Ayder Comprehensive Specialized Hospital/Mekelle University Head Injury Guidelines

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Early Management of Patients with a Head Injury Protocol for Ayder Hospital Surgical Service Mekelle University College of Health Sciences Professor Tony Magana September 2015

Adults Initial assessment The management of patients with a head injury should be guided by clinical assessments and protocols based on the Glasgow Coma Scale and Glasgow Coma Scale Score.

Adult Glasgow Coma Scale and Scoring

Early Management of Head Injury Protocol at Ayder Hospital September 2015

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Indications for referral to hospital Adult patients with any of the following signs and symptoms should be referred to an appropriate hospital for further assessment of potential brain injury:  GCS<15 at initial assessment (if this is thought to be alcohol related observe for two hours and refer if GCS score remains<15 after this time)  post-traumatic seizure (generalised or focal)  focal neurological signs  signs of a skull fracture (including cerebrospinal fluid from nose or ears, haemotympanum, boggy haematoma, post auricular or periorbital bruising)  loss of consciousness  severe and persistent headache  repeated vomiting (two or more occasions)  post-traumatic amnesia >5 minutes  retrograde amnesia >30 minutes  high risk mechanism of injury (road traffic accident, significant fall)  coagulopathy, whether drug-induced or otherwise.

Indications for head CT scan Immediate CT scanning should be done in an adult patient who has any of the following features:  eye opening only to pain or not conversing (GCS 12/15 or less)  confusion or drowsiness (GCS 13/15 or 14/15) followed by failure to improve within at most one hour of clinical observation or within two hours of injury (whether or not intoxication from drugs or alcohol is a possible contributory factor)  base of skull or depressed skull fracture and/or suspected penetrating injuries  a deteriorating level of consciousness or new focal neurological signs  full consciousness (GCS 15/15) with no fracture but other features, eg -- severe and persistent headache -- two distinct episodes of vomiting  a history of coagulopathy (eg warfarin use) and loss of consciousness, amnesia or any neurological feature.

CT scanning should be performed within eight hours in an adult patient who is otherwise well but has any of the following features:  age>65 (with loss of consciousness or amnesia)  clinical evidence of a skull fracture (eg boggy scalp haematoma) but no clinical features indicative of an immediate CT scan  any seizure activity  significant retrograde amnesia (>30 minutes)  dangerous mechanism of injury (pedestrian struck by motor vehicle, occupant ejected from motor vehicle, significant fall from height) or significant assault (eg blunt trauma with a weapon).

In adult patients who are GCS<15 with indications for a CT head scan, scanning should Early Management of Head Injury Protocol at Ayder Hospital September 2015

3 include the cervical spine.

Indications for admission to hospital An adult patient should be admitted to hospital if:  the level of consciousness is impaired (GCS<15/15)  the patient is fully conscious (GCS 15/15) but has any indication for a CT scan (if the scan is normal and there are no other reasons for admission, then the patient may be considered for discharge)  the patient has significant medical problems, eg anticoagulant use  the patient has social problems or cannot be supervised by a responsible adult.

Referral to neurosurgical unit A patient with a head injury should be discussed with a neurosurgeon:  when a CT scan in a general hospital shows a recent intracranial lesion  when a patient fulfils the criteria for CT scanning but facilities are unavailable  when the patient has clinical features that suggest that specialist neuroscience assessment, monitoring, or management are appropriate, irrespective of the result of any CT scan.  All salvageable patients with severe head injury (GCS score 8/15 or less) should be transferred to, and treated in, a setting with 24-hour neurological ICU facility.

Early Management of Head Injury Protocol at Ayder Hospital September 2015

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Children Initial assessment Great care should be taken when interpreting the Glasgow Coma Scale in the under fives and this should be done by those with experience in the management of the young child.

