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Outside Links:
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An Approach to the Head Injured Patient by Paul Marik, MD
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Spine /
C-spine
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Orders for the Spine Injured Patient:
Anesthesia in the Spinal Cord Injured Patient:
Fluids in the Head Injured Pt:
Heterotopic Ossification
Hyperventilation
Glasgow Coma Scale
Intercranial-Pressure Monitoring
Head Injury in the Child:
Neuro Exam Menu
Stroke
ICP
Mannitol
Seizure 'phylaxis
Urologic Management of the Spinal Cord Injured Patient:
- Timing of Surgery in Orthopaedic Patients with Brain Injury:
- Management of Sports Concussion:
- key question is whether the patient has any degree of amnesia (either antegrade or retrograde);
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exam:
- ability to repeat the names of four objects 2 minutes after having been given them
- difficulty with coordination, balance, and/or sensory or motor function;
- MRI or CT scan is required if there are persistent headaches;
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diff dx:
- epidural hematoma: classic situation is loss of consciousness followed by brief recovery (before onset of coma);
- subdural hematoma;
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treatment:
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grade 1 concussion:
- if there is no amnesia and the player is asymptomatic, then he may immediately return to play;
- if there is amnesia, the player may not return to play for one week;
- references:
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Grade 1 or "Ding" Concussions in High School Athletes
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Return-to-play criteria after athletic concussion: a need for revision.
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grade 2 concussion:
loss of consciousness;
- with loss of consciousness athletes need to be admitted for 24 hours for neuro checks;
- 4-week period out of sports;
- last week prior to return, patient must be symptom-free and the athlete should not have symptoms in practice
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safe return to play:
- athlete is symptom free
- able to perform rigorous exercises and remain free of symptoms;
- performs well on cognitive tests;
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second impact syndrome (SIS)
- occurs when return to activities is allowed prior to complete resolution of the symptoms of the first head injury
- what can occur is a second (sometimes minor) head injury can lead to a devastating series of events that can result in sudden death;
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references:
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Relationship Between Postconcussion Headache and Neuropsychological Test Performance in High School Athletes.
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Grade 1 or "Ding" Concussions in High School Athletes.
- Return to play guidelines after a head injury. Clin Sports Med 1998;17:45-60.
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Recommendations for grading of concussion in athletes
- Second-impact syndrome. Clin Sports Med 1998;17:37-44
- Second impact in catastrophic contact-sports head trauma. JAMA 1984;252:538-539.
- Management of Brain Swelling:
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hyperventilation
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glasgow coma scale
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intercranial-pressure monitoring
- sudden massive intraoperative swelling represents hyperemia from defective cerebrovascular autoregulation;
- short term induction of arterial hypotension to SBP of 60-90 mm Hg, in combination w/ administration of additional
mannitol and increased
hyperventilation,
will often reverse acute swelling;
- swelling unrelieved by these means may respond to 500 mg of thiopental upto a total dose of 1 to 2 gm;
- hypotension, particularly in the face of intracranial hypertension or traumatic vasospasm, may result in global or regional ischemia or infarction;
- management of arterial blood pressure should aim to maintain adequate cerebral perfusion pressure (mean arterial pressure minus intracranial pressure) of 40 or greater;
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PEEP does not appear to increase intracranial pressure if the head is elevated to 30 deg;
- halothane should be avoided because its cerebral vasodilator effect may elevate the CVP;
- some recommend elevation of the head of bead to 30 deg;
- references:
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The role of secondary brain injury in determining outcome from severe head injury.
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The deleterious effects of intraoperative hypotension on outcome in patients with severe head injuries.
- Heterotopic Ossification:
- radiographically develops in 3-5% of patients, 1-4 mo (or upto 18 mo) after injury;
- it occurs below the level of the injury, usually at major joints;
- incidence is 40% (1/2 of these are clinically significant);
- after transection of spinal cord, ossification often takes place in soft tissues adjacent to large joints;
- lower extremities are particularly suseptible & most dramatic changes are seen in knee > pelvis > hip;
- characteristic finding is a bilateral accretion of well defined bone which encircle the joints;
- timing of excision:
- in the case of brain injury, hetertopic bone is usually resected once the patients coma has resolved;
- references:
- Excision for the treatment of periarticular ossification of the knee in patients who have a traumatic brain injury.
E Ippolito MD et al. JBJS. Vol 81-A. No 6. June 1999. p 783.
If thou examinest a man having a gaping wound in his head , penetrating to the bone , (and) smashing his skull;
thou shouldst palpate his wound. Shouldst thou find that smash is in his skull deep (and) sunken under the fingers,
while the swelling which is over it protrudes he discharges blood from both his nostrils (and) both his ears, (and)
he suffers with stiffness in his neck, so that he is unable to look at his two shoulders and his breast.
DIAGNOSIS: Thou shouldst say regarding him : "One having a gaping wound in his head, penetrating to the bone, (and)
smashing his skull ; while he suffers with stiffness in his neck . An ailment not to be treated."
TREATMENT : Thou shalt not bind him , (but) moor (him) at his mooring stakes, until the period of his injury passes by.
- The Edwin Smith Papyrus
- Outside Links:
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GMO Manual
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GMO Manual
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Iowa Family Practice Handbook
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Merck Manual
Current Concepts: The Diagnosis And Initial Management Of Head Injury.
Evidence for a humoral mechanism for enhanced osteogenesis after head injury.
Physiological and metabolic response to isolated closed-head injury. Part 2: Effects of steroids on metabolism. Potentiation of protein wasting and abnormalities of substrate utilization.
The role of secondary brain injury in determining outcome from severe head injury.
The deleterious effects of intraoperative hypotension on outcome in patients with severe head injuries.
Lower extremity fracture fixation in head-injured patients.
An Analysis of the Relationship Between Fluid and Sodium Administration and Intracranial Pressure After Head Injury.
Lower Extremity Fracture Fixation in Head-Injured Patients.
Combined continuous monitoring of systemic and cerebral oxygenation in acute brain injury: preliminary observations.
Cerebral blood flow and oxygen consumption in acute brain injury with acute anemia: an alternative for the cerebral metabolic rate of oxygen consumption.
On-line monitoring of global cerebral hypoxia in acute brain injury. Relationship to intracranial hypertension.
Missile injuries to the brain treated by simple wound closure: results of a protocol during the Lebanese conflict.
Continuous monitoring of cerebral oxygenation in acute brain injury: injection of mannitol during hyperventilation.
Traumatic brain injury, hemorrhagic shock, and fluid resuscitation: effects on intracranial pressure and brain compliance.
Combined hemorrhagic shock and head injury: effects of hypertonic saline (7.5%) resuscitation.
Brain edema formation after brain injury, shock, and resuscitation: effects of venous and arterial pressure.
Coagulopathy and catecholamines in severe head injury.
Hypertonic saline (7.5%) versus mannitol: a comparison for treatment of acute head injuries.
Combined continuous monitoring of systemic and cerebral oxygenation in acute brain injury: preliminary observations.
Cerebral blood flow and oxygen consumption in acute brain injury with acute anemia: an alternative for the cerebral metabolic rate of oxygen consumption.
