Cranial Trauma
Gabriel C. Tender, MD
Assistant 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 Keppard
Jose 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
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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
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Vent
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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
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No or low PEEP
Keep PaCO2 at 30-35 (see hyperventilation above)
Meds
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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)
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
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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
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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