Pediatric Glasgow Coma Scale and Scoring (for use in patients under five years of age)

Indications for referral to hospital In addition to the indications for referral of adults to hospital, children who have sustained a head injury should be referred to hospital if any of the following risk factors apply:  clinical suspicion of non-accidental injury  significant medical comorbidity (eg learning difficulties, autism, metabolic disorders)  difficulty making a full assessment  not accompanied by a responsible adult  social circumstances considered unsuitable.

Indications for head CT scan Immediate CT scanning should be done in a child (<16 years) who has any of the following features: Early Management of Head Injury Protocol at Ayder Hospital September 2015

5     

GCS≤13 on assessment in emergency department witnessed loss of consciousness >5 minutes suspicion of open or depressed skull injury or tense fontanelle focal neurological deficit any sign of basal skull fracture.

CT scanning should be considered within eight hours if any of the following features are present (excluding indications for an immediate scan):  presence of any bruise/swelling/laceration >5 cm on the head  post-traumatic seizure, but no history of epilepsy nor history suggestive of reflex anoxic seizure  amnesia (anterograde or retrograde) lasting >5 minutes  clinical suspicion of non-accidental head injury  a significant fall  age under one year: GCS<15 in emergency department assessed by personnel experienced in paediatric GCS monitoring  three or more discrete episodes of vomiting  abnormal drowsiness (slowness to respond).

If a child meets head injury criteria for admission and was involved in a high speed road traffic accident, scanning should be done immediately Indications for admission to hospital Children who have sustained a head injury should be admitted to hospital if any of the following risk factors apply:  any indication for a CT scan  suspicion of non-accidental injury  significant medical comorbidity  difficulty making a full assessment  child not accompanied by a responsible adult  social circumstances considered unsuitable.

Referral to neurosurgical unit  A patient with a head injury should be discussed with a neurosurgeon: --when a CT scan in a general hospital shows a recent intracranial lesion ---when a patient fulfils the criteria for CT scanning but facilities are unavailable  when the patient has clinical features that suggest that specialist neuroscience assessment, monitoring, or management are appropriate, irrespective of the result of any CT scan.  All salvageable patients with severe head injury (GCS score 8/15 or less) should be transferred to, and treated in, a setting with 24-hour neurological ICU facility.

Early Management of Head Injury Protocol at Ayder Hospital September 2015

6 Inhospital Care All medical and nursing staff involved in the care of patients with a head injury should be trained and competent in the use and recording of the Glasgow Coma Scale.

The GCS should not be used in isolation and other parameters should be considered along with it, such as:  pupil size and reactivity  limb movements  respiratory rate and oxygen saturation  heart rate  blood pressure  temperature  unusual behaviour or temperament or speech impairment.

Family members and friends should be used as a source of information.

Observations should be recorded on a chart Children <3 years old who have sustained a head injury are particularly difficult to evaluate and clinicians should have a low threshold of suspicion for early consultation with a specialist paediatric unit.

Children who are admitted should be under the care of a multidisciplinary team that includes a paediatric trained doctor experienced in the care of children with a head injury.

Children should be observed on a children’s ward.

The risk of rapid deterioration is greatest in the first six hours after injury and then decreases. If the patient is admitted on the first day of the injury then repeat evaluation every few hours is indicated if high risk factors such as high energy injury, glasgow coma scale < 15, or focal neurological deficit is present.

Medical staff should assess the patient on admission to the ward and should re-assess the patient at least once within the next 24 hours. Assessment should include examination for the GCS, neck movement, limb power, pupil reactions, all cranial nerves and signs of basal skull fracture.

Any of the following examples of neurological deterioration should prompt urgent re-appraisal by a doctor:  the development of agitation or abnormal behaviour  a sustained decrease in conscious level of at least one point in the motor or verbal response or two points in the eye opening response of the GCS score  the development of severe or increasing headache or persisting vomiting  new or evolving neurological symptoms or signs, such as pupil inequality or asymmetry of limb or facial movement.

