Management of Severe Head Trauma in

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					Management of Severe
  Head Trauma in A&E

       Dr. David Tran
       A&E department
       17 mars 2010
    Management of head injury

   Primary survey: ensure that airways,
    breathing, circulation and cervical spine
    are secure.
    Assessment of mental state (glasgow
    score adapted to the age)
   Alert (A), responds to voive (V),
    Responds to pain (P), unresponsive (U)
    Perform secondary survey

   Neck & cervical spine (tenderness, muscle
   Head: scalp hematoma, laceration,
    swelling, tenderness…
   Eyes: pupils size, equality, reactivity
   Ears: otorrhage, hemotympan
   Nose, mouth, facial fractures
   Motor function: limbs, reflexes, lateralised
    weakness, Babinski’s sign.
Seriousness of head trauma
   Glasgow Score < or = 8 (severe head trauma)
   Glasgow score 9-12 (moderate head trauma)
   Glasgow score > or = 13 (mild head trauma)
Adapted Glasgow Coma Scale
Do not forget neck
   Severe head trauma are frequently
    associated with neck injuries.
   Those injuries often concern the cervico-
    occipital region (C1/C2)
   Neck collar has to be put immediately at
    arrival in A&E and will be removed only
    after imaging.
General management

   IV line, use infusion of isotonic solutions*
    (NaCl 0.9% is the most adapted)
   Intubation: all patients with severe head
    trauma (Glasgow score < or =8) have to
    be intubated.
   Crash induction is the gold standard for
    management of airways.

* Avoid hypotonic solutions like G5% or Ringer Lactate
Induction / sedation

   Crash induction:
   Etomidate 0.3mg/Kg &
   Suxamethonium 1mg/Kg

   Orotracheal intubation          (becareful of the neck)

   Immediate sedation with Hypnovel /
    Fentanyl IV is very important to control
    intracranial pressure        (continuous infusion following
    protocole sedation in SMUR: 10 amp. Hypnovel /1 amp. Fentanyl)
    Interest of early sedation in
    case of severe head trauma
   Control agitation of the patient
   Control of analgesia
   Avoid or decrease intra-cranial
   Adaptation to mechanical ventilation
Monitoring head trauma in A&E

    Non invasive blood pressure/15 min

    SpO2

    Pulse rate on scope

    PCO2    (if not available, blood gaz during
     mechanical ventilation)
    Intracranial pressure
    monitoring (PPC= MAP-ICP)

   Each time there is a severe traumatic
    brain injury (with GCS 3-8) associated
    with CT scanner images of hematomas,
    contusions, swelling, herniation or
    compressed basal cisterns.
    Head CT scanner abnormalities

   Left Epidural
   Effacement of left
   Shift >10mm of the
    medium line
   Signs of ICH
    Head CT scanner abnormalities (2)

   Right Sub-dural
   Shift > 10mm of the
    medium line
   Effacement of the
    right ventricle
Head CT scanner abnormalities (3)

   Frontal contusions
   Effacement of the
    cisterns and sub-
    arachnoid spaces
Head CT scanner abnormalities (4)
            Hyperdense lesion
             in R. frontal lobe
            cerebral contusion

                Biconvexity in the
               left petrus temporal
                      = HED
CT scanner abnormalities (5)

                Ventricles & sub-
                arachnoid spaces
                obliterated = ICH

CT Scanner abnormalities (6)

                   hemorrhage in
                   posterior fossa
   Blood pressure should be monitored
    and hypotension avoided     (Pas > 90mmHg)

   Oxygenation should be monitored and
    hypoxemia avoided    (Pa O2 > 60mmHg

   Mannitol is effective for control of
    raised intra-cranial pressure (ICP)
    Signs of intra-cranial
    hypertension (ICH)
   Signs of transtentorial herniation / ICH:
    anisocoria, mydriasis, neurological lateral signs,
    seizures, bradycardia, hypertension, bradypnea.

   Progressive neurological deterioration not
    attributable to extra-cranial causes.

   Those signs are an indication for immediate
    use of bolus of Mannitol     (up to 1mg/Kg/20 min.)
    Use of Mannitol

   Indication: Signs of intra cranial
   Mannitol 20 or 25%   (20g/100ml or

   Bolus 0.25 to 1g/Kg/20 min.
   Exp: body weight 60 kgs > 15g
    to 60g IV in 20 min. = 100 to
    300ml Mannitol 20%
Administration of Mannitol

   Mannitol is superior to Barbiturates for
    control of high ICP after TBI.

   The osmotic effect of Mannitol is delayed
    for 15-30 min. while gradients are
    established between plasma & cells.

   Its effects persist for about 90 min. to
    several hours.
Use of hypertonic Saline (HS)

   Osmotic mobilization of water across blood
    brain-barrier. (Saline 7,2% or 10%)
   HS as a bolus infusion could be an effective
    adjuvant to Mannitol to treat ICH.
   Potential side effects: central pontic
    myelinolysis in patient with chronic
   More studies are required to determine the
    place of HS in the treatment of ICH.
Goals for management of severe
head trauma

   Any episode of hypotension or hypoxia
    increases head injury mortality.

   Systolic blood pressure > 90mmHg
    (ideal = SBP 120mmHg & MAP 85mmHg )

   SpO2 > 90% (PaO2> 60mmHg)
    Management of severe
    head trauma in A&E
   Neck collar
   Monitoring BP, pulse, SaO2
   IV line and fluid infusion (NaCl 0.9%) to
    restore systolic BP >90mmHg
   Intubation (crash induction) and
    mechanical ventilation.
   Immediate sedation after intubation
Interest of early CT scanner

   CT scanner has to be performed before

    transfert to neurosurgical center.

   The time you spend to perform CT in FVH

    (<15min.) is time you save for the patient

    later. (timing in CR is probably longer)
    Management of imaging

   Head CT scanner without injection
   Complete by images of cervico-occipital and
    cervical region.
   Chest Xray and Pelvis Xray are systematic
   Thorax, abdomen and dorso-lombar rachis
    CT scanner are requested according clinical
Indication of early
Neurosurgery in emergency

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