HEAD TRAUMA GUIDLINES-NEW

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Information about HEAD TRAUMA GUIDLINES-NEW
Science-Technology

Published on January 12, 2009

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HEAD TRAUMA GUIDLINES : HEAD TRAUMA GUIDLINES FARID ATAEI,MD OCTOBER 2007 DEFINITION: : DEFINITION: Head trauma,Head injury,Brain injury,… Traumatic brain injury: An injury to the brain resulting in disorders of motor, sensory and/or cognitive function. Definition varies according to the approach Slide 3: Considerations during writing or reviewing the Guidelines: What Who Whom Where When Why Slide 4: • World Health Organization Guidline • CG4 Head injury: NICE guideline • CG4 Head injury: Full guideline • CG4 Head injury: Clinical practice algorithm no. 1 • CG4 Head injury: Clinical practice algorithm no. 2 • CG4 Head injury: Clinical practice algorithm no. 3 • CG4 Head injury: Clinical practice algorithm no. 4 • CG4 Head injury: Form - Discharge advice • CG4 Head injury: Form - Adult neurological observation proforma • CG4 Head injury: Form - Paediatric neurological observation proforma • CG4 Head injury: Form - Neurosurgical referral letter Slide 5: MATRAC MEMBER HOSPITALS Angel Medical Center, Franklin, NC Cherokee Tribal Hospital, Cherokee, NC District Memorial Hospital, Andrews, NC Grace Hospital, Morganton, NC Harris Regional Hospital (Westcare Health System), Sylva, NC Haywood Regional Medical Center, Clyde, NC Highland Cashiers Hospital, Highlands, NC McDowell Hospital, Marion, NC Mission Hospitals, Asheville, NC Murphy Medical Center, Murphy, NC Margaret R. Pardee Memorial Hospital, Hendersonville, NC Park Ridge Hospital, Fletcher, NC Rutherford Hospital, Rutherfordton, NC St. Luke’s Hospital, Columbus, NC Spruce Pine Community Hospital, Spruce Pine, NC Swain County Hospital (Westcare Health System), Bryson City, NC Transylvania Community Hospital, Brevard, NC Stakeholders : Stakeholders 5 Boroughs Partnership NHS Trust • Addenbrookes Hospital, Cambridge University Hospital NHS Trust • Addenbrooke's NHS Trust • Adults Strategy and Commissioning Unit • Aintree Hospitals NHS Trust • Association for Spina Bifida & Hydrocephalus (ASBAH) • Association of British Neurologists • Association of Educational Psychologists • Association of the British Pharmaceuticals Industry,(ABPI) • Barnsley Hospital NHS Foundation Trust • Barnsley PCT • Biophausia AB • Birmingham & the Black Country Critical Care Network • Birmingham Children's Hospital • Bradford & Airedale PCT • British and Irish Orthoptic Society • British Association for Counselling and Psychotherapy (BACP) Slide 7: British Association of Neuroscience Nurses • British Dietetic Association • British National Formulary (BNF) • British Paediatric Mental Health Group of the Royal College of Paediatrics and Child Health • British Paediatric Neurology Association • British Paramedic Association • British Psychological Society, The • British Society of Interventional Radiology • British Society of Neuroradiologists • British Society of Rehabilitation Medicine • Calderdale and Huddersfield Acute Trust • Calderdale PCT • Central Medical Supplies Ltd • Chartered Society of Physiotherapy (CS Slide 8: Childrens Acute Transport Service • Clinical Effectiveness Committee • Clinovia Ltd • College of Emergency Medicine • College of Occupational Therapists • Commission for Social Care Inspection • Community Practitioners and Health Visitors Association • Connecting for Health • Conwy & Denbighshire Acute Trust • Cornwall Acute Trust • Cyrenians • Department of Health • Department of Health, Social Security and Public Safety of Northern Ireland • Derbyshire Mental Health Services NHS Trust • Derbyshire Mental Health Trust • Dudley Group of Hospitals NHS Trust And……… WHO Guidelines for essential trauma care : WHO Guidelines for essential trauma care Basic facilities (outpatient clinics and/or non-medical providers) : Basic facilities (outpatient clinics and/or non-medical providers) This includes the primary health care (PHC) clinics . These are almost exclusively staffed by non-doctor providers, such as village health workers, nurses and medical assistants. This category also includes outpatient clinics run by doctors, whether in urban or rural settings. In many cases, such facilities represent the first access for injured patients to the health care system. This is especially true in low-income countries where there are no formal emergency medical services (EMS). These guidelines apply to these fixed facilities and not to mobile EMS. The latter will be addressed in a WHO publication which is currently in preparation. Hospitals staffed by general practitioners : Hospitals staffed by general practitioners This includes hospitals without full-time specialist doctors, particularly those without a fully trained general surgeon. Such hospitals may or may not have operating theatre capabilities. These facilities are usually referred to as district hospitals in Africa