Head injury

15 Pages·2004·2.91 MB·English

5256 6ournalofNeurology,Neurosurgery, andPsychiatry 1995;58:526-539
NEUROLOGICAL MANAGEMENT
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Head injury l N
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Theproblems posedbyhead injuries are vast, 13% in those attending hospital but account lish
varied, and vexed. One million patients for a third of patients transferred to neuro- ed
attend hospital in the United Kingdom every surgery and 58% of deaths. Less than one as
year; they present a wide range oftypes and adult in five and less than one child in 10 is 1
0
severities ofinjury and sequelae; and there is admitted to hospital, an overall rate in .1
much controversy, particularly between dif- Scotland of313 per 100 000 peryear.' For all 13
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stages. Head injuries are a majorhealth prob- year; this accounts for 1% of all deaths but .5
lem because of their peak occurrence in for 15%-20% between the ages of 5 and 35. 8.5
young adult men; they account for many Death rates from head injury are already .5
years ofpotential loss oflife up to the age of declininginroadusers as a reflection ofexist- 26
65 years, and for many people with lifelong ing preventive measures and further reduc- on
disability. There are estimated to be as many tions should follow the increasing use of air 1
people neurologically disabled due to head bags. M
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injury as due to stroke. No single approach to y 1
management can cater for the needs of all 9
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patients and their families, but a reasonable, Traumaticbraindamage 5
rational approach follows from a considera- Brain damage after head injury can be classi- . D
tion of the nature of head injuries and their fied by pattern and by time course. The pat- ow
consequences, ofthe scale ofthe problem, of terns of damage recognised by pathologists nlo
the methods oftreatment, and ofthe person- and, increasinglybyimagingin life, are essen- ad
nel andfacilities available. tially separated into focal and diffuse varieties e
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(table 1). It must be accepted that in many fro
patients the most accurate descriptionmaybe m
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history of a blow to the head, a laceration of ferentiation is between primary damage- np
the scalp orhead, or altered consciousness no developing at the moment of impact-and .b
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matter how brief.' Unfortunately, in the secondary damage, due to the subsequent j.c
International Classification ofDiseases, there complications, which may be intracranial or o
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mutually exclusive and that are related to example, missile v non-missile-and on Ja
pathological ratherthan clinical features. This whether or not there is a compound fracture, nu
has greatly limited the collection of reliable and an open orclosedinjury. ary
statistics, except as part of special surveys, Diffuse axonal injury-is the single most 2
but the 10th edition does include an assess- important lesion in traumatic brain damage.4 5, 2
ment ofthe duration ofunconsciousness. It is thought to be responsible for the extent 0
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Epidemiology g
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Thebestguide totheincidence ofhead injury Table1 Lesionscausingfocalanddiffusepatternsof es
is the number ofpatients presenting to a hos- damageafterheadinjury t. P
pital after injury; in Scotland 1976 per Focal Diffuse ro
100 000 per year,2 in the United Kingdom a te
total of nearly one million per year.3 Almost HCoanetmuastioomna: AHxypoonxaila/inijsucrhyaemia cte
NDeeupraorstumregnertyo,f half of these are children less than 15 years ESxutbrdaudruarlal d b
NInesutriotluotgeiocfalSciences, tolhdanatnwdomtaoleosneo.uMtonsutmbienrjurfieemsalaerse dbuyemtoorea SweIlnltirnagcerebral Diffusevascular y co
H4SoTosFup,tihtSeacrlo,ntlGGalennadesrgaolwG51 fiamlplo(r4t1a%n)c,efoofllroowaeddtbrayffaicnaacscsiaduelntts(2i0n%c)r;eatshees IhPnrafeeasmrsocutrrrehnaegcerosis FSautbaermabcohlniosimd pyrig
Abscess Meningitis h
GMTeasdale with the severity of injury, they cause only t.
