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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, 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
2nd
1st hit
hit 1st hit: Head 2nd hit: Head
• mechanical • release of
insult to brain inflammatory
tissue mediators
• blunt or •Hypoxia
penetrating •Acidosis
•Coagulopathy
1st hit: body
• mechanical 2nd hit: body
insult • systemic
•chest, inflammation
abdomen • SURGERY
•extremities
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 4
–To speech 3
–To pain 2
–None 1
Glasgow Coma Scale
• Motor response
–Obeys commands 6
–Purposeful response to pain 5
–Withdrawal to pain 4
–Flexion response to pain 3
–Extension response to pain 2
–None 1
Glasgow Coma Scale
• Verbal response
–Oriented 5
–Confused 4
–Inappropriate 3
–Incomprehensible 2
–None 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
Frontal

• CT scan
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
but in the trauma setting wastes time
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 Severe Moderate Good


vegetative disability disability recovery
Mild (GCS 13-15) 8% 20% 28% 45%
Mod (GCS 9-12) 16% 22% 24% 38%
Severe (GCS <9) 38% 29% 19% 14%
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 – elevated ICP
– blood loss/coagulopathy
– hypoxia
• 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 use
• hypoxia appropriate
monitors
• elevated ICP
– 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
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