UPDATE

MANAGEMENT OF HEAD INJURIES

Donny Argie
Preface
 Bedah Saraf

• Indonesia  280 spesialis Bedah Saraf untuk

247 juta rakyat

• Rasio  1:1.000.000

• JAWA  63 %
 Spesialis dan Konsultan
Permenkes 56, tahun 2014

Rujukan Nasional 14 3 spesialis dan 2 spesialis konsultan per RS

(42 Sp.BS dan 28 Sp.BS(K))
RS Tipe A 22 3 spesialis dan 2 spesialis konsultan per RS
(66 Sp.BS dan 44 Sp.BS(K))
RS Tipe B 301 2 spesialis per RS
(602 Sp.BS)
Jumlah 712 Sp.BS
668 Sp.BS dan 44 Sp.BS(K)
 Standar minimal
penunjang pelayanan Bedah Saraf
di RS Tipe B

• Diagnostik • Terapi
– CT Scan – Basic Microsurgery
– MRI – Operating Microscope
– Angiografi – Basic Craniotomy
– Basic Laminectomy
Indonesia
 Nusa Tenggara Timur

• Kecelakaan Lalu lintas  1320 kasus

• 433 jiwa meninggal dunia

Data Kepolisian Daerah NTT 2012

Management in E/R
Neurosurgical exam in trauma
General physical condition
1. Visual inspection of cranium
a. Evidence of basal skull fracture
i. Raccoon`s eyes
ii. Battle`s sign
iii. CSF rhinorrhea/otorrhea
iv. Hemotympanum or laceration of external auditory canal
b. Check for facial fracture
i. LeFort fracture
ii. Orbita rim fracture
c. Periorbital edema, proptosis
Neurosurgical exam in trauma
General physical condition
2. Cranio-cervical auscultation
a. Auscultate over carotid arteries
Bruit (+)  associated with carotid dissection
b. Auscultate over globe of eye
Bruit (+)  traumatic carotid-cavernous fistula
Neurosurgical exam in trauma
General physical condition
3. Physical signs of trauma to spine
a. Bruising
b. deformity
4. Evidence of seizure
a. Single
b. Multiple
c. Continuing (status epilepticus)
Neurosurgical exam in trauma
Neurologic exam
1. Cranial nerve exam
A. Optic nerve function
I. If conscious:
i. A rosenbaum near vision card  ideal
ii. Count fingers
iii. Hand motion vision
iv. Light perception
II. If unconscious:
I. Afferent pupillary defectswinging flaslight test  indicates
possible optic nerve injury
III. Funduscopic exam
I. Papilledema
II. Pre-retina hemorrhages, retinal detachment, or retinal
abnormalities
Neurosurgical exam in trauma
Neurologic exam
1. Cranial nerve exam
B. Pupil: size in ambient light; reaction to light
C. VII: check for peripheral VII palsy (facial
asymmetry of unilateral upper and lower facial
muscles)
D. VI: abducens palsy  increased ICP or clival
fracture
Neurosurgical exam in trauma
Neurologic exam
2. Level of consciousness/mental status
Neurosurgical exam in trauma
Neurologic exam
2. Level of consciousness/mental status
Neurosurgical exam in trauma
Neurologic exam
2. Level of consciousness/mental status
Neurosurgical exam in trauma
Neurologic exam
3. Motor exam (assesses motor tracts from
motor cortex through spinal cord)
A. Cooperative  check motor strength in all 4
extremities
B. Uncooperative  check for movement off all 4
extremities to noxious stimulus  differentiate
voluntary movement from posturing or
stereotypical spinal cord reflex
Neurosurgical exam in trauma
Neurologic exam
3. Motor exam (assesses motor tracts from
motor cortex through spinal cord)
C. If any doubt about integrity of spinal cord:
• Check resting tone of anal sphincter on rectal exam
• Evaluate voluntary sphincter contraction if patient can
cooperate
• Check anal wink with pinprick
• Assess bulbocavernous reflex
Neurosurgical exam in trauma
Neurologic exam
4. Sensory exam
A. Cooperative patient:
I. Check pinprick on trunk and in all 4 extremities, touch
on major dermatomes
II. Check posterior column function
B. Uncooperative patient:
I. Check for central response to noxious stimulus
(grimace, vocalization)
Neurosurgical exam in trauma
Neurologic exam
5. Reflexes
A. Muscle stretch (deep tendon) reflexes if patient
is not thrasting  preserved reflex indicates that
a flaccid limb is due to CNS injury and not nerve
injury (and vice versa)
B. Check plantar reflex for upgoing toes (babinski
sign)
C. In suspected spinal cord injury: the anal wink and
bulbocavernosus reflex are checked on the rectal
exam
E/R management specifics
 Initial resuscitation
• Monitor BP and avoid hypotension
 SBP < 90 mmHg
• Monitor oxygenation and avoid hypoxia
 O2 saturation < 90%
 Admitting orders for mild head injury
GCS ≥ 14
1. Bedrest with Head Of Bed (HOB) elevated 30-
45°
2. Neuro checks q 2 hrs
3. Isotonic IVF run at maintanance: ≈ 100cc/hr
4. Analgetic
5. Anti-emetic
6. CBC
 Elevating HOB
1. Reducing ICP
1. Enhancing venous outflow
