Transcript Assessment, Management and Decision Making in the Treatment of Polytrauma Patients

Assessment, Management and
Decision Making in the
Treatment of Polytrauma Patients
with Head Injuries
Roman A. Hayda, MD
Original Author
March 2004; Revised July 2006, November 2010
Epidemiologic Aspects
• 80,000 survivors of head injury annually
• 125,000 children <15yo head injured
annually
• 40-60% of head injured patients have
extremity injury
• 32,000-48,000 head injury survivors with
orthopaedic injuries annually
Overview
•
•
•
•
•
Pathophysiology
Initial evaluation
Prognosis
Management of Head Injury
Orthopaedic Issues
– Operative vs. nonoperative
treatment
• Timing of surgery
• methods
– Fracture healing in head injury
– Associated injuries
– Complications
1st
hit
2nd
hit
1st hit: Head
• mechanical
insult to brain
tissue
• blunt or
penetrating
1st hit: body
• mechanical
insult
•chest,
abdomen
•extremities
2nd hit: Head
• release of
inflammatory
mediators
•Hypoxia
•Acidosis
•Coagulopathy
2nd hit: body
• systemic
inflammation
• SURGERY
Evaluation
• ATLS—ABC’s
• History
– loss of consciousness
• Physical exam
– Glasgow Coma Scale
• Radiographic studies
– CT Scan
Evaluation
• Must exclude head injury by evaluation if
– history of loss of consciousness
– significant amnesia
– confusion, combativeness
• Cannot be simply attributed to drug or alcohol use
– neurologic deficits on exam of cranial nerves or
extremities
Physical Exam
• Exam of head and cranial nerves for
lateralizing signs
– dilated or sluggish pupil(s)
• Extremities
– unilateral weakness
– posturing
• decorticate (flexor)
• decerebrate (extensor)
Glasgow Coma Scale
• Eye opening: 1-4
• Motor response: 1-6
• Verbal response: 1-5
Glasgow Coma Scale
• Eye opening
–Spontaneous
–To speech
–To pain
–None
4
3
2
1
Glasgow Coma Scale
• Motor response
–Obeys commands
–Purposeful response to pain
–Withdrawal to pain
–Flexion response to pain
–Extension response to pain
–None
6
5
4
3
2
1
Glasgow Coma Scale
• Verbal response
–Oriented
–Confused
–Inappropriate
–Incomprehensible
–None
5
4
3
2
1
Glasgow Coma Scale
• Sum scores (3-15)
– <9 considered severe
– 9-12 moderate
– 13-15 mild*
• Modifiers—xT– if intubated (Best score possible 11T)
xTP – if intubated and paralyzed (Best score
possible is 3TP)
• Done in the field but best in trauma bay following
initial resuscitation
Radiographic Studies
• CT scan
– required in ALL cases EXCEPT:
• LOC is brief
AND
• patient can be serially examined
– lesions
• focal--epidural, subdural hematoma,
contusions
• diffuse--diffuse axonal injury
• Plain films
– useful only to detect skull fracture
but in the trauma setting wastes time
Frontal
Contusion
Treatment
• Initial
– Intubation if unresponsive or combative to give
controlled ventilation
– pharmacologic paralysis
• after neurologic exam is completed
– Blood pressure and O2 saturation monitoring
• keep systolic > 90 mm Hg
• 100% O2 saturation
ICP Monitoring
• Indications
– severe head injury (GCS < 9)
• abnormal head CT
or
• Coma >6 hrs
– Intracranial hematoma requiring evacuation
– Delayed neurologic deterioration from mild to
moderate (GCS>9) to severe (GCS < 8)
– Requirement for prolonged ventilation
– Pulmonary injury, surgery etc.
ICU Management Goals
• O2 saturation 100%
• Mean arterial pressure 90-110 mm
Hg
• ICP < 20 mm Hg
• Cerebral Perfusion Pressure
(CPP=MAP-ICP) >70 mm Hg
ICU Adjuncts
•
•
•
•
•
HCT~ 30-33%
PaCO2= 35±2 mm Hg
CVP= 8-14 mm Hg
avoid dextrose IV
maintain euthermia or mild hypothermia
Factors Influencing Prognosis
• Age
– Younger pts have greatest potential for survival and
recovery
– 61-75% mortality if over 65
– 90% mortality in elderly with ICP >20 and coma for
more than 3 days
– 100% mortality if GCS < 5, uni- or bilateral dilated
pupils, and age over 75
Bottom line: survival and recovery not predictable except in old pts
• Treat presuming recovery
Factors Influencing Prognosis
• Hypotension--50% increase in mortality with
single episode of hypotension
• Hypoxia
• Delay in treatment
– prolonged transport
– surgical delay when lateralizing signs present
Potentially controllable!!