Headinjury 527
Table2 Complicationsafterheadinjurythatcause biomechanical forces acting at the moment of
secondaryresultstothedamagedbrain injury. Nevertheless, the distinction is still a J
Intracranial Systemic useful clinical concept and underlines the Ne
importance of focusing management on the u
HSwaeelmliantgoma HHyyppeorxciaarbia avoidance orreversal ofsecondary events. rol N
Raisedintracranialpressure Hypotension Clinically the processes ofprimary and sec- e
VInafseocstipoansm FSeevveerrehypocarbia ondary damage are reflected in three principle uro
Epilepsy Anaemia patterns of evolution, each with implications s
Hydrocephalus Hyponatraemia for management: (1) The patient loses con- urg
sciousness or develops other neurological fea- P
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tures at the time of injury, but improves as yc
time passes; this correlates with damage that hia
of the impairment of consciousness in the is principally primary from which natural try
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stains show "retraction balls", which repre- moment of or soon after injury and persist 10
sent swollen blobs ofaxoplasm. These lesions without change: such a patient may go on to .1
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are distributed centripetally and with increas- show natural recovery but also is at increased 36
ing injury extend from the subcortical white riskofsecondary complications. /jn
matter into the centrum semiovale, internal Many of the issues in early treatment of np
capsule, and brain stem. In more severe head injuries concern the appropriate .58
cases, they are accompanied by haemorrhage approach to investigation and management of .5
from small macroscopic tissue tears. These these cases. The issues facing the clinician, .52
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gliding contusion-the corpus callosum, the future deterioration and increased damage? 1 M
superior cerebellar peduncle, and the dorso- a
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lateral aspect ofthe brain stem. These lesions 1
can be recognised on the cut surface of the Classification: severity 99
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MRI.67 and fuels controversy about head injuries can w
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Ischaemic brain damage is by far the most be traced to variations and discrepancies lo
common secondary insult8 and is still found between different approaches to classification ad
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ischaemic damage is contributed to by and the approaches that areused; clarification m
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quate supply ofoxygen.' 11 The frequency of The first purpose of classification of sever- p
secondary ischaemic insults, particularly in ity is in management in the acute stage: the .bm
patients with other injuries, has been high- critical factors are the patient's condition on j.c
lighted by recent findings made with analysis arrival at hospital, how this is evolving, and om
of continuous monitoring.'2-'4 In a series of what complications canbe expected. The sec- o/
patients with varying severity of head injury, ond is the potential for recovery, after initial n
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92% were found to have one or more insults assessment and acute management have been an
lasting for at least five minutes, despite being completed-when the ongoing assessment of u
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in a well equipped and staffed intensive care the depth and duration of neurological ry
unit. impairment is of primary interest. The third 25
IPimanry and secondary traumatic brain concerns the inter-relation between the injury , 2
damage are becoming less easy to separate. and late sequelae-here the total quantum of 02
Thus it is recognised that axonal injury, once injury is important, both initial and due to 3 b
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partial injury, in continuity, to complete dis- ple, by duration of amnesia; this is particu- s
ruption over some hours."5 The sequence larly relevant to medicolegal issues. The t. P
includes unfolding of the axolemma, loss of difference in perceptions between those who ro
membrane properties, damage to the cyto- have seen the patient at the acute stag-acci- tec
skeleton, and interruption ofaxoplasmic flow dent and emergency consultants, general and te
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leading to local swelling and then disruption. orthopaedic surgeons, neurosurgeons-and b
Also, secondary damage from insults such as those who usually become involved only later y c
hypoxia may occur within minutes, before in the assessment of sequelae-neurologists, op
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52.8 Teasdale
Table3 Glasgowcomascale, comascore, andmodificationsforchildrenunderfiveyears duration has become difficult to apply as a
