About 1.4 million people suffer a traumatic brain injury every year. 80% of those are seen in the emergency department. We need to recognize the signs of a TBI and know what to do in the trauma bay for these patients.
- Common mechanisms of injury
- Motor Vehicle Collisions
- Warning signs of major complications
- LOC / GCS
- Diagnostics – how do we know?
- CT Scan
- Interventions that may be done IN the trauma bay
- ICP Monitoring
- What happened?
- Patient complaints – if awake
- Could drugs or alcohol be involved (we are not cops!)
- Physical Assessment
- Asess airway, rate, depth
- Unilaterally Fixed
- Pinpoint vs Dilated
- On the skull
- Leaking from the ears, eyes, nose, other
- Racoons eyes
- Battle’s Sign
- Halo Sign
- Less than 8 = intubate!
- CT Scan
- Tox screen
- Establish and maintain an airway
- Get IV access
- 2 large bore IV’s – Go big or go home
- Admin fluids based on patients status
- Admin mannitol as prescribed
- Admin anticonvulsants as neccessary
- Assist with craniotomy / ventrucular shunt
- ICP Monitoring
- Be aware of instituitional protocols
- Intracranial Regulation
- Clinical Judgement
- Instruct patients in the importance of seatbelt safety
- Instruct parents and children in the importance of helmet use and when (Sports, bicycles, skateboarding, etc).
- Signs of head injuries for civilians
Welcome everyone to our continuing series on emergency medicine and trauma. Today we are going to talk about Head Injury and traumatic brain injuries, or TBI
Now come on, admit it, you all just read that with arnold’s voice in your head, right. Anyway just want to let you know that today we are going to talk specifically about what we do for a suspected TBI in the trauma bay. We are not going to get into subdural vs epidural or the types of brain injuries. There are some great lessons in the neuro sections of NRSNG so if you want more information on the specifics, head over there and check it out….after we’re done here of course.
When it comes to TBI there are some very common ways they occur. Car crashes, falls, sports injuries. And bear in mind, when we talk about falls, we do not have to fall from very high. A fall from standing can cause a TBI if a person lands on their skull. So in that vain, we want to know what happend. any detail will help us with our diagnosis and subsequent treatment.
If our patient is awake, what are his complaints? Headache, blurry vision, i can’t feel my legs. Our patients are always our greatest source of information.
It’s important when trying to diagnose a TBI to keep the thought of drugs or alcohol in the back of your mind. Many times I have seen a patient brought into the trauma bay “found down” who is confused and smells of alcohol. It’s one thing to think of him as a common drunk and treat him as such, but as there was no witnesses to his “falling down” you might want to get a CT scan to make sure his altered mental status is due to intoxication as opposed to a brain injury.
Some signs of a major complication. First, and easiest to assess is the level of consciousness. Are they A&Ox4 (person, place, time, and situation). I know the situation one isn’t used by everyone, but its telling if your guy knows who he is, where he is, what day it is, but cant remember a thing about the accident or why he is in a hospital.
We want to watch for posturing. We talk about 2 types when it comes to TBI: Decorticate and decerebrate. Decorticate is when the arms are drawn up to the chest and the hands are clenched. Decorticate, or towards the core. Decerebrate is the involuntary extension of the upper extremities. A hallmark is the arms and legs are rotated internally but the hands and wrists are rotated away from the body. Both of these are ominous signs of a severe brain injury.
The pupils. Look at your patients eyes. Are his pupils reactive, are they dilated, are they pinpoint. Most importantly are they equal. Unequal pupils in the presence of a head trauma can be indicative of a brain injury.
Hemiparesis or hemipalegia. If your guys is losing feeling on one side of his body or can’t move one side of his body, i think it goes without saying that there may be a problem. The question is whether it is an injury to his spinal cord or a brain injury
When we do our assessment, as always, ABCs first. Does our guy have an airway and is he breathing. Take note of the quality of the breaths, the rate, the depth.
