Page 831 - TNFlipTest

Toronto Notes 2019
Neurotrauma
Neurosurgery NS33
• fluidandelectrolyteimbalance
■ iatrogenic (most common)
■ SIADHcausedbyheadinjury
■ diabetes insipidus (DI)
■ may lead to cerebral edema and raised ICP
• coagulopathy
Intracranial Conditions
• raisedICPduetotraumaticcerebraledemaORtraumaticintracranialhemorrhage
Brain Injury Outcomes
• mildlytraumatic(GCS13-15):post-concussivesymptoms:H/A,fatigue,dizziness,nausea,blurred vision, diplopia, memory impairment, tinnitus, irritability, low concentration; 50% at 6 wk, 14% at 1 yr
• moderatelytraumatic(GCS9-12):proportionaltoage(>40)andCTfindings;60%good recovery, 26% moderately disabled, 7% severely disabled, 7% vegetative/dead
• severe (GCS ≤8): difficult to predict, correlates with post-resuscitation GCS (especially motor) and age
Late Complications of Head/Brain Injury
• seizures:5%ofheadinjurypatientsdevelopseizures
■ incidence related to severity and location of injury (increased with local brain damage or intracranial
hemorrhage)
■ post-traumatic seizure may be immediate, early, or late
■ presence of early (within first wk) post-traumatic seizure raises incidence of late seizures
• meningitis:associatedwithCSFleakfromnoseorear
• hydrocephalus:acutehydrocephalusordelayednormalpressurehydrocephalus(NPH)
• Post-ConcussionSyndrome:headache,dizziness,cognitivechanges,psychologicalandbehavioural
symptoms
Spinal Cord Injury
• seeOrthopedics,OR23andEmergencyMedicine,ER9
NEUROGENIC AND SPINAL SHOCK
1. neurogenic shock: hypotension that follows spinal cord injury (sBP usually ≤80 mmHg) caused by
■ interruption of sympathetics (unopposed parasympathetics) below the level of injury
■ loss of muscle tone due to skeletal muscle paralysis below level of injury → venous pooling (relative
hypovolemia)
■ blood loss from associated wounds (true hypovolemia)
2. spinal shock: transient loss of all neurologic function below the level of the spinal cord injury, causing flaccid paralysis and areflexia for variable periods
Whiplash-Associated Disorders
• definition:traumaticinjurytothesofttissuestructuresintheregionofthecervicalspinedueto hyperflexion, hyperextension, or rotational injury to the neck
Initial Management of Spinal Cord Injury
• majorcausesofdeathinspinalcordinjuryareaspirationandshock
• thefollowingpatientsshouldbetreatedashavingaspinalcordinjuryuntilprovenotherwise:
■ all victims of significant trauma
■ minor trauma patients with decreased LOC or complaints of neck or back pain, weakness,
abdominal breathing, numbness/tingling, or priapism
Stabilization and Initial Evaluation in the Hospital
1. ABCs, immobilization (backboard/head strap), oxygenation, Foley catheter to urometer, temperature regulation
2. hypotension: maintain sBP >90 mmHg with pressors (dopamine), hydration, and atropine ■ DVTprophylaxis
3. monitor CBC/electrolytes
4. focused history (see Trauma Assessment, NS30)
5. spine palpation: point tenderness or deformity
6. motor level assessment (including rectal exam for voluntary anal sphincter contraction)
7. sensory level assessment: pinprick, light touch, and proprioception
8. evaluation of reflexes
9. signs of autonomic dysfunction: altered level of perspiration, bowel or bladder incontinence, priapism 10. radiographic evaluation
■ 3 views C-spine x-rays (AP, lateral, and odontoid) to adequately visualize C1 to C7-T1 junction
■ flexion-extension views to disclose occult instability
■ CT scan (bony injuries) typically most trauma centres use CT as the modality of choice for looking at
fractures, very sensitive with the high resolution scanners
■ MRI mandatory if neurological deficits (soft tissue injuries)
A Trial of Intracranial-Pressure Monitoring in Traumatic Brain Injury
NEJM2012;367:2471-2481
Background: ICP monitoring is frequently used to monitor severe traumatic brain injury, but controversy exists over whether it is beneficial.
Methods: Study sample (n=324 patients, ≥13 yr) consisted of those who had severe traumatic brain injury and were being treated in ICU in Bolivia or Ecuador. Patients were randomly assigned to one management group:
1. ICP-monitoring based management.
2. Management based on imaging and clinical examination. Primary outcome was a composite of survival time, impaired consciousness, functional status (at 3, 6 mo), and neuropsychological status (at 6 mo).
Results: No significant difference between management groups based on primary outcome, 6-mo mortality, median length of ICU stay, or occurrence of serious adverse events. However, duration of brain-specific treatments (e.g. use of hyperosmolar fluids or hyperventilation) higher in the imaging-clinical examination group (4.8 d vs. 3.4
d, p=0.002).
Conclusion: Maintaining monitored ICP at 20 mmHg or less is not superior to care based on imaging and clinical examination.
Resolution of spinal shock is indicated by the return of reflexes (most commonly the bulbocavernous reflex)
Pharmacological Therapy for Acute Spinal Cord Injury: Congress of Neurological Surgeons (CNS) and American Association of Neurological Surgeons (AANS) Guidelines
Neurosurgery 2013;72(Suppl 2):93-105
Level I Recommendations
• NoClassIorClassIImedicalevidencesupports the use of methylprednisone in the treatment of acute SCI. Several Class II and Class III studies have been published stating inconsistent effects of methylprednisone likely related to random chance or selection bias.
• AdministrationofGM-1ganglioside(Sygen)for the treatment of acute SCI is not recommended.
Early vs. Delayed Decompression for Traumatic Cervical Spinal Cord Injury: Results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS)
PLoS ONE 2012;7:e32037. doi:10.1371/journal. pone.0032037
Introduction: This study sought to determine the relative effectiveness of early (<24 h after injury) versus late (≥24 h after injury) decompressive surgery following a traumatic cervical spinal cord injury (SCI).
Methods/Population: A prospective cohort study completed in 2002-2009 involving 6 North American institutions. Participants were 16-80 yr with a cervical SCI. Outcomes evaluated were changes
in American Spinal Injury Association Impairment Scale (AIS) grade at 6 mo follow-up, complications, and mortality.
Results: Of 313 participants enrolled, 182 underwent early surgery and 131 underwent late surgery. 222 participants were available for follow-up at 6 mo. The odds of at least 2 grade AIS improvement were greater for those who had early surgery compared to those with late surgery (OR = 2.83, 95% CI 1.10, 7.28). Mortality was observed for each group during the first 30 d post injury. No statistically significant differences were observed for complications (p=0.21).
Conclusion: Early decompression surgery following a SCI is safe and associated with higher AIS improvement at 6 mo following injury.