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Trauma

Trauma

  • Depressed skull fracture, severely displaced/angulated fracture, open fracture, femoral neck/intertrochanteric fracture
    • Take straight to the Operating Room
    • More Angulation after fractures in a child will not lead to permanent deformity
  • LOC: CT w/o Contrast
  • Linear skull fractures
    • Closed: Leave alone
    • Open: Close
    • Comminuted or depressed: Operating room
  • Midface Fractures
    • Le Fort I – maxilla at the nasal fossa
      • Unstable maxilla
      • Diagnosis: CT
    • Le Fort II – maxilla, nasal bones, medial orbits
      • Unstable maxilla + Nasal Bone mobility
      • Incorrect teeth placement
      • Diagnosis: CT of the face
      • Management
        • ENT Consultation
    • Le Fort III – maxilla, zygoma, nasal bones ± cranial bones
      • Airway often compromised
      • “floating” maxilla/face from the rest of the head
    • Orbital Blowout Fracture
      • Limited upward gaze, swelling and ecchymosis infraorbitally
      • Fracture of superior portion of maxillary sinus
      • Diagnosis: CT
    • Zygomaticomaxillary-Orbital Complex Fractures
      • “tripod” fractures
    • Zygomatic-frontal and temporal sutures and orbital floor
      • MVA or Assult
      • Facial flattening, CN V palsy, Trismus, diplopia
      • Diagnosis: CT
      • Treatment
        • Surgical Repair

Intercranial Pressure (ICP)

  • Normal <15 mmHg, maintain ICP <20 and cerebral perfusion pressure >60
    • ICP to monitor CPP
    • CPP = MAP – ICP
      • Arterial line required for MAP
    • Increased ICP + Hyponatremia: SAH
    • Increased ICP
      • Headache, Nausea, Vomiting, AMS
      • Cushing’s Reflex
        • Late stage indicator
    • Headaches (worse at night), Nausea/vomiting and AMS
    • ± focal neurologic symptoms, and seizure
    • Valsalva, leaning forward, cough make it worse
      • Worrisome finding suggestive of brainstem compression
        • Hypertension, bradycardia, respiratory depression
      • Brain Tumors, trauma, cerebral edema, hemorrhage, hydrocephalus, hepatic encephalopathy, impaired venous outflow
      • Treatment
        • Emergent treatment if GCS ≤8 + Cushing’s reflex
          • Elevation of the bed (increase venous flow)
          • Sedation (control hypertension, decrease demand)
          • Hyperventilation (decrease CO2, cerebral vasoconstriction)
            • pCO2 to 26-30 is goal
        • IV Mannitol (draws fluid from tissues)
        • CSF Removal (Hyrdrocephalus)
        • Lidocaine if intubation is needed

Traumatic Brain Injury (TBI)

  • Biomechanically induced alteration of brain function
    • Etiology
      • Accidents > Sports
    • Symptoms
      • Amnesia, confusion
      • Headache, dizziness, and nausea/vomiting immediately following
      • Mood and cognition changes days to weeks later
    • Diagnosis: Clinical
      • Head CT/MRI if: >60 y/o, progressive headache, seizure, repeated vomiting after the trauma, persistent drowsiness or amnesia, focal deficits, dangerous injuries
      • May have abnormal EEG
    • Treatment
      • Mild (Concussion)
        • Remove from play
        • Graduated return to play:
          • Evaluated for recurrence of symptoms while performing stepwise increases in activity
          • Can return to play if asymptomatic for 7 days w/o meds
        • Symptomatic for ≥10 days

Cerebral Contusion

  • General
    • Bruising of the brain caused by traumatic head injury
    • Coup or Contrecoup
    • Loss of consciousness and severe Headache are common
    • Brain herniation possible if significant edema
  • Treatment
    • Surgery if herniation
    • Symptomatic treatment otherwise

Cerebral Edema

  • General
    • CPP = MAP – ICP = 0  brain death
    • Causes
      • Hyperammonemia
      • Meningitis
      • Acute Liver Failure
      • Valproate Toxicity (>180mg/L)
      • Drowning
  • Vasogenic Cerebral Edema
    • Etiology
      • Surrounding Metastatic brain tumor
        • V shaped
    • Increased extracellular fluid 2/2 BBB disruption and increased vascular permeability from endothelial damage causing disruption of tight junctions
      • May enhance on imaging
      • ECS expands
    • Responds to dexamethasone
  • Cytotoxic Cerebral Edema
    • Etiology
      • Head injury, CVA, Hematoma, Circular shape
    • Increase in intracellular fluid 2/2 neuronal, glial, or endothelial cell membrane injury
    • BBB intact
    • No protein extravasation, no enhancement on CT or MRI
      • Cells swell then shrink
  • Ischemic Cerebral Edema
    • Occurs in combination with cytotoxic and vasogenic edema
    • BBB is closed initially but may open
    • Fluid Extravasates late
    • May cause delayed deterioration following intracerebral hemorrhage
  • Treatment
    • Steroids/Emergent Decompression
    • Mannitol
    • Hypertonic Saline
    • Therapeutic hyperventilation if unresponsive to other treatment
    • Head of bed 30 degrees

