Transcranial sonograms for closed head injuries?

[DarkProtonics]

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Do you EM guys ever perform transcranial sonograms for closed head injuries? I don't see it done too often; isn't it faster and cheaper then a CT or MRI?

 

[EM_Rebuilder]

I had not heard of using U/S to look for things like bleeds in the crainum. Time is not always the only issue though.

I think the issue that arises is anyone going to do anything about anything based on an U/S of the brain...... NSG might take someone for a clot evacuation, but they certainly are going to require a CT first and are not going to cut someone with just an U/S...

Interested in seeing what others say...

 

[DarkProtonics]

I had not heard of using U/S to look for things like bleeds in the crainum. Time is not always the only issue though.

I think the issue that arises is anyone going to do anything about anything based on an U/S of the brain...... NSG might take someone for a clot evacuation, but they certainly are going to require a CT first and are not going to cut someone with just an U/S...

Interested in seeing what others say...

Time isn't the only issue...but "time is brain", correct?

I suppose the neurointerventionalists might take the pt after the sonogram in the ED, coil the bleeding vessel, and send the pt up to NS for a craniotomy to excise the subdural hematoma that was raising the ICP.

 

[DrQuinn]

Time isn't the only issue...but "time is brain", correct?

I suppose the neurointerventionalists might take the pt after the sonogram in the ED, coil the bleeding vessel, and send the pt up to NS for a craniotomy to excise the subdural hematoma that was raising the ICP.

Nah.

TCDs I used to do in the Neuro-ICU during my Neurosurgeyr rotation in residency, but have no place in the ED.

Think about it this way.

You bonk your head. You're ok, but a little woozy. Heat CT is normal. Go home. Take some tylenol. Read up on my closed head injury instructions. Prepare to have a short temper, headaches, nausea, and insomnia for a few weeks.

You bonk your head. You're unconscious and not waking up. YOu need to be on a breathing machine. Head CT is normal, your vents are open, no sign of DAI. You go upstairs to the ICU. They can do what theey want up there. TCDs, EEGs, PET scans, whatever. Doesn't matter to me, and I'm not going to order them in my ED.


Q

 

[nymbarra]

Because it's Doppler assessment, TCD is good for assessing cerebral blood flow, probably not as good for differentiating blood from CSF. At CHOA it is used to evaluate for sickle-cell associated CVAs, and sometimes for IVH. No one wants to give a head CT to kids unless indicated because they have an estimated 0.1% risk of developing malignancy as a result of the whopping dose of radiation.

I don't think there is much in the literature for TCD use in assessing CHI. Some small correlation studies, no prospective head-to-head studies. My guess is that the sensitivity of ultrasound, as well as inter-rater/operator reliability, would be markedly inferior to CT in looking for any traumatic bleeds. Usually there are no instability issues in patients with isolated CHI (like there may be in abdominal trauma, and thus the purpose for the FAST), so CT is quick and sensitive for suspected CHI.

However, it would be interesting to see how ultrasound technology develops and how that might change our use...

 

[southerndoc]

We did it on infants in the children's ED. However, any positive study was followed up with a head CT.

 

[deleted65604]

My understanding is that they are only used on infants because infants have mostly cartilaginous, or very thinly calcified skulls. They can get great images through the anterior fontanelle. These are done a lot in the NICU because they are prone to intraventricular bleeds, and aren't great candidates to be carted off across the hospital to cold CT scanners. I've never tried to ultrasound someones brain, but maybe I'll smear goo on my head tomorrow and see what kind of images I get. I'm betting not many ultrasound waves will get through this thick cranium.

 

[southerndoc]

My understanding is that they are only used on infants because infants have mostly cartilaginous, or very thinly calcified skulls. They can get great images through the anterior fontanelle. These are done a lot in the NICU because they are prone to intraventricular bleeds, and aren't great candidates to be carted off across the hospital to cold CT scanners. I've never tried to ultrasound someones brain, but maybe I'll smear goo on my head tomorrow and see what kind of images I get. I'm betting not many ultrasound waves will get through this thick cranium.

There are some places doing research on use of TCD for ischemic stroke (to see if there are changes in the MCA).

 

[Seaglass]

I expect Paul may be in shortly to add to this conversation - at Christiana they are doing an interventional TCD trial for stroke. I believe they also do TCD for brain death there in the ED (by they I mean the EPs). In an American ED trans cranial US has less utility because CT is usually a few feet away and gives you a lot more information. It is a handy skill to have though if you do medical missions or may be deployed when CT is not available - the information can be used to triage people to CT. As for the numbers - Optic nerve sheath diameters for increased ICP are sensitive but not specific. I'm not sure how well TCD relates to ICP given that you are looking at very specific areas of blood flow.

 

[BKN]

Do you EM guys ever perform transcranial sonograms for closed head injuries? I don't see it done too often; isn't it faster and cheaper then a CT or MRI?

Talk about back to the future. Was used before CT scanning. The idea was to look through the thin temporal bone and measure midline shift of the third ventricle.

And yes, I remember this from personal experience.

Grandpa

 

[peerie]

This is an interesting post, I think it could be very handy in a rural er sometime. I would like to experiment with it and see what kind of results I get. I think it would work well with kids who get bonked in the head, and you have to decide to send them up to the nearest 'big' hospital.


Seaglass, you child has grown up quite a lot! Is that the same kid as the one with the sun glasses?

 

[Hallm_7]

This is an interesting post, I think it could be very handy in a rural er sometime. I would like to experiment with it and see what kind of results I get. I think it would work well with kids who get bonked in the head, and you have to decide to send them up to the nearest 'big' hospital.


Seaglass, you child has grown up quite a lot! Is that the same kid as the one with the sun glasses?

But even rural ERs have CT scanners. I've never seen a hospital that doesn't have a CT scanner, and I've been in tiny hospitals (as in 25 total beds). I'm sure there are hospitals that don't have CT scanners, but they are few and far between.

 

[BKN]

But even rural ERs have CT scanners. I've never seen a hospital that doesn't have a CT scanner, and I've been in tiny hospitals (as in 25 total beds). I'm sure there are hospitals that don't have CT scanners, but they are few and far between.

Also, if the patient is alert, he is very unlikely to have a mid line shift that can be detected by ultrasound.

If he has altered mental status- he's going to be transferred to a place with neurotrauma capabilites regardless of US findings.

 

[Apollyon]

Talk about back to the future. Was used before CT scanning. The idea was to look through the thin temporal bone and measure midline shift of the third ventricle.

And yes, I remember this from personal experience.

Grandpa

Have I told you recently that you are my hero?