoring Technology Ventricular catheter (Camino catheter) External strain gauge Accurate, low-cost, reliable Parenchymal monitor: drifting values Subarachnoid, subdural, epidural: no

Treatment Seizure Prophylaxis: 

Treatment Seizure Prophylaxis Standards: Proph use for late sz: NO Guides: None Guides: High risk: prevent early sz Phenytoin, carbamazepine effective Reduces spikes in ICP in theory No difference in long-term outcome

Treatment Seizure Prophylaxis, Rx -CR: 

Treatment Seizure Prophylaxis, Rx -CR Reduced secondary damage due to increased metabolism, ICP, glutamate Six RCTs RR for early sz prophylaxis: 0.34 (95% CI:.21-0.54) For every 100 patients treated, 10 would remain seizure-free for the first week No reduction in late seizures or outcome

TreatmentSteroids: 

Treatment Steroids Standards: Not recommended No decrease in ICP No improved outcome Guides: None Options: None

TreatmentCalcium Channel Blockers-CR: 

Treatment Calcium Channel Blockers-CR Prevent vasospasm, keep blood flow Four RCTs Considerable uncertainty Two RCTs, traumatic SAH, nimodipine Pooled OR 0.59 for death (95% CI .37-.94) Pooled OR 0.67 for death, disability

Outcome Predictionin TBI Patients: 

Outcome Prediction in TBI Patients

Outcome PredictionEarly Indicators of Prognosis: 

Outcome Prediction Early Indicators of Prognosis Uses prognostic indicators as tests Absence or presence related to outcome Outcome measure: Lived or died 2 x 2 table Class I evidence 70% Positive Predictive Value (PPV)

Outcome PredictionGlasgow Coma Scale Score: 

Outcome Prediction Glasgow Coma Scale Score Lower GCS, stepwise higher mortality Standardized bedside measurement After pulmonary, hemodynamic Rx Without sedatives, paralytics By any trained medical personnel

Outcome PredictionAge: 

Outcome Prediction Age Higher age, stepwise higher mortality No inter-rater variability Consistent with other trauma data

Outcome PredictionPupil Exam: 

Outcome Prediction Pupil Exam Bilat absent light reflex: higher mortality Asymmetry: andgt; 1 mm diameter difference Dilated pupil: andgt; 4 mm size Fixed pupil: andlt; 1 mm response to light Record duration of pupillary abnormality over time (ie abn pupil for 2 hours)

Outcome PredictionRecording the Pupil Exam: 

Outcome Prediction Recording the Pupil Exam Fixed, dilated or both Asymmetry at rest or to light Evidence of orbital trauma Record after pulm, hemodynamic resus Any trained personnel can record data

Outcome PredictionHypotension, Hypoxia: 

Outcome Prediction Hypotension, Hypoxia Persistent SBP andlt; 90 mm Hg: 67% PPV With hypoxia: 79% PPV for bad outcome Measure frequently, record hypotension Any trained personnel can record data

Outcome PredictionHead CT Findings: 

Outcome Prediction Head CT Findings Four categories with prognostic value Basal cisterns and increased ICP signs Traumatic subarachnoid hemorrhage Midline shift Intracranial lesions

Head CT PrognosisBasal Cisterns, Increased ICP: 

Head CT Prognosis Basal Cisterns, Increased ICP Compressed or absent basal cisterns Three-fold risk of raised ICP, mortality Related to pupillary activity May be related to focal lesions, GCS, insults due to hypoxia, hypotension

Slide80: 

Basal cisterns noted near brainstem

Head CT PrognosisSubarachnoid Hemorrhage: 

Head CT Prognosis Subarachnoid Hemorrhage Occurs in 26-563% of severe TBI Most commonly over convexity Mortality increased two-fold with tSAH Blood in basal cisterns, 70% PPV bad Extent of tSAH is related to outcome Signif independent outcome predictor

Slide82: 

Head CT PrognosisMidline Shift: 

Head CT Prognosis Midline Shift I: Age andgt; 45 andamp; andgt; 5 mm shift, 78% PPV bad II: Shift andgt; 15 mm, 70% unfavorable outcome Shift related to increased ICP, variable amt Other CT parameters more impt than shift Recheck CT midline shift after surgical Rx

Slide84: 

R to L midline shift with subfalcine herniation

Slide85: 

R to L midline shift with R uncal herniation

Head CT PrognosisIntracranial Lesions: 

Head CT Prognosis Intracranial Lesions Coma? Think intracranial lesions II: Mass lesion, 78% PPV poor outcome Mass, age andgt; 45: 79% dead or vegetative Mortality higher in acute subdural hematoma than extradural hematoma Hematoma volume is related to outcome Worst outcome: subduralandgt;DAIandgt;epidural

Slide87: 

ConclusionsEmergency Physicians & TBI: 

Conclusions Emergency Physicians andamp; TBI It is a significant public health problem We see is commonly in the EDs Mild TBI in all comprehensive EDs Severe TBI seen in trauma centers EPs manage the airway and early resus What happens early can influence outcome

ConclusionsTBI: The Clinical Entity: 

Conclusions TBI: The Clinical Entity Direct brain injury with bleeding, swelling Secondary effects related to ICP, CBF Cytotoxic cascade related to ischemia Early resuscitation: prevent ongoing injury Early diagnosis: predicts Rx and outcome

ConclusionsE.D. TBI Therapy: 

Conclusions E.D. TBI Therapy Despite few standards, an algorithm exists Treat hypotension, hypoxia, elevated ICP ICP monitor and ventricular drainage Mild hyperventilation, bolus mannitol Barbiturates, other ICU interventions Use all aggressively with decompensation

ConclusionsTBI Outcome Prediction: 

Conclusions TBI Outcome Prediction Related to four CT findings Compressed basal cisterns Subarachnoid hemorrhage Midline shift andgt; 5-15 mm (age dependent) Mass lesion and hematoma volume Worst outcome: subduralandgt;DAIandgt;epidural

RecommendationsTBI Therapy Implications: 

Recommendations TBI Therapy Implications Optimize early diagnosis and resuscitation Document findings that suggest outcome Know the ICP management algorithm Know which CT findings are relevant Be able to predict neurosurgeon’s role Continually review the guidelines

Sports-Related Severe TBIQuestions?: 

Sports-Related Severe TBI Questions? www.google.com www.ferne.org www.cochrane.org www.braintrauma.org www.internationalbrain.org edsloan@uic.edu (312) 413-7490