Posterior Reversible Encephalopathy Syndrome (PRES)

  • Synonymous Names:
    • Reversible posterior cerebral edema
    • Posterior leukoencephalopathy syndrome
    • Hyperperfusion encephalopathy
    • Brain capillary leak syndrome
  • Etiology
    • Hypertensive crisis
    • Cyclosporine
    • Eclampsia/preeclampsia
    • Allogenic Bone Marrow Transplantation
    • Renal Disease
    • Autoimmune Disease
    • Sepsis/Shock
  • Features
    • Thunderclap headaches not responsive to analgesics
    • AMS
    • Visual Disturbances
      • Hallucinations, cortical blindness
    • Seizures (generally tonic clonic)
    • Hemiparesis
  • Post-partum
  • Neuroimaging:
    • Brain MRI w/symmetrical hyperintense T2/Flair signal abnormalities in subcortical posterior parietooccipital white matter
    • CT
      • Intracerebral hemorrhage, bilateral vasogenic edema
  • Treatment
    • Lowering BP, antiepileptic
    • Most patients have reversal of symptoms in 2 weeks

Diffuse Axonal Injury

  • General
    • Traumatic acceleration/deceleration shearing forces
    • Coma with head CT showing diffuse small bleeds at grey-white junction
    • Fewer than 10% regain consciousness
  • Intracranial Hemorrhage
    • Epidural Hematoma (M-MMA)
      • Etiology
        • Middle Meningeal Artery disruption
          • Largest artery that supplies dura
      • Blood between the dura and the skull
        • Confined by cranial suture lines
          • Sphenoid bone MCC/temporal bone next
      • Symptoms
        • Initial loss of consciousness after head trauma, followed by lucid interval, then lethargic and comatose
        • MC in adolescent age range
      • Hematoma
        • Increased ICP
          • Brain begins to herniate
            • Brief loss of consciousness followed by lucid interval, then lethargy/confusion/coma
          • Reticular formation compression causes AMS
            • Possible CN III Palsy 2ndary to transentorial herniation
            • Ipsilateral hemiparesis, mydriasis, ptosis, down and out, contralateral homonymous hemianopsia
              • Lumbar puncture is contraindicated (death)
            • Contralateral hemiparesis
            • Diagnosis: Non-contrast CT Scan for size and location
      • White Lens inside (biconvex), does not cross suture lines
      • Biconvex intense lens shaped hematoma
        • MRI if CT is inconclusive
      • Treatment
        • Urgent surgical evacuation (craniotomy) for symptomatic patient’s w/ hematoma evacuation
        • Conservative if small
      • Transentorial (Uncal) Herniation
  • Compression of the contralateral crus cerebri against the tentorial edge: Ipsilateral Hemiparesis
  • Compression of the ipsilateral CN III by herniated uncus: Loss of PNS causes mydriasis, ptosis, down and out gaze and ipsilateral pupil due to unopposed CN 4 and 6 actions (late)
  • Compression of PCA: Contralateral Homonymous Hemianopsia
  • Compression of Reticular Formation: Altered Level of Consciousness, coma
    • Subdural Hematoma (B – Bridging Veins)
  • MC in elderly and alcoholics (atrophied brain ± fall)
    • Anticoagulant use increases risk
  • Tearing of bridging veins between dura and arachnoid membrane * Acute Subdural Hematoma
  • Gradual HA and confusion over 1-2 days, no LOC
    • Usually <24 hours for symptoms
    • Vomiting, nausea, focal neuro deficits
    • Increased ICP
  • Retinal hemorrhages in children = abuse
  • White crescent inside
  • Not confined by cranial suture lines
  • Diagnosis: Non-contrast CT scan of the head
    • Hyperintense crescent-shaped lesion, does not cross midline due to falx
  • Treatment
    • No Midline Shift/Deviation
      • Prevent increases in ICP (conservative)
    • Midline Shift/Neurologic deficits/rapidly expanding

      • 10mm, midline shift >5mm, herniation

        • Fixed, large pupil, hemiparesis
      • Craniotomy and surgical evacuation
      • Subacute Subdural Hematoma
        • Usually 1 day – 2 weeks
      • Chronic Subdural Hematoma
        • Symptoms >2 weeks
        • Pale crescent inside
        • No head trauma history
        • HA, confusion, seizure, unilateral weakness
        • Diagnosis: non-contrast CT scan
          • Hypodense, crescent-shaped lesion that may contain small bright areas
        • Treatment
          • Craniotomy for drainage
      • Subarachnoid
        • Basilar Skull Fracture
        • Traumatic, Nasotracheal intubation contraindicated
        • Periorbital Ecchymosis “Raccoon Eyes”, retroauricular or mastoid ecchymosis “Battle Sign”, clear otorrhea, clear rhinorrhea, Hemotympanum (dark purple or blue discoloration of the tympanic membrane)
          • 1-3 days after the event
        • Dura mater tears are associated with BSFs
          • Clear or bloody CSF from the ear or nose
        • Diagnosis: Non-contrast CT Scan of the head
          • Check Cervical spine with CT
        • Treatment
          • Conservatively, observation
          • If CSF from the nose (not ear)
          • Surgical intervention to repair dura mater