HEAD TRAUMA

What is the incidence?

What percentage of trauma deaths result from head trauma?

70,000 fatal injuries/year in the United States, 500,000 head injuries per year

50%

What indicates coma by GCS score?

What does unilateral, dilated, nonreactive pupil suggest?

What do bilateral fixed and dilated pupils suggest?

What are the four signs of basilar skull fracture?

What is the initial radiographic neuroimaging in trauma?

Should the trauma head CT scan be with or without IV contrast?

8 (Think: “less than eight—it may be too late”)

Focal mass lesion with ipsilateral herniation and compression of CN III

Diffusely increased ICP

1.Raccoon eyes—periorbital ecchymoses

2.Battle’s sign—postauricular ecchymoses

3.Hemotympanum

4.CSF rhinorrhea/otorrhea

1.Head CT scan (if LOC or GCS 15)

2.C-spine CT

3.T/L spine AP and lateral

Without!

What is the worrisome ICP?

What determines ICP (Monroe-Kelly hypothesis)?

What is the CPP?

What is Cushing’s reflex?

What are the three general indications to monitor ICP after trauma?

What is Kocher’s point?

Chapter 75 / Neurosurgery 723

20 mm H2O

1.Volume of brain

2.Volume of blood

3.Volume of CSF

Cerebral Perfusion Pressure mean arterial pressure—ICP (normal CPP is70)

Physiologic response to increased ICP:

1.Hypertension

2.Bradycardia

3.Decreased RR

1.GCS 9

2.Altered level of consciousness or unconsciousness with multiple system trauma

3.Decreased consciousness with focal neurologic examination abnormality

Landmark for placement of ICP monitor bolt:

What is the acronym for the treatment of elevated ICP?

Can a tight c-collar increase the ICP?

Why is prolonged hyperventilation dangerous?

What is a Kjellberg? (pronounced “shellberg”)

How does cranial nerve examination localize the injury in a comatose patient?

“ICP HEAD”: INTUBATE CALM (sedate)

PLACE DRAIN (ventriculostomy)/ PARALYSIS

HYPERVENTILATE TO PCO2 35 ELEVATE head

ADEQUATE BLOOD PRESSURE (CPP 70)

DIURETIC (e.g., mannitol)

Yes (it blocks venous drainage from brain!)

It may result in severe vasoconstriction and ischemic brain necrosis!

Use only for very brief periods

Decompressive bifrontal craniectomy with removal of frontal bone frozen for possible later replacement

CNs proceed caudally in the brain stem as numbered: Presence of corneal reflex (CN 5 7) indicates intact pons; intact gag reflex (CN 9 10) shows functioning upper medulla (Note: CN 6 palsy is often a false localizing sign)

What are the three types of subdurals?

1.Acute—symptoms within 48 hours of injury

2.Subacute—symptoms within 3 to 14 days

3.Chronic—symptoms after 2 weeks or longer

What is the treatment of epidural and subdural hematomas?

What classic findings appear on head CT scan for a subdural hematoma?

Mass effect (pressure) must be reduced; craniotomy with clot evacuation is usually required

Curved, crescent-shaped hematoma (Think: sUbdural cUrved)