Blunt Head Trauma


Article Author:
Micelle Haydel


Article Editor:
Bracken Burns


Editors In Chief:
Chaddie Doerr


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
2/28/2019 1:54:31 PM

Introduction

Traumatic Brain Injury (TBI) is a significant cause of morbidity and mortality in the United States, with an annual occurrence of more than 1.5 million. Patients with moderate and severe TBI comprise the about 20% of TBI, and those with moderate TBI have a mortality of about 15% while those with severe TBI have an associated mortality approaching 40%. The majority (approximately 80%) of patients with TBI have mild TBI which is associated with a less than 0.5% mortality, but about 25% experience extended post-concussive symptoms including a headache, dizziness, difficulty concentrating, and depression. [1][2][3]

Etiology

Falls are the most common cause of TBI, and motor vehicle-related incidents are the second leading cause of TBI. Motor vehicle-related TBI includes automobile, motorcycle, and bicycle accidents and pedestrians struck by those vehicles. Sports, recreation, and work-related injuries are the third leading cause of TBI, and assaults are the fourth leading cause of TBI. Blast injuries are the leading cause of TBI in active duty military personnel in war zones.[4][5][6]

Epidemiology

TBI is the most common cause of death in people younger than the age of 25. The majority of fatal TBI is due to motor vehicle-related incidents, falls, and assaults. Mortality due to motor vehicle accidents is greatest in the young-adult age group attributed to alcohol use and excessive speed. Mortality due to falls is greatest in patients over age 65, which is also the age group with the highest mortality in any TBI. Neurosurgical intervention such as craniotomy, elevation of skull fracture, ICP monitor, or ventriculostomy is required in about 40% of patients with severe TBI and about 10% of patients with moderate TBI.  [7][8]

Pathophysiology

Most patients with moderate to severe TBI have a combination of intracranial injuries. The majority of patients with moderate to severe TBI have related diffuse axonal injury to some degree. Diffuse axonal injury typically is caused by a rapid rotational or deceleration force that causes stretching and tearing of neurons, leading to focal areas of hemorrhage and edema that are not always detected on initial CT scan. Subarachnoid hemorrhage (SAH) is the most common CT finding in TBI and is caused by tears in the pial vessels. Subdural and epidural hematomas are the most frequent type of mass lesion identified in TBI. Cerebral contusions occur in about a third of patients with moderate to severe TBI, caused by direct impact or acceleration-deceleration forces that cause the brain to strike the frontal or temporal regions of the skull. Intracerebral bleeding or hematoma, caused by coalescence of contusions or a tear in a parenchymal vessel, occurring in up to a third of patients with moderate to severe TBI.  [9][10]

History and Physical

The majority of patients with TBI have a straightforward clinical presentation, but it is also important to solicit the mechanism of injury, current anticoagulation use, symptoms of head or neck pain, post-traumatic seizure, and any history of repeat head injury or past central nervous system surgeries.

The initial resuscitation should proceed in a step-wise fashion to identify all injuries and optimize cerebral perfusion by maintaining hemodynamic stabilization and oxygenation. The initial survey also should include a brief, focused neurological examination with attention to the Glasgow Coma Scale (GCS), pupillary examination, and motor function.

After addressing any airway or circulatory deficits, a thorough head-to-toe physical examination must be performed with vigilance for occult injuries and careful attention to detect any of the following warning signs:

  • Inspection for cranial nerve deficits, periorbital or postauricular ecchymoses, cerebrospinal fluid rhinorrhea or otorrhea, hemotympanum (signs of a base of skull fracture)
  • Fundoscopic examination for retinal hemorrhage (a potential sign of abuse in children) and papilledema (sign of increased ICP)
  • Optic nerve sheath diameter of greater than 5 mm on ultrasound has been shown to correlate well with increased intracranial pressure in patients with TBI
  • Palpation of the scalp for hematoma, crepitance, laceration, and bony deformity (markers of skull fractures)
  • Auscultation for carotid bruits, painful Horner syndrome or facial/neck hyperesthesia (markers of carotid or vertebral dissection)
  • Evaluation for cervical spine tenderness, paresthesias, incontinence, extremity weakness, priapism (signs of spinal cord injury)
  • Examination of motor and sensory extremities (for signs of spinal cord injury)

