Head Injury

1
Head Injury

• Practical Aspects of Management and Transfer.
• Susanne Young

2
CONTENT

• Head Injuries Background
• INITIAL MANAGEMENT
• Current Guidelines- ATLS
• Prevention of secondary Brain Injury (1-4)
• Use of adjunct therapies
• TRANSFER
• Which Sedative?
• AAGBI

3
BACKGROUND

• Head injury accounts for approximately 300 per
  100 000 hospital admissions per year of these, 9
  per 100 000 die.
• RTA's account for about 25 of cases and about
  60 of deaths many die before reaching hospital.
  
• The aim of management is to minimise damage
  arising from secondary complications.

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PROGNOSIS

• Traumatic Brain Injury- prognosis at 48HRS
• GCS lt8- severe
• 9-12- moderate
• 13-15- mild

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INITIAL MANAGEMENT

• A-secure a clear airway and control cervical
  spine
• B-treat hypoventilation, severe chest injury
• C-control haemorhage and treat shock
• D-assess disability
• E-exposure, prevent hypothermia

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Principles of management

• Prevention of secondary cerebral injury
• 1 Hypoxia
• 2 ICP
• 3 CPP and CBF
• 4 Cerebral metabolism

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1 HYPOXIA

• PO2 lt10kPa for any reason
• If hard collar Consider
• 2 person Manual in-line immobilisation
• 3rd person cricoid
• Use of McCoy blade
• ?Blind Nasotracheal intubation exc if Basal
  skull - if skilled

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2 Control of ICP

• Signs of raised ICP (gt20mmHg)
• Papilloedema, BP , HR ,fixed pupils, flaccid,
  irreg resps (brainstem involvement)
• ?Hypoventilate- if in doubt DONT
• Moderate hypocapnia CO2 3.5-4 OK
• Consider if GCS drops suddenly
• Very low CO2 vasoconstriction ischaemia

9
Control of ICP (contd).

• Fluid balance- overload can exacerbate cerebral
  and pulmonary oedema
• Sedate initially-
• Propofol first line
• Add Midaz if ineffective
• ? Thio- may cause haemodynamic disturbance
• ? Mannitol 0.25-1g/kg (100ml 20).
• Buys time only, nephrotoxic- watch uo.

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3 Control of CPP and CBF

• CPP MAP- ICP mmHg
• Min CPP 60/70 for adequate perfusion
• Cushing reflex designed to restore CPP in
  presence of ICP therefore
• Dont treat Hypertension!
• Mainstay of treatment is to keep SBPgt90
• Steroids ineffective (palliative care only)

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Control of Cerebral Metabolism

• Prevent fits. Prophylaxis in first week.
• Phenytoin 15mg/kg loading
• Avoid Benzos if poss.
• ? Active cooling
• Moderate hypothermia (32-33 for 24hrs) of benefit
  if GCS at presentation5-7

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TRANSFER

• INTUBATE AND VENTILATE- but dont hyperventilate.
• SEDATE WITH PROPOFOL
• A LINE, CATHETER, ECG etc
• Prophylactically- join AAGBI!
• become a member of the Group of Anaesthetists in
  Training (GAT).
• Free insurance to cover you during any
  inter-hospital ambulance transfers !