Cranial Trauma Gabriel C. Tender, MD Assistant Professor of Clinical Neurosurgery Louisiana State University in New Orleans.

Cranial Trauma

Gabriel C. Tender, MDAssistant Professor of Clinical Neurosurgery

Louisiana State University in New Orleans

Patient #1

• Walked in the ER after being hit in the head• Initial GCS 14 – E4 V4 M6 (confused, but

could maintain conversation)• Started vomiting in the ER• In CT scan he lost consciousness and GCS

dropped to 9 – E2 V2 M5 (opening eyes to pain only, muttering sounds, localizing pain)

Patient #1

Patient #1

Patient #2

• Involved in football accident• GCS 10 – E2 V3 M5• Localize pain on R, not moving L side as much

Patient #2

Patient #2

Patient #3

• Involved in high-speed MVA• Sedated and intubated in the field • Initial GCS 7 before sedation – E1 V1 M5

Patient #3

Cranial Trauma

• What is the most important factor on physical examination?• Level of consciousness

Cranial Trauma

• GCS stratification (max: E4 V5 M6)• 14-15 mild

• 9-12 moderate

• 3-8 severe• NB: A confused patient cannot have a GCS of 15 (verbal is

4, so his GCS is 14 at the most)

Mild Head Injury

Orders for minor/moderate CHI

Mild Head Injury

Moderate and Severe Head Injury

• What else is important (in comatose patients)?• Lateralization

• Blown pupil

• Different reaction to pain (left vs. right)

• Babinski on one side only

• Rectal tone if a spinal cord injury is suspected

General Initial Assessment

Exploratory Burrholes

• Indication (rare)• Patient dying of rapid transtentorial herniation

(ipsilateral blown pupil and/or contralateral paralysis or decerebration) not improved with mannitol and hyperventilation

Exploratory Burrholes

Head CT

CT evaluation – midline shift

CT evaluation – the basal cisterns

Head CT

Epidural Hematoma (EDH)

Acute Subdural Hematoma (SDH)

Parenchimal Lesions (Contusions)

Posterior Fossa Lesions

Cranial Fractures

ICP Monitoring

Insertion Point

• 13 cm from the nasion, or just behind the hair line

• 3 cm from the midline (usually on the right), or midpupillary line

• For ventriculostomies• Aim for the ipsilateral epicanthus to hit the frontal

horn, or go perpendicular to the bone (“straight down”) to hit the body of the lateral ventricle

• If you haven’t hit the ventricle by 5 cm, STOP! (you’re going in the wrong direction; pull out and choose a new direction)

Ventriculostomy

Ventriculostomy

ICP monitors

ICP monitors – Integra (Licox)

• Monitors both ICP and PaO2• Is more difficult to insert and maintain• Has more drift

ICP monitors – Integra (Licox)

• Tricks for insertion• Use the drill that comes in the ICP monitor box, NOT the one in the cranial

access kit

• When you drill, put the drill stop at about 1.3-1.5 cm (you have to go through the bone)

• Make sure you puncture the dura

• Don’t tighten the second knob until you’re done inserting the monitors

• Take all the three stylets out before inserting the Camino fiberoptic ICP monitor

• You will feel some resistance when you go through the dura; gently overcome it

• Do not insert the monitor past the black dot• Once all three monitors are inserted, tighten the second knob

ICP monitors – Codman

• Monitors ICP only• Is easy to insert and maintain• Has less drift

ICP monitors – Codman

• Tricks for insertion• When you drill, put the drill stop at about 1.3-1.5 cm (you have

to go through the bone)

• Make sure you puncture the dura

• Zero with the monitor tip in sterile water

• Do not insert the monitor past 5 cm (put a black mark at 5 cm from the tip)

When to treat increased ICP?

Increased ICP Treatment - Hyperventilation

Increased ICP Treatment - Hyperventilation

Increased ICP Treatment - Mannitol

No steroids for TBI!

Barbiturate Coma

ICP treatment

ICP treatment

Nutrition

Posttraumatic Seizures

MCLNO Clinical Neurophysiology Laboratories Electroencephalography, Evoked Potentials, Polysomnography

Medical Director Electrophysiologists Technologists

Bruce Fisch, MD Piotr Olejniczak, MD Tom Miller, REEGT

Edward Mader, MD Lisa KeppardJose Padin, MD Terri Ware

IVF

• Do NOT use D5; use ½ NS w/ 20 KCl • Keep them euvolemic to dry (about 1cc/kg/hr)• If brain edema is an issue, keep serum Na

above 140• Mannitol and/or

• 3% saline (start at 15cc/hr, increase up to 50/hr)

• Check serum Na and osmol q6 hrs – do not exceed serum Na of 155 or serum osmol of 320

Admit Orders for Severe CHI

• Admit to ICU• S/P TBI• Cond: critical• Vitals q1hr w/ neuro checks (if on Propofol, stop and check q4 hrs)• Bedrest, HOB to 30*, loosen c-collar when patient sedated• NPO• IVF

• ½ NS w/ 20 K @ 80-100 cc/hr• If significant brain edema, start 3%NS @ 15/hr, increase up to 50/hr (keep serum Na at 145-155, serum osmol 300-320)

• Vent• No or low PEEP• Keep PaCO2 at 30-35 (see hyperventilation above)

• Meds• Propofol drip or Ativan 2-10mg iv q1hr for sedation or ICP>20 for>5’• MSO4 2-10 mg iv q1hr prn pain or ICP>20 for>5’• Mannitol 25g iv q4hrs prn ICP>20 for>5’ (hold if serum Na >155 or osmol>320)• Cerebyx 1g iv now (loading dose), then 100mg q8• Pepcid 20mg iv bid• Ancef 1g iv q8 if scalp wound or ICP monitor

• Nursing – per ICU routine• Labs

• CBC, CMP, Dilantin level qAM• Serum Na and osmol q6 if on 3% NaCl or Mannitol

• Repeat head CT in am (at least 2 CTs per patient, one on arrival and one next day)• Call for problems

Brain Death Exam in Adults

• Absence of brainstem reflexes• Fixed pupils• Absent corneal reflexes• Absent oculovestibular reflex (cold water calorics)• Absent oculocephalic reflex (not if C-spine not cleared)• Absent gag and cough reflex

• No response to deep central pain• Apnea test (last test to perform!)• Vital signs

• Core temp > 32.2*C (90*F)• SBP>90 mm Hg

• No drugs in the system!

GSW to the Brain

• Immediate actions• Control bleeding from scalp• Shave scalp to identify entrance/exit wounds

• Assume ICP is elevated and treat• Start antibiotics• Obtain CT, rarely angio• Patients with GCS 3 and no hematoma

should usually not be operated upon

GSW to the Brain - Goals of Surgery

Summary

• On arrival, check• Level of consciousness (GCS)• Signs of lateralization

• Ipsilateral blown pupil• Contralateral hemiplegia• Unilateral Hoffman / Babinski

• CT scan• Size of the hematoma / contusions• Midline shift / effaced cisterns

• ICP monitor if GCS<8*• For decreasing GCS, time is of essence