Evaluation

Non-contrast cranial CT is the imaging modality of choice for patients with TBI. CT findings associated with a poor outcome in TBI include midline shift, subarachnoid hemorrhage into the verticals, and compression of the basal cisterns. MRI may be indicated when the clinical picture remains unclear after a CT to identify more subtle lesions.[11][12]

Treatment / Management

Airway adjuncts are indicated in patients not able to maintain an open airway or maintain more than 90% oxygen saturation with supplementary oxygen. Oxygenation parameters should be monitored using continuous pulse oximetry with a target of more than 90% oxygen saturation. Ventilation should be monitored with continuous capnography with an end-tidal CO2 target of 35 mmHg to 40 mmHg. Placement of a definitive airway is recommended in the patient with a GCS of less than 9.  [13]

Systemic hypotension negatively impacts the outcome in the setting of TBI, and current studies have demonstrated improved outcome in patients with a systolic blood pressure (BP) =greater than or equal to 120 mmHg. Isotonic crystalloids should be used to prevent and correct hypotension; colloidal solutions have not been shown to improve outcomes.

Serial neurological examinations allow for early identification of patients with elevated ICP, and subsequent implementation of primary bedside interventions to improve venous outflow and reduce metabolic demands. Initial bedside approaches to increase ICP include elevating the head of the patient's bed 30 degrees, ascertaining that the cervical collar is not impeding venous outflow, and appropriate analgesics and sedation.

Routine hyperventilation should be avoided during the first 24 hours, and should only be used as a temporizing measure in the setting of impending herniation. Hyperosmolar therapy such as mannitol or hypertonic saline can further reduce intracerebral volume. ICP monitoring is indicated in patients with TBI when they have a GCS less than 9, an abnormal CT, and the approach to refractory elevated intracranial pressure includes high-dose barbiturates and possibly a decompressive hemicraniectomy.[14]

Complications

  • Intracranial hemorrhage
  • Brain edema
  • Elevated intracranial pressure
  • Vasospasm
  • Seizures
  • Infection
  • Hydrocephalus
  • Memory loss
  • Hyponatremia

Pearls and Other Issues

Patients with pre-existing anticoagulant or antiplatelet use have a poorer outcome with TBI. Acute, rapid reversal of anticoagulant agents should be considered early. Correction agents for patients on antiplatelet or anticoagulant agents with TBI include Vitamin K, Protamine Sulfate, Prothrombin Complex Concentrate (PCC), Fresh Frozen Plasma (FFP), Activated factor VIIa (rFVIIa). Identification of an up-to-date medication list is extremely important to choose the appropriate correction agent.

 

Enhancing Healthcare Team Outcomes

Blunt head trauma is a common presentation to the emergency room. The key to treatment of blunt head trauma is prevention. Most cases are preventable, and hence the education of the public is essential. At the time of injury, the patient and family should be educated on using safety devices during sports and other-high-risk activities. The caregiver of the elderly should be educated on the prevention of falls in the home and parents should be educated on child safety during driving and playground activities. Those who have a neurological deficit may benefit from physiotherapy and occupational therapy. The pharmacist should educate the patient on abstaining from alcohol and use of sedative drugs. In addition, the patient should be warned about seizures and the need to take anticonvulsants.[15][16] (Level V)

Outcomes

The outcome after blunt head trauma depends on the type of injury, the severity of the injury, patient age, the presence of any neurological deficit, comorbidity and any secondary injury. The GCS at 24 hours is a strong predictor of cognitive recovery at 24 months after the injury. The mortality rates do vary from 4-40% at five years after blunt head trauma. Younger people fare much better than older individuals. Individuals with a neurological deficit and those taking oral anticoagulants at the time of injury often have a poor outcome. The pupillary function before and after the injury is also predictive of outcome. Those with bilateral unresponsive pupils tend to have a grave prognosis and a higher risk of remaining in a vegetative state. Finally, studies show that diabetics also tend to fare worse with blunt head trauma compared to nondiabetics.[17][18] (Level V)