Outcome
• Glasgow Outcome Score:
–
–
–
–
–
1-dead
2-vegetative
3-cannot self care
4-deficits but able to self care
5-return to preinjury level of function
Outcome Prediction
• Glasgow scale (post resuscitation) 44-66%
accuracy in determining ultimate outcome
– 39% with an initial GCS of < 5 made functional
recovery
• CT based scoring (Marshall Computed
Tomographic score) only 71% accurate
Outcome Prediction
• Serum markers (S-100B)
– Accuracy of 83% (Woertgen, J Trauma, 1999)
– Good sensitivity in moderate to severe injury
even with extracranial injury (Savola, J Trauma, 2004)
– May be elevated in 29% fx pts without head
injury (Unden, J Trauma, 2005)
Clinical utility not defined
Prognosis
• Significant disability @ 1 yr
• Disability even in “mild” injury
– Glasgow cohort: 742 pts with 71% follow-up
• Rate of combined severe and moderate disability similar among
groups (48%, 45% and 48%)
• Age >40, previous head injury, comorbidities increased disability
(Thornhill, BMJ, 2000)
Dead or
vegetative
Severe
disability
Moderate
disability
Mod (GCS 9-12)
8%
16%
20%
22%
28%
24%
45%
38%
Severe (GCS <9)
38%
29%
19%
14%
Mild (GCS 13-15)
Good
recovery
Prognosis of the Severely
Head Injured Patient
• Gordon (J Neurosurg Anes ’95)
– 1,294 pts with severe injury(GCS <9) at 10 year
follow-up
•
•
•
•
55% good recovery
19% significant disability
7% vegetative
19% mortality
• Sakas (J Neurosurg ‘95)
– 40 pts with fixed and dilated pupils
• 55% younger than 20 years made independent functional
recovery
• 25% mild to moderate functional disability
• 43% mortality
Orthopaedic Issues in the Head
Injured Patient
• Role in resuscitation
– pelvic ring injury
– open injuries
– long bone fractures
• Treatment methods and timing
• Associated injuries
• Complications
Initial Surgery in the
Head Injured is
Damage Control Surgery
Damage Control Orthopaedics
• Goal
– Limit ongoing hemorrhage, hypotension, and
release of inflammatory factors
– Limit stress on injured brain
– Initial surgery
• <1-2 hrs
• limit surgical blood loss
Damage Control Orthopaedics
• Methods
– Initial focus on stabilization
• External fixation
• Limited debridement
• Limited or no internal fixation or definitive care
– Delayed definitive fixation (5-7 days)
Resuscitation: Role of
Orthopaedics
• Goal: limit ongoing hemorrhage and
hypotension
– pelvic ring injury-external fixation reduced
mortality from 43% to 7%
(Reimer, J Trauma, ‘93)
– open injury--limit bleeding
– long bone fracture--controversial
Long Bone Fracture in the Head
Injured Patient
• Early fixation (<24 hours) well accepted in
the polytrauma patient
• In the head injured patient early fixation
may be associated with
– hypotension
– blood loss/coagulopathy
– hypoxia
– elevated ICP
• Advocates of early and delayed treatment
Early Osteosynthesis
• Hofman (J Trauma ‘91):
– 58 patients with a GCS < 7
– lower mortality and higher GOS with operative
treatment within 24 hours
• Poole ( J Trauma ‘92):
– 114 patients with head injury
– delayed fixation did not protect the injured brain
• McKee (J Trauma ’97):
– 46 head injured with femur fractures matched with 99
patients without fracture
– no difference in neurologic outcome or mortality
Early Osteosynthesis
• Bone (J Trauma ‘94):
– in 22 patients (age <50) with a GCS 4-5
– 13.6% (early fixation) vs 51.3% (delayed fixation)
mortality rates
• Starr (J Orthop Trauma ‘98):
– 32 pts with head injury
– 14 early, 14 delayed, 4 nonoperative
– delayed fixation associated with 45X greater pulmonary
complications but did not affect neurologic
complications
Early Osteosynthesis
• Kalb (Surgery ‘98):