Early Management of Head Injury Protocol at Ayder Hospital September 2015

7 If re-assessment confirms a neurological deterioration, many factors need to be evaluated but the first step is to ensure the airway is clear, and that oxygenation and circulation are adequate.

Clinical signs of shock in a patient with a head injury should be assumed, until proven otherwise, to be due to hypovolaemia caused by associated injuries.

Whilst an intoxicating agent may confuse the clinical picture, the assumption that deterioration or failure to improve is due to drugs or alcohol must be resisted.

If systemic causes of deterioration such as hypoxia, fluid and electrolyte imbalance, or hypoglycaemia can be excluded, then resuscitation should continue according to accepted trauma protocols.

After traumatic brain injury, agitation may be a sign of neurological deterioration, hypoxia, electrolyte disturbance, drug/alcohol withdrawal, or seizures. Medical evaluation should be done in conjunction with pharmacological therapy for behavior.

Therapeutic Goals and Interventions Systolic BP < 90 mm Hg and O2 Saturation < 90% should be avoided.

Mannitol Mannitol in doses of 0.25mg/kg to 1.0mg/kg may reduce ICP. It is most useful as a temporizing measure such as to treat a patient suspected of having a mass lesion which may be surgical while preparing that patient for surgery. It is most effective in bolus doses rather constant infusion which may be repeated every 6 hours. Most of the world wide experience deals with controlling intracranial pressure which is being monitored. It should not be a part of routine head injury management. Side effects of hypotension, increases in size of intraparenchymal brain hemorrhage, and kidney dysfunction may occur.

The use of mannitol for head injury treatment in developing countries without ICP monitoring has not been well studied.

Indications:  Salvageable Head Injury with GCS 8 or less. To be given initially for three days at .25mg/kg IV q6 hours. If neurological deterioration may increase to .5mg/kg and then 1.0mg/kg.  Deterioration from GCS > 8 to less for three days as above  Pre-operative .25mg/kg dose for suspected or known mass lesion. May be repeated intraoperatively.  Post-operative management of cerebral edema Enteral feeding should be begun by 72 hours after injury. Hyperglycemia should be avoided as increased intracellular lactic acidosis can worsen brain injury.

Seizures and Seizure Prophylaxis Early Management of Head Injury Protocol at Ayder Hospital September 2015

8 Prophylactic anticonvulsants does not reduce late seizure development or improve outcomes.

Anticonvulsant treatment indications: ď&#x201A;ˇ Phenytoin use according to body mass and age for a seizure in the first few days and continued for one week. Closed head injuries without seizure do not require anticonvulsant prophylaxis. ď&#x201A;ˇ Craniotomy for intraparenchymal lesion (evacuation of hemorrhagic contusion or lobectomy) Infection Prophylaxis Routine single dose of Ceftriaxzone 1 gm IV on call for adults and 50mg/Kg in children for closed head injuries requiring surgery.

Single dose of periprocedural antibiotics for intubation only unless the patient has signs of aspiration pneumonia already present.

DVT Prohylaxis Low molecular weight heparin is contraindicated in the presence of acute head injury. Graduated stockings or pneumatic compression stockings if available are appropriate.

Hyperventilation Profound hypercarbia may increase ICP and profound hypocarbia may decrease cerebral perfusion.

Hyperventilation is to be avoided in the first 24 hours after injury. Temporary mild hyperventilation pre-operatively or intra-operatively may be used.

Steroids There is no sound scientific evidence supporting the use of steroids for head injury.

Barbituates Under special circumstances such as post-operative swelling or diffuse cerebral swelling in a viable patients in consultation with neurosurgical staff pentobarbital at 3mg/kg/ hour may be given for up to three days to attempt to control brain swelling.

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Surgical Management Guidelines Epidural hematoma  An epidural hematoma greater than 30 cm squared should be evacuated regardless of GCS score  An epidrual hematoma less than 30 cm squared, midline shift less than 5mm, and thickness less than 15 mm in a patient without neurological deficit can usually be considered for nonsurgical treatment  Acute epidural hematoma is best treated by craniotomy rather then burr holes. Tacking up of the dura to prevent rebleeding should be done.

