Case Studies in Neuro Trauma SCRTAC

8/12/2019 Case Studies in Neuro Trauma SCRTAC

1/60

Saving Lives By Strengthening Our Regions Trauma Care System

December 5, 2013 KELLI CASPER, APNP

CASE STUDIESIN NEURO

TRAUMA


2/60

GOALS

Brief anatomy review Discuss important exam findings in brain and

spine trauma

Discuss key management principles in brainand spine trauma

Case study of Epidural Hematoma

Case study of Diffuse Axonal Injury

Case study of Cervical Spinal Cord Injury


3/60

ANATOMY REVIEW


4/60


5/60


6/60


7/60

TRAUMATIC BRAIN INJURY

A traumatic brain injury occurs every 7seconds and results in death every 5minutes in the US

TBI accounts for 1/3 of all trauma relateddeaths in the US

Annual cost of TBI medical care in the US

approximately $56 billion (Heegaard & Biros, 2007)


8/60

MANY FLAVORS OF BLUNT TBI

Skull fractures

Brain contusions

Hematomas/Intracerebral hemorrhages Epidural Hematoma

Subdural Hematoma

Traumatic SAH Diffuse axonal injury


9/60

CATEGORIZING HEAD INJURY

Minimal: GCS= 15, No loss of consciousness, No amnesia

Mild: GCS= 14 OR GCS= 15 plus EITHER: Brief LOC < 5 min OR impaired alertness

or memory

Moderate: GCS 9-13 OR LOC > 5 min OR Focal neurologic deficit

Severe: GCS 5-8

Critical: GCS 3-4

(Greenberg, 2010)


10/60

TBI PATHOGENESIS

Primary injury: immediate impact injury

Secondary injury: ensuing neuropathologic processes afterinitial injury

Our job in the hospital is to

intervene and disrupt these

processes and secondary

mechanisms


11/60

SECONDARY BRAIN INJURY

Amino acid andcytokinerelease

Free radicalsformed

Mitochondrialdamage

BBB damageAltered CBF

Increased ICP

Brain damage/cell death

Functional deficits


12/60

INTERVENING FACTORS IN TBI

Hypoxia

Hypotension

Cerebral edema

Increased ICP

Reduced cerebral blood flow

Electrolyte imbalance


13/60

PRACTICE GUIDELINE DEFINITIONS

Level I: High degree of clinical certainty Level A: Based on consistent Class I evidence (well-designed,

prospective randomized controlled studies)

Level B: Single Class I study or consistent class II evidence whencircumstances preclude clinical trials

Level II: Moderate degree of clinical certainty

Level C: Usually derived from Class II evidence (one or more well-designed comparative clinical studies or less well-designedrandomized studies) or a preponderance of Class III evidence

Level III: Unclear clinical certainty

Level D: Generally based on Class III evidence (case series,historical controls, case reports and expert opinion). Useful foreducational purposes and to guide future research

(Greenberg, 2010)


14/60

CASE STUDY #1

51 y/o male fell down a flight of cement stairsafter domestic altercation striking the lefttemporal area. Lost consciousness for about 10minutes.

By the time EMS arrived, the patient was fullyawake. He was brought to the ED forevaluation. GCS 15 in ED. CT scan without

contrast of head showed a small left temporalepidural hematoma and left temporal bonefracture.


15/60

EPIDURAL VS SUBDURAL HEMATOMAS

Epidural 1% of head trauma

admissions

Arterial source (MMA)

(85% of cases)

Can expand rapidly

More often requires

surgical evacuation

Mortality 20-55%

Classic presentation

Subdural Seen in 10-20% of head

trauma cases

Usually venous source of

bleeding (bridging veins)

Usually expand less rapidly

than EDH

More often has associated

underlying brain injury

(contusions, SAH)


16/60

Epidural: Usually produces more mass effect

Subudural: Usually more diffuse and concave

appearance


17/60


18/60


19/60

Small epidural hematoma (< 1 cm maximum thickness)


20/60

CASE STUDY #1

Patient was admitted to ICU for observation EDH can rapidly expand

Moderate head injury

Neuro checks every hour

HOB elevated 40 degrees NPO status

Seizure prophylaxis started

Temporal region associated w/higher seizure risk Minimize sedation!