and primary health centers in India. In some areas, particularly in East Africa, certain medical assistants have been highly trained to act in the capacity of general practitioners, even performing Operations such as Caesarean section. The facilities in which they work are more likely to fall into this category, rather than the basic designation above. Hospitals staffed by specialists : Hospitals staffed by specialists This includes hospitals whose personnel includes at least a general surgeon. Staff at such facilities may also include orthopedic surgeons and members of other subspecialties (i.e. specialists with responsibility for more narrowly defined fields within each specialty). Such facilities have operating theatres. These facilities are usually referred to as regional hospitals in Africa, community health centers or district hospitals in India, or general hospitals in Latin America. Tertiary care hospitals : Tertiary care hospitals This includes hospitals with a broad range of subspecialties. Such facilities are usually, but not exclusively, teaching or university hospitals. They usually represent the highest level of care in a country or large political division within a country. There are notable differences in the capabilities of tertiary care hospitals worldwide. In some countries, surgical staff may be quite extensive in their range of subspecialties, and in others, more limited Resource matrix: designation of priorities : Resource matrix: designation of priorities Slide 16: “Essential” (E) resources “Desirable” (D) resources “Possibly required” (PR) resources “Irrelevant” (I) resources “Essential” (E) resources : “Essential” (E) resources The designated item should be assured at the stated level of the health care system in all cases. As this Essential Trauma Care Project covers the spectrum of facilities across the world, the E designation represents the “least common denominator” of trauma care common to all regions, including even those where access to resources is most severely restricted. It is felt that these services could and should be provided to injured patients at the level of health facility concerned “Desirable” (D) resources : “Desirable” (D) resources The designated item represents a capability that increases the probability of a successful outcome of trauma care. It also adds cost. Such items are not likely to be cost-effective for all facilities of a given level in environments with the poorest access to resources. Hence, they are not listed as essential. However, for countries with greater resource availability, such items may ultimately be designated essential in their own national plans. “Possibly required” (PR) resources : “Possibly required” (PR) resources In environments with poorer access to resources, some trauma treatment capabilities might need to be shifted to lower levels of the health care system in order to increase their availability. Such services usually represent only minimal increased cost, relative to the provision of such services only at higher levels of the health care system. Shifting to a lower level in the health care system would usually imply that a provider with less advanced trauma-related training and skills would be performing procedures that might otherwise be performed by more highly trained personnel. Hence, it is to be emphasized that the “PR” designation is different from the “desirable” designation. PR represents a potential necessity to increase availability of trauma care services in environments with poorer access to resources. It is anticipated that the PR designation will apply primarily to low income countries, but not to middle-income. “Irrelevant” (I) resources : “Irrelevant” (I) resources This implies that one would not ordinarily expect this capability at the given level of the health care system, even with full availability of resources. Resource matrix: designation of priorities : Resource matrix: designation of priorities Slide 23: MATRAC MEMBER HOSPITALS Angel Medical Center, Franklin, NC Cherokee Tribal Hospital, Cherokee, NC District Memorial Hospital, Andrews, NC Grace Hospital, Morganton, NC Harris Regional Hospital (Westcare Health System), Sylva, NC Haywood Regional Medical Center, Clyde, NC Highland Cashiers Hospital, Highlands, NC McDowell Hospital, Marion, NC Mission Hospitals, Asheville, NC Murphy Medical Center, Murphy, NC Margaret R. Pardee Memorial Hospital, Hendersonville, NC Park Ridge Hospital, Fletcher, NC Rutherford Hospital, Rutherfordton, NC St. Luke’s Hospital, Columbus, NC Spruce Pine Community Hospital, Spruce Pine, NC Swain County Hospital (Westcare Health System), Bryson City, NC Transylvania Community Hospital, Brevard, NC TRAUMA SURGERY SERVICEMISSION HOSPITALSDESIGNATED LEVEL II TRAUMA CENTER : TRAUMA SURGERY SERVICEMISSION HOSPITALSDESIGNATED LEVEL II TRAUMA CENTER Consider Immediate Trauma Center Diversion/Transfer if: Head injury with depressed or deteriorating GCS, lateralizing signs, penetrating injury. Not