old result ofsevere head injuries now almost uni- J
Inadults (scoreinnormaladultsis15) formly being sedated, intubated, and venti- Ne
EyeTSpooopnsetpnaeinenecgohurselsyponse: 43 hlaotuerds,aannddairneitihaelnsceeveruintayssiessussauballelyfoarssmeassneyd urol N
Topain 2 bythe findings on admission. e
BesNtomnoetorresponse(inarms): 1 Moderate head injury was defined by uro
Obeyscommands 6 Rimmel etalas a patientwith a coma score of su
Localisationtopainfulstimuli 5 9-12.25 This group until recently did not rg
NSpoarsmtiaclfflleexxiioonnttooppaaiinnffuullssttiimmuullii 43 receive as much attention as either the severe Ps
BesNEtxotvneeernbsailonretsopopnaisnef:ulstimuli 21 toor liedsesnetrifinyjurcioenss.isTthenetlgyroaunpdmathyebededfiifnfiitciuolnt ychia
IIOCnnroacinpeofpnmurtpsoerepderdhieantseiwbloerdssounds 4532 ncaereTrdhiseedsomcurotus.t2ti6nuynsbaetfiosrfeacmtourcyhdeffuirntihteironwiosrokfias try: firs
None 1 mild or even minor head injury as a patient t p
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Modificationsofnortnalresponseinchildrenunder5 with a Glasgow coma score of 13-15.27 The b
Age Bestmotor Bestverbal problem is that patients with a coma score of lish
response response e
15 make up by far the overwhelming number d
<6-61m2omnotnhtshs LFolceaxliiosnation SSmmiilleessaannddccrriieess ofpatients classified in this group.228 In prac- as
1-2years Localisation Soundsandwords tice, a patient with a coma score of 15, com- 1
2-5years Obeyscommands Wordsandphrases 0
pared with those with scores of 13 or 14, has .1
1
a much lower risk of complications at the 3
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acute stage2930 and fewer and less persistent /jn
subsequent sequelae. The inclusion within n
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COMA, CONCUSSION, AMNESIA the same category ofall patients with a coma .5
8
Changes in consciousness provide the basis of score of 13-15 underestimates the true sever- .5
most approaches to the classification ofsever- ity ofthe injury in patients with scores of 13 .52
ity'6; this reflects the importance of diffuse or 14. It also gives an impression of undue 6
axonal injury in the initial events and in caus- seriousness to those with a coma score of 15. on
ing later sequelae. The Glasgow coma scale It is more appropriate to separate out patients 1 M
(table 3) separately assesses eye, verbal, and with a coma score of 15 and refer to these as a
motor performance.17 This separation, appro- havinghad a minorinjury. y 1
priate conceptually because each may change Description of severity in later stages is 99
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tance of the Glasgow approach. The amnesia."3 The duration of amnesia after the w
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temptation, however, to summate the scores injury-post-traumatic amnesia-is a widely lo
of the different components into an overall accepted index. It maybe difficult to estimate ad
coma score ranging from 3-15 could not be precisely and is best regarded as a logarithmic ed
resisted'8 '1 and the total "coma score" now scale: very mild, less than five minutes; mild, fro
provides the most widely used basis for classi- five to 60 minutes; moderate, one to 24 m
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tervoevnerisfy.this is at the price ofsome initial con- onTchheancgleasssiofficcaotnisonciooufssneevsesrimtyaybassoemdetsiolmeelsy p.bm
The most widely used definition for severe overlook the importance of focal injury. j.c
head injury is now a patient with a Glasgow Computed tomography and MRI show that om
coma score of 3-8. Originally, the definition cortical contusions can occur in the absence o/
used in the international studies coordinated of prolonged unconsciousness but lead to n
from Glasgow,2223 was that the patient was in prolonged confusion and sequelae such as Ja
a coma for six hours, coma being defined as memoryimpairment and epilepsy.33 nu
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no eye opening, no comprehensible verbal ry
response, and not obeying commands.24 In 25
some 80% of cases the notation for coma Prevention , 2
translates into a coma score of 8 or less, Prevention is possible at three stages: fore- 02
hence the adoption ofthe score. The six hour stalling the accident; minimisingthe degree of 3 b
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Table4 ClassificationofheadinjuriesbytheGlasgowcomascoreintosevere, moderate, mild, andminor rote
AGrCiSvaoln ACtatseensde(r%s) Admissions MInujlutriypl(e%/) NRioskfroafctIuCreH Fracture Dead(%) cted
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Minor 15 95 42 32 1 1:10000 1:100 <1 y
Mild 13/14 1 38 J 32 l 3-5 c
Moderate 9-12 4 13 371:3 1:15 9 op
Severe 3-8 1 7 63 1:50 1:8 35-40 y
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ICH=Intracranialhaematoma; GCS=Glasgowcomascore. h
t.