Avoid hypertension


21/60

UNFOLDING EVENTS

Overnight becoming increasingly agitated followed byincreasing somnolence and difficulty arousing

Thrashing of left extremities only

No longer following commands and not speaking

Left pupil 5mm and fixed, Right pupil 2mm, responsive tolight

Neurosurgeon being called

Patient declined rapidly, developing respiratory distress

Rapid response called and patient emergently intubated OR was called for emergent craniotomy and evacuation of

hematoma.


22/60

DISCUSSION OF EVENTS

Agitation/Restlessness is often first sign of increasing

ICP

Somnolence and hemiparesis will follow as ICPcontinues to rise

Pupil dilates (late sign)


23/60


24/60

TREATMENT COURSE

Surgical evacuation via Craniotomy withevacuation of EDH

He eventually regained consciousness andable to ambulate and use right hand


25/60

CASE STUDY #2

47 y/o male in MCA on highway, lost control,no helmet, thrown from motorcycle.

Unresponsive at scene, CPR initiated

Intubated at scene, arrived to ED GCS 3,chemically paralyzed and sedated.

Neuro exam very limited


26/60

DIFFUSE AXONAL INJURY


27/60

INITIAL PERTINENT CLINICAL INFORMATION

SBP on admit to ICU 140s. MAP 80s.

Pupils unequal, R= 4mm, reactive to 2mm,L= 8mm, non-reactive to light.

Sodium: 141

H/H: 13.3/38.8

Platelet: 227,000

PCO2 = 37, PO2 = 129


28/60

INITIAL TREATMENT COURSE

Arterial line inserted. Central line inserted. HOB elevated 40 degrees

Sedated with propofol / fentanyl drips

Loaded with Cerebyx (Fosphenytoin) 20 mg PE/kg, then

TID ICP bolt placed by Neurosurgeon. Initial ICPs 7-9mm Hg.

CPP 60s

Mannitol 25 gm IV every 6 hours started

Stress ulcer prophylaxis, Protonix 40 mg IV daily Bilateral SCDs placed for DVT prophylaxis

Serum electrolytes / osmolality q 6 hrs


29/60

DISCUSSION OF TREATMENT

ICP monitoring & goals CPP monitoring & goals

Sedation goals

Mannitol treatment

3% saline treatment DVT prophylaxis

Stress ulcer prophylaxis (SUP)

Nutrition goals

Refractory increased ICP

Barbituate coma

Decompressive Craniectomy


30/60

TYPES OF ICP MONITORING DEVICES

Goal ICP < 20


31/60

CEREBRAL PERFUSION PRESSURE

Importance of Cerebral Perfusion Pressure

CPP = Mean arterial pressure (-) Intracranialpressure

Goal > 60 mm Hg, prefer > 70 mm HG


32/60

MANNITOL(LEVEL II RECOMMENDATION FOR INTRACRANIAL HTN AFTER SEVERE TBI)

Pros Increases cerebral

blood flow by itsplasma expansion andosmotic effect

Reduces ICP withinminutes

Possible free radicalscavenging

(Greenberg, 2010)

Cons Risk of acute renal

failure

Risk of hypotension

May draw more fluidinto CNS causingworsening cerebraledema

Electrolytedisturbances due toexcessive urinaryoutput


33/60

HYPERTONIC SALINE

Pros Effective at reducing

ICP through osmoticeffects similar toMannitol

Less risk ofhypovolemichypotension

(Greenberg, 2010)