2. Promoting displacement of CSF from the
intracranial compartment to the spinal
compartment
2. Reducing MAP at the level of the carotid
arteries
3. The onset of action of raising the HOB is
immediate
Admitting orders for moderate head injury
GCS 9-13
1. Orders as for mild head injury
2. NGT and Urinary catheter
3. For GCS=9-12 admit to ICU, for GCS=13 admit
to ICU if CT shows any significant abnormality
4. Patients with normal or near normal CTs
should improve within hours
5. Any patient who fails to reach a GCS of 14-15
within 12 hrs should have a repeat CT at that
time
Admitting orders for severe head injury
GCS ≤ 8
1. Orders as for moderate head injury
2. Intubation  secure the airway in patients
who are unable to maintain their airway or
who remain hypoxic despite suplemental O2
 Management recommendation
Low risk for intracranial • CT scan is not usually
injury indicated
1. Asymptomatic • Plain SXRs are not
2. H/A recommended
3. Dizziness • Patients in this group
4. Scalp hematoma, may be managed with
laceration
obervation at home
 Management recommendation
Moderate risk for intracranial • Brain CT scan
injury • SRX: not recommended unless
1. History of change or loss of CT scan not available
consciuosness on or after
injury • Observation
2. Progressive H/A – At home
3. Alcohol or drug intoxication – In-hospital
4. Vomitting
5. Posttraumatic amnesia
6. Signs of SBF
7. Multiple trauma
8. Serious facial injury
9. Possible skull penetration or
depressed fracture
10. Suspected child abuse
11. Significant subgaleal swelling
 Management recommendation
High risk for intracranial injury
1. Depressed level of
consciousness not clearly
due to alcohol, drugs,
metabolic abnormalities
2. Focal neurological findings
3. Decreasing level of
consciousness
4. Penetrating skull injury or
depressed fracture
• Brain CT scan
• If there are focal findings,
notify operating room to be on
standby. For rapid
deterioration, consider
emergency burr holes
• SRX usually not recommended
– A fracture is rarely surprising
– Inadequate for assessing for
intracranial injury
– Possibly useful for localizing a
radio-opague penetrating foreign
body
Discharge instructions for head injuries
Seek medical attention for any of the following:
1. A change in level of consciousness (including difficulty in
awakening
2. Abnormal behavior
3. Increased headache
4. Slurred speech
5. Weakness or loss of feeling in an arm or leg
6. Persistent vomitting
7. Enlargement of one or both pupils that does not get
smaller when a bright light is shined on it
8. Seizures
9. Significant increase in swelling at injury site
 Criteria for observation at home
1. Normal cranial CT
2. Initial GCS ≥ 14
3. No high risk criteria
4. No moderate risk criteria
5. Patient is now neurologically intact
6. There is a responsible, sober adult that can observe
the patient
7. Patient has reasonable access to return to the
hospital E/R if needed
8. No “complicating” circumstances (e.g. no suspicion of
domestic violence, including child abuse)
Thank you
 Mannitol in the E/R
indications
1. suddent deterioration prior to CT
2. Evidence of mass effect (focal deficit, e.g.
hemiparesis)
3. Evidence of intracranial hypertension
1. Pupillary dilatation (unilateral or bilateral)
2. Asymmetric pupillary reaction to light
3. Decerebrate or decorticate posturing
 Mannitol in the E/R
indications
4. After CT, if a lesion that is associated with
increased ICP is identified
5. After CT, if going to O.R.
 Mannitol in the E/R
contraindications
1. Hypotension or hypovolemia
2. Relative contraindication: mannitol may
slightly impede normal coagulation
 Mannitol in the E/R

• Intermitten boluses may be more effective

than continuous infusion
• Effective doses range from 0.25-1 gr/kg body
weight
• Peak effect occurs in ≈ 20 min
 Furosemide
• The use of furosemide has been advocated,
but little data exists to support this.
• Loop acting diuretics may reduce ICP by
reducing cerebral edema and may also slow
the production of CSF
• 10-20 mg IV q 6 hrs
 Steroids
• The use of steroids is not recommended for
improving outcome or reducing ICP in patients
with severe TBI
• High dose steroids is associated with
increased mortality and is contraindicated
• Significant side effect may occur including
coagulopathies, hyperglycemia with its
undesirable effect on cerebral edema, and
increased incidence of infection