Pupils, well we just talked about that.
Posturing…talked about that too.
Blood: where is it, is in on his skull, can you tell where its coming from. Is he leaking from his ears, eyes, nose, mouth. By the way blood leaking from a hole he already has, this is one place we don’t want to put direct pressure. We don’t want to cause increased ICP if we can avoid it and if there is a skull fracture causing leaking from one of those orifices, you can bet that the brain is starting to swell.
There are some common signs associated with head injuries. Periorbital ecchymosis, or racoons eyes is a sign of a basal skull fracture. Mastoid ecchymosis, or Battle’s sign is a sign of a mid skull fracture. You usually see this a bruising behind the ears. Halo Sign. This is a general identifier of cerebrospinal fluid leaking. You drop some of the leaking fluid onto some gauze and if you see the blood in the center and an outer yellowish ring…..halo sign…get it, the halo around the blood.
Glascow coma sclale or GCS. We want to assess this properly. Motor response, verbal response, eye opening. This is scored from 3-15. No zeros in GCS guys. I have said it before, your computer screen technically has a GCS of 3. Now when assessing GCS< there is an old trauma saying of Less than 8, intubate. This usually means that the patients LOC is so low that he can not protect his own airway. It doesn’t mean he is not breathing, but the concern for his neurologic status warrants an ET tube.
So in the trauma bay…..we establish and maintain that airway.
We get IV Access….and none of this 22 gauge nonsense. Go big or go home, 18g, 16g, 14g. The larger you can get the better. A true trauma patient is going to need fluids, blood, and quickly. You want to be able to get it into him as fast as possible so we want the biggest opening we can maintain. Think of it this way….is it easier to pour water through a straw or a garden hose. Exactly.
We want to position our patient properly, usually, after our assessments are completed and the c-spine is cleared, we might raise the bed to 30-40 degrees. Enough to facilitate blood flow but not too high or too low to cause more ICP.
We want to think about medications. Mannitol is a standard in the trauma bay for reducing ICP. It is an osmotic diuretic and helps to reduce the fluid buildup in the brain. If we are concerned about seizures (as is common in TBI), we can give some anticonvulsants. Drugs like dilanting, keppra, valium, check with your facility on their protocols in TBIO.
Always remember that radiology is your friend. We can’t diagnose a true TBI unless we can see the brain, if they are stable enough, get them to CT.
While labs aren’t the first priority, they are important. We want that tox screen and alcohol level and sometime the labs can tell us if there was a medical issue that cause the events leading up to the TBI.
Now if the pressure is great enough, and can not be relieved by conventional methods, our wonderful neurosurgeons might have to pull out their power tools like the one right here. They will perform a craniotomy, or drill holes in the skull to relieve the pressure. And trust me, i have seen fluids shoot 10 feet froma craniotomy hole, its truly impressive. Once the holes are drilled, they will usually insert an ICP monitor into the opening to keep an eye on the pressure. This is sometimes referred to as placing a bolt. And why, well because it looks like a bolt you would screw something in with.
Some concepts for you. We have to use our clinical judgement with these patients. Is this a TBI, is this metabolic, are they just drunk?
We have to maintain their intracranial regulation, whether through position, medication, or invasive procedure.
And we have to prioritize. ABCs first as usual, but then what our our next steps, what is the pressing issue for our patient that needs to be corrected.
A few key points:
Remember the signs, we learned about halo sign, battle sign, racoon sign. Even if you can’t remember which is which, know that they all indicate bad things.
Think of your differentials. Is this a TBI or are they drunk, or is it both?
Position our guy appropriately, not to high in the bed and not too low.
If a true TBI, we need to reduce the pressure in the skull, position, medication, invasive intervention
An first and foremost, use your patient. Watch the level of consciousness Our patients are our greatest source of information.
OK guys, so that was just a quick overview of treating TBI in the trauma bay. Thanks again for joining us and as always