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Assessment, Management and

Decision Making in the


Treatment of Polytrauma Patients
with Head Injuries
Roman A. Hayda, MD
Created March 2004; Revised July 2006

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

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

Evaluation
ATLSABCs
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*

ModifiersxT 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

Frontal
Contusion

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
setting wastes time

but in the trauma

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
normal CT and at least two of the following
age over 40
uni- or bilateral flexor or extensor posturing
history of systolic BP < 90 mm Hg

when unable to follow serial neurologic exams


i.e. for operative or lengthy diagnostic procedures

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= 352 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

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

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

Advances in Care of Head Injured


ICP monitoring
Evolution of anesthetic agents
Improvement in neuroanesthetic techniques
Allow for safer surgery in the head injured

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 is not
significantly affected

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
Avoid periarticular procedures
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%

Demetraiades, <9
J Trauma, 0010.2%

Evaluation more difficult


Optimal protocol for evaluation and management
controversial

C Spine Injury
Minimum requirement
Cervical collar
Plain films (3 views)
CT entire C spine

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
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