Impact brain apnoea is a topic I've wanted to cover for a little while now. It's something that I became aware of about eighteen months ago and I've been planning to put something on the Rollcage Medic site for the last couple of months. Chatting to a motorsport medical provider recently gave me the spark to get on with it and track down someone who I could tease out the topic with.
And through the myriad corridors that make up the online world of FOAMed (Free Open Access Medical education, #FOAMed) I met Mark Wilson, who apart from his knowledge on this topic, is a really interesting guy. He'll be featuring at the SMACC conference in Chicago this June if you want more of him after this podcast.
While your suspicion of Impact Brain Apnoea might be heightened for an arrested trauma patient with what appears to be an isolated head injury (especially after listening to this podcast), you usually won't be able to confirm this until after the patient has been treated in the ED resus bay and had their CT imaging completed. So, use a standardised approach to the undifferentiated trauma patient and make sure you are covering the basics.
If it turns out that the injury has caused Impact Brain Apnoea, there may still be other critical injuries as well and airway, ventilation and perfusion support is still central to management. So, use a standardised approach to the undifferentiated trauma patient and make sure you are covering the basics.
While the duration of Impact Brain Apnoea seems to be proportional to the force of the blow, it is a transient condition and is eminently surviveable if supported properly. So, yet again, use a standardised approach to the undifferentiated trauma patient and make sure you are covering the basics.
There is a phase of catecholamine surge associated associated with Impact Brain Apnoea, which may result in pulmonary oedema, myocardial impairment including leakage of troponin and gut mucosal ulceration. However, this too is self limiting and with proper supportive care, the patient should get through it.
Listen carefully about 9 minutes in where Mark casually summarizes the London HEMS approach to the shocked polytrauma patient from first contact to scene departure in one sentence. Mastery!
It was also great to hear Mark in talking about the prehospital resuscitation of a patient, start with a quick step back to mention scene safety and management and so avoid getting sucked into the tunnel vision of the patient on the ground in front of him. Good stuff.
Finally, make sure you listen all the way to the end. If you don't yet know about the GoodSAM app, you should.
Resources and references
Some of the historial papers
Littré A: Histoire de l’Académie Royale des Sciences 54, Année 1705. Paris, 1706, Obs. XII, p 54.
Alexis Littre's description of head trauma without visible injury that has been credited as the first documented description of Impact Brain Apnoea (though it has been criticised for not having examined for an associated craniocervical injury to explain the patient's death).
(You can access a link to article by providing your name and email at this url: http://pdf12.landbooks.org/pdf/histoire-de-l-acad-eacute-mie-royale-des-sciences-ann-eacute-e-1714-avec_1w7wyg.pdf)
Koch, W and Filehne, W. Belträge zur experimentellen chirurgie. Arch Klin Chir. 1874; 17: 190–231.
Gross AG: A new theory on the dynamics of brain concussion and brain injury. J Neurosurg 15:548–561, 1958.PMID:13576198. One of the early studies of the effects of percussive blows to the head.
Experimental cerebral concussion. D. Denny-Brown and W. Ritchie Russell. J Physiol. 1940 Dec 20; 99(1): 153. PMCID: PMC1394062
One of the early literature reviews of animal experiments exploring the relationship of percussive blows to the head and subsequent apnoea and other deficits.
Treatment of severe head injuries. IanN. Maciver et al. The Lancet, Volume 272, Issue 7046, 13 September 1958, Pages 544–550.
Impact Brain apnoea rises again
The Neglected Prehospital Phase of Head Injury: Apnea and Catecholamine Surge. John L D Atkinson. Mayo Clinic Proceedings; January 2000, Volume 75, Issue 1, Pages 37–47
The early critical phase of severe head injury: importance of apnea and dysfunctional respiration.Atkinson, JLD, Anderson, RE, and Murray, MJ. J Trauma. 1998; 45: 941–945.
The role of secondary brain injury in determining outcome from severe head injury. Chesnut, RM, Marshall, LF, Klauber, MR et al. J Trauma. 1993; 34: 216–222
Resources and Links
GoodSAM app on iTunes
GoodSAM overview on Tim Leeuwenburg's KI Doc site: "Are you a Good Samaritan?"
Gareth Davies, a colleague of Mark's, discussed Impact Brain Apnoea with Iain Beardsell at the London Trauma Conference last year. Their interview is hosted on the St Emlyn's website.
EMCrit Podcast 135 – Trauma Thoughts with John Hinds. Covers a motorsport orientated approach to blunt traumatic arrest and key points on impact brain apnoea.
John Hinds "The motorcyclist in extremis: Cases from the Races" talk at smaccGOLD
Posted by Matthew Mac Partlin. Posted In : Interviews