1. Head Trauma Meira Louis Rob Lafreniere August 25, 2011

2. Outline • Case 1 (10-15 min) • Mild concussion in adolescent • When to image? • Return to play guidelines • Case 2 (10 minutes) • Skull fractures • Case 3 (30 min) • Severe TBI • Priorities in management • Intubation • Cooling • Case 4 (30 min) • Moderate TBI • Seizure prophylaxis • Anticoagulation management • Herniation

3. Structure • Group work (30 minutes) • Cases 1-4 (25-30 minutes each)

4. Case 1 • 16yo playing hockey • Checked into boards wearing helmet • 20 second LOC • 1 hour later, has headache and amnesia • Seen in the WRC section of the PLC P 72 RR 14 BP 110/75 Sat 99% T 36.9

5. To image or not to image? • Decision one: child or adult?

6. Adult Decision Rules VS

8. NEXUS II • 1. Evidence of significant skull fracture • 2. Scalp haematoma • 3. Neurologic deficit • 4. Altered level of alertness • 5. Abnormal behaviour • 6. Coagulopathy • 7. Persistent vomiting • 8. Age greater than 65 years

11. What about the children?

13. What’s the catch?

14. Can we skip the CT altogether?

17. Second Impact Syndrome

18. Return to Play

19. Case 2a

20. Case 2b Case 2b

21. Case 2c

22. Case 3 • 28yo male assaulted with metal pole • GCS on scene 6 • Obvious large hematoma to temple • No other significant injuries P 120 RR 16 BP 95/65 Sat 99% on NRB

23. Priorities of Management

24. Priorities of Management

25. Drugs to Intubate

26. Peds Drugs for Intubation

27. Lidocaine for premedication? What about Fentanyl ?

28. Prophylactic Cooling

29. Case 4 • 72yo male who fell off the bank of the Bow River while fishing • Brief LOC, GCS 15 at the PLC • Transferred to FMC as one hour later GCS had begun to decline P 70 RR 8 BP 150/105 Sat 99% on NRB • Now unresponsive. Paramedics state he had a seizure en route.

30. Talk and Deteriorate • Subdural hematomas • Epidural hematomas • Contusions with edema • Anti-coagulation

31. Recombinant Factor VIIa

32. Seizure Prophylaxis • Glasgow Coma Scale (GCS) Score < 10 • Cortical contusion • Depressed skull fracture • Subdural hematoma • Epidural hematoma • Intracerebral hematoma • Penetrating head wound • Seizure within 24 h of injury

33. Acutely Elevated ICP • Hyperventilation • Mannitol • Hypertonic Saline • Barbituates

34. Hyperventilation

35. Mannitol

36. Hypertonic Saline

37. Barbituates

38. On the Horizon....

39. Herniation Syndromes

40. Kernohan’s Notch Syndrome

41. Take Home Points • Mild • When to image? • Remember your CT head rules • Return to play guidelines • Moderate/Severe • Hypoxia and hypotension are your enemies • Cooling has not been shown to help • Seizure prophylaxis in penetrating head trauma • Be suspicious for herniation