Management of head trauma, evidence based strategies.
Luc van den Hauwe
Epidemiology:
10 million globally
1,7 million USA
75-85% mild trauma according to GCS
Goal is to stop secondary damage: Swelling, edema, herniations, vascular complications, brainstem injury
Detect injuries that require immediate treatment
Detect injuries thar benefit from early treatment
Determine prognosis
- Clinical prediction rules in radiology:
Predict diagnosis/prognosis from:
Patient history
Clinical examination
Lab findings
These rules need to be tested on a large population and validated in other centres.
"Evaluating treatment options is complicated because of mixed injuries"
GCS
Eyes 1-4: 1=no response, 2=open in response to pain, 3= open in response to speach, 4= spontaneous
Motor 1-6: 1=no response, 2= extention in response to pain, 3= abnormal flexion, 4= flexion/withdrawal, 5= locates, 6= obeyes commands
Verbal 1-5: 1= no response, 2= incomprehensible sound, 3=inapropriate, 4=disoriented, 5= normal conversation
Trauma severity by GCS score: <9 severe, 9-12 moderate, 13-15 minor (6-10% findings on CT), 15 minimal
Marshall scale:
Diffuse 1: no visible
Diffuse 2: shift<5mm, no lesion >25cm3
Diffuse 3: compressed cisterns + 2
Diffuse 4: shift >5mm, no lesion >25cm3
non-evacuated lesion
evacuated lesion (>25cm3)
modified marshall scale, bla med antal och typ av lesion: http://www.rescueicp.com/marshall.htmlmodified marshall
Classification of trauma by:
Mechanism
Clinical severity: injury severity score, GCS score -- made harder by early sedation shifting classifcation towards structural classification.
Structural damage: Marshall scale, rotterdam scale
Prognosis scales: CRASH, IMPACT
Developing methods: MRI DWI, SWI, FMRI, DTI
Moderate and severe (by GCS) cause 52,000 deaths and 80,000 disabilities in USA.
Canadian head rules 37% minskad bildtagnning och 98.4% sensivitivity (extern validering)
CHIP (Både med och utan LOC(loss of consiousness))
New Orleans Criteria