 


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Blunt Head Trauma - Questions

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A nine-year-old girl had an unwitnessed fall from her bicycle. She was not wearing a helmet. She is confused, oriented to person only, and cannot remember the accident. The exam shows no obvious trauma to the head except an abrasion of the lower lip and fractures of the front lower teeth. The neurologic exam is otherwise negative. What should be the first step in her evaluation?



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A 12-year-old girl had an unwitnessed fall off her bicycle. She was not wearing a helmet. She is confused, oriented to person only, and cannot remember the accident. Exam shows no obvious trauma to the head except an abrasion of the lower lip and fractures of the front lower teeth. Neurologic exam is otherwise negative. CT of the head shows no skull fractures, brain contusions, or intracranial hemorrhages. Five hours after the accident she is still disoriented and confused. By the next morning, she has returned to normal. When can she resume normal activities such as sports and riding her bike?



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A male who was involved in a serious head injury is about to be discharged for long term rehabilitation. His family want to know his prognosis. which of the following is most predictive of his cognitive recovery in future?.



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A 14-year-old child had a concussion following a head injury while playing soccer. Her symptoms include headache and repeated vomiting. What is the next best management of this patient?



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A 16-year-old is playing football when he is knocked out for two minutes but recovers quickly. He is awake and alert and has a normal exam. CT of the head is normal. How long should he be placed at complete physical and cognitive rest?



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An 80-year-old male trips and hits his head on a table. He is transported to the hospital but never regains consciousness. While in the hospital, he develops urosepsis and has a cardiac arrest. Autopsy shows advanced coronary artery disease and a pulmonary embolism that seems to have occurred 3 days prior. What should be the official cause of death?



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A 22 year old male presents to the emergency room after suffering an acute concussion. Which of the following was the most likely mechanism of injury?



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Your patient with a cerebral contusion from a traumatic brain injury has evidence of neurological decompensation. What should be ordered?



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Your emergency department patient has traumatic cerebral contusions and a GCS of 8. While waiting for transfer to the intensive care unit, he has developed a dilated pupil and decorticate posturing. Which of the following should you not implement?



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A teenager is hit on the head while playing football. It appears that he had a serious injury and does not remember where he is. He is brought to the emergency room. In athletes who have a concussion, losing consciousness for what period of time is an indication for a more aggressive workup?



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A teenager was hit in the head during a football game. He lost consciousness (LOC) for more than a minute and was managed in the emergency room. He has a Glasgow coma scale of 15 and is alert. He would like to return to school sports. What is the current protocol for return to activity in such scenarios?



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A teenager was hit in the head during a football game. He lost consciousness (LOC) for more than a minute and was managed in the emergency department. He has a Glasgow coma scale of 15 and is alert. He would like to return to school sports. You recommend that he first have complete rest with no activity and then start with light aerobics, follow by sport-specific activity. Based on current guidelines what is the time interval between each step of the recovery protocol?



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A teenager was hit in the head during a football game. He lost consciousness for more than a minute and was managed in the emergency room. He has a Glasgow coma scale of 15 and is alert. He would like to return to school. He is told to rest first. However, he would like to know if he can take acetaminophen for his headache and for how long. What should he be told?



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Blunt Head Trauma - References