– 123 patients, head AIS > 2, 84 early, 39 late fixation
– early group had increased fluid requirement but no
other difference in mortality or complication
– emphasized the role of appropriate monitoring
• Scalea (J Trauma ‘99):
– 171 patients, mean GCS 9, 147 early, 24 late fixation
– early fixation no effect on length of stay, mortality,
CNS complications
Delayed Osteosynthesis
• Reynolds (Annals of Surg ‘95):
– Mortality 2/105 patients, both early rodding (<24 hrs)
– one due to neurologic and the other pulmonary
deterioration
• Jaicks (J Trauma ‘97):
– 33 patients with head AIS > 2; 19 early fixation 14 late
– early group required more fluid in 48 hrs (14 vs 8.7 l);
more intraoperative hypotension (16% vs 7%); lower
discharge GCS (13.5 vs 15)
Delayed Osteosythesis
• Townsend (J Trauma ‘98):
– 61 patients with GCS < 8;
– hypotension 8 X more likely if operated < 2 hrs and 2 X
more likely when operated within 24 hrs
– no difference noted in GOS
Advances in Care of Head Injured
• ICP monitoring
• Evolution of anesthetic agents
• Improvement in neuroanesthetic techniques
Allow for safer surgery in the head injured
Fracture Care
• Ultimate neurologic outcome continues to be
difficult to predict
– Presume recovery
– Avoid treatments that may compromise neurologic
outcome
• All interventions must strive to reduce
musculoskeletal complications inherent in the
head injured patient
• Management decisions made in conjunction with
trauma/neurosurgical team
Algorithm for Fracture care in
Head injured
• Severe Head injury (GCS<9) or unstable pt
DAMAGE CONTROL SURGERY
Convert to definitive at 5+ days
• Mild head injury (GCS 13-15); stable pt
Consider EARLY TOTAL CARE
• Intermediate head injury
Determined by pt stability; complexity of
surgery
Operative Fracture Care
• Surgery is often optimal form of fracture treatment
in the head injured polytrauma patient
• Advantages
–
–
–
–
Alignment
Articular congruity
Early rehabilitation
Facilitated nursing
care
Galleazzi, ulna and olecranon fx
with compartment syndrome
Operative Fracture Care
• Perform early surgery when appropriate
– MUST minimize
• hypotension
• hypoxia
• elevated ICP
use
appropriate
monitors
– Consider temporary methods
(external fixation)
• Fixation must be adequate
– Patient may be non compliant
– “accelerated” healing cannot be relied upon
Nonoperative Fracture
Management
• Treatment of choice when
– nonoperative means best treat that particular fracture
– operative risks outweigh potential benefits
• Modalities
–
–
–
–
splint
brace
cast
traction
• Caveat
– device must be removed periodically to inspect
underlying skin for decubiti
Bone Healing in
the Head Injured Patient
• Humoral osteogenic factors are released by
the injured brain
• Exuberant callus MAY be seen
• Soft tissue ossification is
common
• Ultimate union rate
of fractures inconsistently
affected
Fracture Healing with Head
Injury
• Cadosch, JBJS-A, 2009
– Case matched series of 17 pts with avg GCS 5.6,
treated with IM nail
– Union 2X faster; 37-50%> callus; serum induced
osteoblast proliferation
• Boes, JBJS-A, 2006
– Experimental model of 43 rats with IM nailed femur fx
+/- head injury
– More fx stiffness in head injury cohort
– Serum of head injured rats promoted stem cell
proliferation
Complications
• Heterotopic Ossification
– up to 89-100% incidence
periarticular injury
with head injury
• Contractures
• Malunion
Recurrent elbow dislocation
secondary to extensor posturing
and heterotopic ossification
Heterotopic Ossification
• Associated with ventilator dependency
• Use approaches/techniques less associated
with H.O.