Cons May cause severe

hypernatremia

Electrolyte

disturbances Not enough convincing

evidence to supportuse over Mannitol

No changes inneurologic outcomeover Mannitol


34/60

SUPPORTIVE CARE

Sedation / Pain management Nutrition

Stress Ulcer prophylaxis

DVT prophylaxis

Skin care

Oral hygiene


35/60

CONTINUED HOSPITAL COURSE

IVC filter placed (DVT risk with ICH) Percutaneous bedside tracheostomy placed, dobbhoff placed for

nutrition

Required a few days of Levophed for goal CPP > 60

ICPs remained relatively normal

Gradually began to open eyes, and although not commanding,localized purposefully to stimulus

~ 12 days post-injury, nodding to questions, trying to mouthwords, began sitting on edge of bed

~ 18 days post-injury, speaking more sense, less agitation,progressing in PT/OT/Speech, trach removed

Discharge to a brain rehab facility ~ 3 weeks post-injury


36/60

SPINAL CORD INJURY

12,000 new cases each year

Average age at time of injury ~ 40 years

77% of these are males

$4 Billion spent annually on acute andchronic care of spinal cord injured patients

(Chittiboina, et al. 2012)


37/60

CAUSES OF SCI

Cause%

MVC's

Falls

Violence

Other/unknown

Sports

(Chittiboina, et al. 2012)


38/60

CASE STUDY #3

22 y/o male dove into shallow lake. Friendspulled him out of water, patient unable to

move arms or legs. In ED, cervical CT scanshowed at C7 burst fracture.


39/60

CT CERVICAL SPINE


40/60

MRI CERVICAL SPINE


41/60

INITIAL NEUROLOGICAL EXAM

Alert and oriented with normal speech CN IIXII grossly intact

Motor exam showed preserved biceps 3+/5,triceps 2/5 bilaterally, Hand intrinsics absenton right side, subtle finger movement on leftside

No motor or sensory perception below C7

+ priapism


42/60

DISCUSSION

Level of Injury

Complete Injury vs Incomplete Injury

Spinal shock


43/60

LEVEL OF INJURY

Some use level of completely normalfunction

Some use most caudal segment with motor

function at least 3/5

Know the major spinal nerve root motordistribution

Know the major spinal nerve root sensorydermatomes

MAJOR SPINAL NERVE ROOT MOTOR


44/60

MAJOR SPINAL NERVE ROOT MOTOR

DISTRIBUTIONSSegment Muscle Action to Test

C1C4 Neck muscles

C3, C4, C5 Diaphragm Inspiration/FEV1

C5, C6 Deltoid, Biceps Abduct arm, Elbow flexion

C6, C7 Extensor carpi radialis Wrist extension

C7, C8 Triceps, Extensor digitorum,hand intrinsics Elbow Extension, FingerExtension

L2, L3 Iliopsoas Hip flexion

L3, L4 Quadriceps Knee extension

L4, L5 Medial hamstrings, tibialis

anterior

Ankle dorsiflexion

L5, S1 Lateral hamstrings, posterior

tibialis, extensor hallucis

longis

Foot inversion, great toe

extension, ankle

plantarflexion


45/60

MUSCLE STRENGTH

Grade Strength

0 No contraction

1 Flicker or trace contraction

2 Movement with gravity eliminated

3 Movement against gravity

4 Movement against resistance

4 slight resistance

4 moderate resistance

4+ strong resistance

5 Normal strength


46/60

SENSORY DERMATOMES


47/60

DISCUSSING SPECIAL REFLEXES IN SCI

Priapism

Cremasteric reflex

Anal cutaneous reflex (anal wink)

Bulbocavernous reflex


48/60

COMPLETE VS INCOMPLETE SCI

Incomplete lesionAny residual motor or

sensory function more

than 3 segments below the

level of injury Sensation or voluntary

movements in LEs

Preserved sensation

around anus, voluntary

rectal sphinctercontraction

Complete lesion No preservation of any

motor and/or sensory

function more than 3

segments below the levelof injury


49/60

SPINAL SHOCK

Hypotension following spinal cord injury Interruption of the sympathetics (implies

injury above T1)