to wait for your turn Trauma Surgeon Emergency Medicine Physician Nursing, Radiology Laboratory, Respiratory therapy, Security, Clergy. General consideration and approach to Trauma MANAGEMENT OF TRAUMATIC BRAIN INJURY : MANAGEMENT OF TRAUMATIC BRAIN INJURY DEFINITION: Traumatic brain injury: An injury to the brain resulting in disorders of motor, sensory and/or cognitive function. GUIDELINES: 1. Perform primary survey according to ATLS guidelines: a. Provide urgent airway for GCS =8. Hypoxia is devastating to the injured brain. i. If sedatives and paralytics are to be used, conduct a rapid but thorough neurological exam, including: a) Level of consciousness. b) Ability to verbalize. c) Ability to open eyes. d) Ability to move all extremities to verbal command or pain. e) Presence of abnormal posturing. f) Presence of abnormal reflexes. g) Presence of rectal tone if unable to move lower extremities (if feasible). h) Pupillary response. i) Gag reflex. ii. Maintain C-spine precautions including rigid collar. Slide 26: b. Check for chest injury; ventilate to maintain pCO2 = 35-40 mmHg. c. Determine hemodynamic status, resuscitate from shock with Lactated Ringers solution. Maintain normovolemia and normal hemodynamics. d. Expose patient, when able, to look for any non-obvious injury. 2. Rapid Sequence Induction to Intubation for brain injured patients. a. Preoxygenate, monitor SaO2. b. All equipment out, tested and readily available. This should include equipment for back up airway if unable to intubate. c. Maintain manual in-line cervical immobilization. Will need to remove cervical collar to adequately open mouth for intubation. d. Maintain cricoid pressure until tube position confirmed. e. Lidocaine 1 mg/kg IV Slide 27: f.Adequate analgesia/sedation as indicated with morphine/fentanyl or versed/etomidate.* g. Succinylcholine 1-1.5 mg/kg IV* h. Vecuronium 0.1 mg/kg IV to maintain neuromuscular blockade after intubation.* i. If long acting neuromuscular blocker is to be utilized, the patient must receive scheduled analgesia and sedation. * The choice of medications utilized should be determined by the intubating physician or paramedic. He/she should use the medications with which he/she is most familiar. All drug regimens should have: lidocaine, analgesia, sedation, short duration neuromuscular blocking agent and perhaps intermediate duration neuromuscular blocking agent. Slide 28: 3. Resuscitate patient as above until hemodynamic and pulmonary stability is achieved. 4. Calculate the pre intubation Glasgow Coma scale. GCS can non be determined on pharmacologically relaxed patient. 5. Obtain a head CT scan: a. GCS =14. b. Any patient with focal neurologic deficit. c. Any patient with witnessed loss of consciousness >5 minutes. NOTE: CT brain is not necessary prior to transfer if clinical examination dictates rapid transfer. This is especially true if obtaining a CT will delay transfer. Slide 29: 1. CT priorities: a. CT should be abandoned if patient requires emergent operation to stop hemorrhage or immediately repair life-threatening injury. Notify neurosurgery immediately of this situation. b. CT should be obtained, otherwise, to determine presence of space-occupying clot prior to other surgeries. 2. Sedation: a. Uncooperative or thrashing patients should be treated with sedation. i. Morphine 0.1 mg/kg IV if associated with painful injury. ii. Versed 0.1 mg/kg IV for agitation. iii. If intubated, pancuronium or vecuronium 0.1 mg/kg IV or cisatracurium 0.2 mg/kg IV if sedation is not satisfactory to allow ventilatory control or cooperation with the diagnostic studies. Do not give paralyzing agent without associated pain medications and sedative. 3. Hyperventilation: Hyperventilating to pCO2 below 30 mmHg without appropriate monitoring may result in cerebral ischemia and worsening of secondary brain injury. Slide 30: This is to be avoided and uncontrolled hyperventilation (p CO2 < 35 mmHg) is no longer recommended. 4. Seizures: a. Administer Ativan 0.1 mg/kg boluses repeatedly until seizure breaks. Be prepared for respiratory depression. b. Prophylaxis with Dilantin 15 - 20 mg/kg at a rate not to exceed 50 mg/min or fosphenytoin (Cerebyx) 15 - 20 mg given at rate not to exceed 150 mg/min. i. Administer if seizure has occurred. ii. Consider administration if there is a high likelihood of post-traumatic seizure. 1) Penetrating injury. 2) Skull fracture with depression. 3) Intraparenchymal hematoma. Mannitol: at the discretion of the Neurosurgeon, a mannitol bolus of 0.5 - 1 gm/kg can be given for evidence of rising intracranial pressure. Mannitol should not be used in hemodynamically unstable patients. PRACTICE GUIDELINES: NECK IMMOBILIZATION PRIOR TO CERVICAL SPINECLEARANCE : PRACTICE GUIDELINES: NECK IMMOBILIZATION PRIOR TO CERVICAL SPINECLEARANCE OBJECTIVES: 1. To define appropriate methods for cervical spine immobilization prior to clearance. ………….. Slide 32: Thank you

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