• Prophylaxis
– XRT
– Indocin
• Excision
Contractures
• Occurs due to spasticity/posturing
• Effects
– Inhibits restoration of function
– Complicates nursing care
– Predisposes to decubitus ulcers
Contractures
• Treatment:
– Prevention
• splinting/positioning
• early physical and occupational therapy
– Established
•
•
•
•
serial casting
manipulation
surgery
nerve blocks
Associated Injuries
• Normal methods of clinical and radiologic
assessment may not apply in the head
injured patient
– C spine injury
– Occult fractures and injury
C Spine Injury
• Incidence increases with increasing severity of
head injury
C spine injury
GCS
Incidence
13-15
1.4%
9-12
6.8%
<9
10.2%
Demetraiades, J Trauma, ’00
• Evaluation more difficult
• Optimal protocol for evaluation and management
controversial
C Spine Injury
• Minimum requirement
– Cervical collar
– CT entire C spine with reconstructions
• Adjuncts
– MRI
• Difficult in vent patient
• May over call injury
– “Dynamic” flexion extension radiographs in the
obtunded patient
• Safety and reliability not established
Occult Injuries
• Fractures, dislocations and peripheral nerve
injuries may be “missed”
– Up to 11% of orthopaedic injuries may be
“missed”
– Peripheral nerve injuries are particularly
common (as high as 34%)
– Occult fractures in children with head injury are
also common (37-82%)
Occult Injuries
• Detailed physical exam with radiographs of
any suspect area due to bruising, abrasion,
deformity, loss of motion
• Consider EMG for unexplained neurologic
deficits
• Bone scan advocated in children with
severe head injury @ 72 hrs
Summary
• Orthopaedic injuries are common in head injured
polytrauma patients
• Head injury outcome is difficult to predict
• Management requires multidisciplinary approach
• Operative management is safe and often improves
functional outcome if secondary brain insults are
avoided
– Hypotension, hypoxia, increased ICP
References
Bayir H, Clark RS, Kochanek PM. Promising strategies to minimize secondary brain injury after head trauma. Crit Care Med. 2003;31:S112–S117.
Bandari M, Guyatt GH, Khera V, et al. Operative management of lower extremity fractures in patients with head injuries. Clin Orthop Relat Res.
2003;407:187–198.
Boes M, Kain M, Kakar S, et al. Osteogenic Effects Of Traumatic Brain Injury On Experimental Fracture-Healing. JBJS-A. 88:738-743, 2006.
Bone J, K McNamara, B Shine, J Border: “Mortality in multiple trauma patients with fractures” J Trauma, 37, 262-265, 1994
Brohi K Healy M, Fotheringham T, et al.Helical Computed Tomographic Scanning for the Evaluation of the Cervical Spine in the Unconscious,
Intubated Trauma Patient. J Trauma. 2005;58:897–901.
Cadosch D, Gautschi O, Thyer M, et al. Humoral Factors Enhance Fracture-Healing and Callus Formation in Patients with Traumatic Brain
Injury. JBJS-A. 91:282-288, 2009
Demetraiades D, K Charalambides, S Chahwan et al: Nonskeletal cervical spine injuries: Epidemiology and Diagnostic pitfalls. J Trauma, 48 (4):
724-727, 2000.
Davis DP, Serrano JA, Vilke GM, et al. The predictive value of field versus arrival Glasgow Coma Scale score and TRISS calculations in
moderate-to-severe traumatic brain injury. J Trauma. 2006;60:985–990.
Flierl MA, Stonebak JW, Beauchamp KM, et al. Femur Saft Fixation in Head Injured Patients: When is the right time? J Orthop Trauma. 24:
107-114. 2010
Garland D, M Rhoades. Orthopaedic Management of Brain Injured Adults, CORR 131:111-120, 1978
Grossman R, C Loftus: Principles of Neurosurgery, 2nd ed, New York: Lippincott-Raven, 1998.
Hariri R, A Firuk, S Shepard: “Traumatic brain injury, hemorrhagic shock, and fluid resuscitation: effects on intracranial pressure and brain
compliance” J Neurosurg 79: 421. 1993.