Acute Subdural Hematoma  An acute subdural hematoma with a thickness greater than 10 mm or midline shift greater than 5 mm should be evacuated regardless of GCS score  Patients who have a large parenchymal contusion and acute subdural less than 10mm with an admission GCS< 9 and then subsequent deterioration may be a candidate for surgery.  In severe cases of brain swelling. Bone flap removal and duraplasty may be necessary.

Surgery for Traumatic Intraparenchymal Lesions  Surgery for resection of intraparenchymal lesions is not within the normal procedure guidelines for general surgery.  Patients with focal intraparenchymal lesions who present with a GCS of 8 will be initially placed on medical management protocols.  Patients with a GCS of 8 who deteriorate despite medical management will be discussed with the neurosurgical staff as regards to management Chronic Subdural Hematoma  A totally asymptomatic patient with evidence of a chronic subdural hematoma may be conservatively followed  A symptomatic patienet with chronic subdural hematoma should undergo timely operation  The best outcome in chronic subdural hematoma was found in a prospective study utilizing the two burr hole technique with subdural drain placement. At Ayder an initial burr hole will placed frontally or parietally depending upon where the greatest thickness of the hematoma is found. If after irrigation of the subdural space the brain does not expand to the dura then a second burr hole will be placed. If the clot is gelatinous then the burr holes will be converted to a craniotomy. A pediatric feeding tube will always be place in the subdural space at least one centimeter beyond the proximal last side hole and exited through a separate stab wound.  The subdural drain may be removed when the old blood drainage converts to CSF. The drain should be removed by the morning of the third day after surgery.  After surgery while the subdural drain is in place the patient's head should be kept flat to maximize brain re-expansion which will push out the remaining subdural hematoma  If patient deteriorates following surgery after initial improvement or fails to improve then consideration for a repeat CT scan should be done.

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Closed Depressed Skull Fracture  Patients with a closed depressed fracture with a depression less than 1 cm and no neurological findings or associated hematoma requiring surgery are potential candidates for conservative treatment  A closed depressed fracture with a depression 1 cm or greater and/or neurological deficit should under timely surgical intervention.  Patients with simple depressed fractures without dural tear require only routine pre-operative antibiotic prophylaxis and no anticonvulsant prophlaxis.

Open Depressed Skull Fracture  Patients with an open depressed fracture greater than the depth of the calvarium should undergo surgery.  Operation should be done within the first 48 hours after injury to reduce the risk of infection.  The bone flap or fragments should be cleaned with betadiene and saline thoroughly before replacement  A water tight closure of the dura should be attempted..  Debridement of nonviable and contaminated brain should be done.  A seven day course of intravenous Ceftriaxzone and Metronidazole should be given for cases where there is only minimal contamination and surgery is performed within 48 hours after injury.  An 18 day course of intravenous Ceftriaxzone and Metronidazole should be given for cases where there is gross contamination or penetration of the brain and/or there is a delay of more than 48 hours.  Anticonvulsant prophlaxis should be given to all patients with dural laceration and open brain injury.

Useful References 1. Guidelines for the Management of Severe Traumatic Brain Injury, 3rd Edition. Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons. Journal of Neurotrauma. Volume 24. Supplement 1.2007 2. Surgical Management of Traumatic Brain Injury Group. Neurosurgery. Volume 58. No. 3.

Supplement S2. March 2006 3. Guidelines for Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents-2nd Edition. Pediatric Critical Care Medicine. Volume 13. No. 1.

Supplement 1. 2012 4. Early Management of Patients with a Head Injury. Scottish Intercollegiate Guidelines Network.May 2009. Online at NHS Quality Improvement Scotland. .

Early Management of Head Injury Protocol at Ayder Hospital September 2015