References

Lamb LC,DiFiori M,Comey C,Feeney J, Cost Analysis of Direct Oral Anticoagulants Compared with Warfarin in Patients with Blunt Traumatic Intracranial Hemorrhages. The American surgeon. 2018 Jun 1     [PubMed]
Daher P,Teixeira PG,Coopwood TB,Brown LH,Ali S,Aydelotte JD,Ford BJ,Hensely AS,Brown CV, Mild to Moderate to Severe: What Drives the Severity of ARDS in Trauma Patients? The American surgeon. 2018 Jun 1     [PubMed]
Harvell BJ,Helmer SD,Ward JG,Ablah E,Grundmeyer R,Haan JM, Head CT Guidelines Following Concussion among the Youngest Trauma Patients: Can We Limit Radiation Exposure Following Traumatic Brain Injury? Kansas journal of medicine. 2018 May     [PubMed]
Abolfotouh MA,Hussein MA,Abolfotouh SM,Al-Marzoug A,Al-Teriqi S,Al-Suwailem A,Hijazi RA, Patterns of injuries and predictors of inhospital mortality in trauma patients in Saudi Arabia. Open access emergency medicine : OAEM. 2018     [PubMed]
Joyce T,Huecker MR, Pediatric Abusive Head Trauma (Shaken Baby Syndrome) null. 2018 Jan     [PubMed]
Thierauf-Emberger A,Lickert A,Pollak S, A moving human body causes fatal blunt trauma: an unusual traffic accident. International journal of legal medicine. 2018 Jun 6     [PubMed]
George E,Khandelwal A,Potter C,Sodickson A,Mukundan S,Nunez D,Khurana B, Blunt traumatic vascular injuries of the head and neck in the ED. Emergency radiology. 2018 Aug 10     [PubMed]
Joachim M,Tuizer M,Araidy S,Abu El-Naaj I, Pediatric maxillofacial trauma: Epidemiologic study between the years 2012 and 2015 in an Israeli medical center. Dental traumatology : official publication of International Association for Dental Traumatology. 2018 Apr 27     [PubMed]
Leetch AN,Wilson B, Pediatric Major Head Injury: Not a Minor Problem. Emergency medicine clinics of North America. 2018 May     [PubMed]
Essien EO,Fioretti K,Scalea TM,Stein DM, Physiologic Features of Brain Death. The American surgeon. 2017 Aug 1     [PubMed]
Masterson Creber RM,Dayan PS,Kuppermann N,Ballard DW,Tzimenatos L,Alessandrini E,Mistry RD,Hoffman J,Vinson DR,Bakken S, Applying the RE-AIM Framework for the Evaluation of a Clinical Decision Support Tool for Pediatric Head Trauma: A Mixed-Methods Study. Applied clinical informatics. 2018 Jul     [PubMed]
McGrew PR,Chestovich PJ,Fisher JD,Kuhls DA,Fraser DR,Patel PP,Katona CW,Saquib S,Fildes JJ, Implementation of a CT scan practice guideline for pediatric trauma patients reduces unnecessary scans without impacting outcomes. The journal of trauma and acute care surgery. 2018 Sep     [PubMed]
Bukur M,Teurel C,Catino J,Kurek S, The Price of Always Saying Yes: A Cost Analysis of Secondary Overtriage to an Urban Level I Trauma Center. The American surgeon. 2018 Aug 1     [PubMed]
Rybkin I,Kim M,Amin A,Tobias M, Development of Delayed Posttraumatic Acute Subdural Hematoma. World neurosurgery. 2018 Sep     [PubMed]
McLoughlin RJ,Green J,Nazarey PP,Hirsh MP,Cleary M,Aidlen JT, The risk of snow sport injury in pediatric patients. The American journal of emergency medicine. 2018 Jun 2     [PubMed]
Khor D,Wu J,Hong Q,Benjamin E,Xiao S,Inaba K,Demetriades D, Early Seizure Prophylaxis in Traumatic Brain Injuries Revisited: A Prospective Observational Study. World journal of surgery. 2018 Jun     [PubMed]
Watanabe T,Kawai Y,Iwamura A,Maegawa N,Fukushima H,Okuchi K, Outcomes after Traumatic Brain Injury with Concomitant Severe Extracranial Injuries. Neurologia medico-chirurgica. 2018 Sep 15     [PubMed]
Aiolfi A,Khor D,Cho J,Benjamin E,Inaba K,Demetriades D, Intracranial pressure monitoring in severe blunt head trauma: does the type of monitoring device matter? Journal of neurosurgery. 2018 Mar     [PubMed]

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