Hofman P, Goris J. Timing of Osteosynthesis of Major Fractures in Patients with Severe Brain Injury, J Trauma, vol 31(2): 261-263
Jaicks R, S Cohn, B Moller: “Early fracture fixation may be deleterious after head injury” J Trauma, vol 42 (1): 1-6) 1997
Jeremitsky E, Omert L, Dunham CM, et al. Harbingers of poor outcome the day after severe brain injury: hypothermia, hypoxia, and
hypoperfusion. J Trauma. 2003;54:312–319.
Kalb D, A Ney, J Rodriguez, et al: “Assessment of the relationship between timing of fixation of the fracture and secondary brain injury in
patients with multiple trauma” Surgery vol 124 (4)739-745, 1998.
Kushwaha V, D Garland. Extremity fracture in the patient with traumatic brain injury JAAOS, 6(5): 298-307, 1998.
Li J, Guo Z, Han J, et al. Expression of vascular endothelial growth factor in bony callus of patients with fracture combined with head injury
versus simple fracture patients and its clinical significance. J Clin Rehab Tissue Eng Res. 13:5453-5456, 2009.
Marion D “Head Injury” in: The Trauma Manual, Peitzman A, M Rhoades, C Schwab, D Yealy eds, New York: Lippincott-Raven, 1998.
Masson F, Thicoipe M, Aye P, et al. Epidemiology of severe brain injuries:a prospective population-based study. J Trauma. 2001;51:481–489.
Moore E, K Mattox, D Feliciano: Trauma, 2nd ed, Norwalk, CT: Appleton and Lange, 1998.
Moppett IK. Traumatic Brain Injury: assess, resuscitation and early management. Br J Anaesth 99: 18-31. 2007.
Morshed S, Miclau T 3rd, Bembom O, et al. Delayed internal fixation of femoral shaft fracture reduces mortality among patients with
multisystem trauma. J Bone Joint Surg Am. 2009;91:3–13.
Nau T, Aldrian S, Koenig F, et al. Fixation of femoral fractures in multipleinjury patients with combined chest and head injuries. ANZ J Surg.
2003; 73:1018–1021.
Poole GV, J Miller, S Agnew, J Griswold: “Lower extremity fracture Fixation in Head injured Patients” J Trauma, 32(5) 654-659, 1992.
Reimer BL, Butterfield S. Diamond DL, et al., Acute mortality associated with injuries to the pelvic ring: The role of early patient mobilization
and external fixation, J Trauma 35 (1993), 671–677.
Reynolds MA, J Richardson, D Spain, et al: “Is the timing of fracture fixation important for the patient with multiple trauma” Annals of Surgery,
222(4): 470-481, 1995.
Savola O, Pyhtinen J, Leino T, Siitonen S, Niemelä O, Hillbom M. Effects of Head and Extracranial Injuries on Serum Protein S100B Levels in
Trauma Patients. J Trauma, 5: 1229-1234, 2004
Scalea T, J Scott, R Brumback, et al: “Early fracture fixation may be just fine after head injury: No difference in central nervous system
outcomes” J Trauma vol 46 (5): 839-845, 1999.
Starr A, J Hunt, D Chason, C Reinert: “Treatment of femur fracture with associated head injury” J Orthop Trauma, vol 12 (1): 38-45, 1998.
Thornhill S, Teasdale G, Murray GD, et al. Disability in young people and adults one year after head injury: prospective cohort study BMJ 2000;
320 : 1631
Townend W,Muller K,Waterloo K, Ingebrigtsen T, Lecky F. Validation Of Serum S-100b As A Predictive Marker For Mild Head Injury
Outcome. Emerg Med Journal. 24:381, May 2007.
Townsend R, T Lheureau, J Protetch et al: “Timing fracture repair in patients with sever brain injury J Trauma 44: 977-983, 1998
Undén J, Bellner J, Eneroth M, et al. Raised Serum S100B Levels after Acute Bone Fractures without Cerebral Injury J Trauma 58: 59-61. 2005
Woertgen C, R Rothoerl, C Metz, A Brawanski: Comparison of clinical, radiologic, and serum markers as prognostic factors after severe head
injury, J Trauma, vol 47 (6): 1126-1130, 1999ICL, 49, 2000
If you would like to volunteer as an author for
the Resident Slide Project or recommend
updates to any of the following slides, please
send an e-mail to [email protected]
E-mail OTA
about
Questions/Comments
Return to
General/Principles
Index