ACUTE HEAD INJURY

Most patients with head trauma are young and many have associated injuries.

Specific lesions include skull fractures, subdural and epidural haematomas, brain concussions
and contusions, penetrating head injuries, and traumatic vascular occlusions and dissections.

The significance of head is dependent not only on the extent of irreversible neuronal damage at
the time of injury but also on the occurrence of any secondary insults.

These additional insults include:

(1) Systemic factors such as hypoxemia, hypercapnia, or hypotension.

(2) Formation and expansion of an epidural, subdural or intracerebral hematoma.
(3) Sustained intracranial hypertension.

The Glasgow Coma Scale (GCS) score generally correlates well with severity of injury and
outcome.

A GCS of 8 or less is associated with approximately 35% mortality.

Operative treatment is usually elected for depressed skull fractures, evacuation of epidural,
subdural, and some intracerebral hematomas, and debridement of penetrating injuries.

Intracranial Hypertension is to be expected in such patients and should be treated with

hyperventilation, mannitol, barbiturates or propofol.

Preoperative Management
It should actually begin in the emergency department.

- Airway patency must be ensured

- Also ensure adequacy of ventilation and oxygenation
- Correct systemic hypotension. (control haemorrhage, administer IV fluids, blood,
inotropes)
- Supplemental oxygen should be given to all head injury patients.
- All patients must be assumed to have a cervical spine injury until a cervical spine x’ray,
CT scan etc rules it out. A rigid cervical collar must be applied.
- Patients with obvious hypoventilation, absent gag reflex, or a persistent GCS of less than
9 require tracheal intubation and hyperventilation.
- All patients should be carefully observed for deterioration.
- Ensure urinary catheter is inserted.
- NG tube when basilar skull fracture is ruled out.
Intraoperative Management
- Check anaesthetic machine (work station) with ancillary equipment.
- Prepare for a difficult intubation.
- Draw drugs (including thiopental or propofol, lidocaine, analgesia, muscle relaxants,
emergency drugs, and other drugs)
- Establish monitoring (ECG, pulse oximetry, blood pressure, temperature, capnography,
urine)
- All patients should be regarded as having a full stomach and should have cricoid
pressure applied during ventilation and intubation.
- Preoxygenate for 5 minutes by mask before intubation.
- The adverse effects of intubation on ICP are blunted by prior administration of
thiopental 2-4mg/kg, or propofol 1.5-3mg/kg, fentanyl 1ug/kg and a short acting
neuromuscular blocking agent (suxamethonium 1.5mg/kg).
- If the patient is hypotensive (systolic blood pressure <100mmHg) a smaller dose of
induction agent should be used or lidocaine should be substituted.
- Use of suxamethonium in closed head injury is controversial because of its potential for
increasing ICP and the rare occurrence of hyperkalaemia in these patients.
- Alternatives in difficult intubation include awake fiberoptic intubation and
tracheostomy.
- Blind nasal intubation is contraindicated in basilar skull fracture which is suggested by
CSF rhinorrhea or otorrhea, haemotympanum, or ecchymosis into periorbital tissues
(raccoon sign) or behind the ear (Battle’s sign)
- Inhalational agent = isoflurane…avoid halothane.
- A barbiturate-opioid-muscle relaxant-technique is commonly used.
- You may use invasive monitoring.
- Hypotension- treated with inotropes
- Hypertension- treated with adequate analgesia, hyperventilation or additional doses of
thiopental.
- Excessive hyperventilation should be avoided to prevent excessive reduction in CBF.
- Beta adrenergic blockade is effective in controlling hypertension due to tachycardia.
- Maintain CPP between 70 and 110 mmHg. (CPP=MAP-ICP)
- DIC may be seen with severe head injuries. Such injuries cause the release of large
amounts of brain thromboplastin.
- DIC should be diagnosed by coagulation testing, and treated with platelets, fresh frozen
plasma, and cryoprecipitate.
Postoperative Management
- Management depends on your decision to extubate or not.
- If patient is stable enough for extubation, ensure airway is patent after extubation, and
ventilation and oxygenation is adequate.
- Patient should be transferred to the recovery ward and handed over to the recovery
ward staff.
- Administer supplementary oxygen, adequate analgesia and continue with IV fluid
resuscitation.
- If patient is not stable enough to be extubated, transfer patient intubated and ventilated
to the ICU.
- Patient should be sedated, paralyzed if necessary, and mechanically ventilated.