Loss of vascular tone below level of injury Leaves parasympathetics relatively unopposed causing a

relative bradycardia

Loss of muscle tone results in venous

pooling Blood loss from other associated wounds


50/60

TREATMENT COURSE

Cervical immobilization with rigid collar initially

Methylprednisolone drip started per protocol

Placed in cervical tongs by Neurosurgeon in ICU

Central/Arterial lines placed

Levophed drip used in ICU for maintaining SBP > 90 SCDs for DVT prophylaxis

Foley catheter insertion

NPO

SUP: Protonix 40 mg IV daily Anxiety & Pain control with small doses Ativan/Fentanyl as

needed

Pre-operative readiness for surgical stabilization


51/60

CERVICAL TRACTION

Level III recommendation Purpose: to restore anatomic alignment

Complications:

Skull penetration of pins

Reduction of cervical dislocations may cause neurologic

deterioration (i.e. retropulsed disc)

Higher level injuries (C1-C3) need caution (fragmentspulled toward canal)

Infection (Osteomyelitis)good pin care is essential


52/60


53/60

HOSPITAL COURSE / OUTCOME

Early physical and occupational therapies

Improving left hand intrinsics by POD 2

Transferred to a Spinal Cord Rehab facilityby POD 3


54/60

STEROID PROTOCOL IN SCI

Still highly controversial Considered Level III Recommendation

Asserted that beneficial (sensory & motor)effects at 6 weeks, 6 months and 1 year areseen for both complete and incompleteinjuries only if given within 8 hour of injury

(Greenberg, 2010)


55/60

STEROID PROTOCOL

Administration: 16 Gm/256 ml bacteriostatic water

30 mg/kg initial IV bolus over 15 minutes, followed by 45

minute pause, then maintenance drip at 5.4 mg/kg/hour x

23 or 47 hours**

(Greenberg, 2010)


56/60

DVT PROPHYLAXIS IN SCILevel I

Recommendation

Level II

Recommendations

Level III

Recommendations* LMW heparin, rotating bed,

adjusted dose heparin or

some combination of these

measures

* Low dose heparin +

pneumatic compression

stockings or electrical

stimulation

Not recommended: low-

dose heparin used alone

Not recommended: oral

anticoagulation alone

Duplex doppler

ultrasound, venography

are recommended as

diagnostic tests for DVT

in patients with SCI

Vena Cava interruption

filters for patients who do

not respond to or are not

candidates for

anticoagulation

*Titrate dose of SQ heparin q 12hours to a PTT of 1.5 x control

*Heparin 5000 units q 12 hours

(Greenberg, 2010)


57/60

EVALUATING STABILITY


58/60

TYPES OF VERTEBRAL FRACTURES


59/60

BRACING OPTIONS


60/60

REFERENCES

Blumenfeld, H. Neuroanatomy through Clinical Cases. SinauerAssociates, Inc., Sunderland, Massachusetts; 2002.

Fix, J.D. Neuroanatomy. Lippincott Williams & Wilkins, 3rdedition, 2002.

Greenberg, M.S. Handbook of Neurosurgery. Thieme Publishing,7thedition, 2010.

Heegard, W. & Biros, M. (2007). Traumatic Brain Injury.Emergency Medicine Clinics of North America, 25, 655-678.

Lindsay, K.W., Bone, I. & Callander, R. Neurology andNeurosurgery Illustrated. Churchill Livingstone, 4thedition, 2004.

Ling, G. & Marshall, S. A. (2008). Management of Traumatic BrainInjury in the Intensive Care Unit, Neurologic Clinics, 26, 409-426.

Chittibonia et al. (2012). Head and Spinal Cord Injury. NeurologyClinics, 30 (1), 241-276.

Date post:	03-Jun-2018
Category:	Documents
Upload:	sweetcharmed-go
View:	219 times
Download:	0 times

Case Studies in Neuro Trauma SCRTAC

Documents