Headinjury 529
injury occurring on impact; and reducing the patients with minor, mild, or moderate injury
risk ofsecondary complications-the focus of andhence the focus inthese is on the identifi- J
medical management in the acute stage. cation ofpatients at risk ofsecondary compli- N
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Accident prevention requires modification of cations-principally a traumatic haematoma. u
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behaviour by the public and is effective usu- The patient with a severe head injury who is l N
ally only when enforced by legislation. The in a comahasboth evidence ofalreadyhaving e
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introduction ofspeed limits, the use ofsafety sustained a substantial amount ofbrain dam- ro
belts byvehicle occupants, and the wearing of age and also a much greater risk of both su
helmets by motor cyclists have all proved intracranial and extracranial complications. rg
effective. More stringent limits on the alcohol Assessment, diagnosis, investigation, Ps
level allowed in drivers, and the universal use observation, monitoring, treatment, and reha- yc
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of air bags, with rigorous enforcement could bilitation each have a crucial part in the man- ia
further contribute to a reduction in injuries agement of head injury. The diversity of try
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assaults and falls and in pedestrian victims of is optimum for all victims. On the other t p
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road accidents. There is increasing evidence hand, attempts to tailor management to each blis
that the wearing of helmets by cyclists pre- individual patient, based on a process of h
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vents injuries, but this remains to be backed deduction and deliberation, does not provide d
up by legislation. The dangers ofbrain dam- effective care for head injuries. Instead, as as
age from boxing are well recognised.34 What with all trauma, an approach based on a 1
0
doctors should do is to emphasise the inade- series ofrecommendations, criteria, or guide- .1
1
quacy of current prefight medical examina- lines, is both more efficient and effective. 3
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tions in minimising the risk and to point to These enable an approach that is consistent /jn
the long term dangers, highlighted by the between cases and between centres; they n
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increasing evidence ofa biological connection reduce confusion and enhance communica- .5
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betweenhead injuryand dementia.35 tion and improve outcome.'839 Widely .5
accepted approaches to head injury manage- .5
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menthavebeenrecentlyreviewed.">4 6
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Diagnosis n
Two questions need to be answered in every ASSESSMENT 1 M
suspected head injury: is it a head injury, and The approach to assessment varies with the a
is it only a head injury? There is little doubt perceived severity ofinjury. When the patient y 1
about the occurrence ofa head injury when a has impaired consciousness, assessment and 9
9
clear history is available from either the vic- resuscitation must follow the principles oflife 5
tim or an onlooker. Difficulties arise in the support, as it is taught in the Advanced . D
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person presenting with impaired conscious- Trauma Life Support (ATLS) system." The w
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ness of unknown onset and duration, espe- identification and correction ofan obstructed lo
cially when there is evidence of alcohol airway, of inadequate ventilation, or shock ad
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intake. There is compelling evidence that must take priority over the detailed assess- d
when in doubt it is safer to regard the victim ment ofthepatient's neurological state.43 fro
as having a head injury than to attribute Assessment can begin at the roadside and m
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to the head may come from careful examina- Unfortunately, many patients still arrive at p
tion clinically or from the result of a skull specialised units either from the scene of an .bm
radiograph. Conversely, when a head injured accident or from another hospital with j.c
patient has impaired consciousness, there is a hypoxia, shock, or other factors worsening o
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temptation to focus too much attentionto the prognosis.45 On arrival athospital, assessment o/
head and to overlook important injuries else- and resuscitation must be completed before n
where.37 The initial clinical examination the patient is moved for further investigation Ja
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should note carefully any abnormal neurolog- or treatment. The temptation to focus on the u
a
ical symptoms or signs as a reference point head and carry out premature CT or other ry
forcomparison with subsequent examinations investigations must be resisted in favour of a 2
5
and interviews. The niceties of the compre- proper, thorough general survey and manage- , 2
hensive neurological examination are, how- ment.46 0
2
ever, of considerably less relevance than Assessment of the patient's neurological 3
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regularreliable assessments ofconsciousness. state is quickly and effectively carried out y
with the Glasgow coma scale for overall con- gu
sciousness, noting any side to side differences es
Management in limb movement to detect hemiparesis or t. P
The essence ofmanagement ofhead injury is otherfocal neurological deficit and examining ro
the provision of optimum circumstances for the pupil size and response to light.18 The eye te
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recovery from damage already sustained- opening, verbal, and motor responses of the te
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principally primary damage-and the avoid- Glasgow coma scale are well known and can b
ance of the development or exacerbation of be modified for application to children under y c
damage due to complications-principally five years old (table 3).4 Neurological assess- o
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secondary damage. In the acute stage survival ment should be repeated and documented y
and natural recovery can be expected in most often-for example, at least every 10 minutes rig
h
t.
530 Teasdale
TableS IndicationsforCTandreferralofpatientswithrecentheadinjury (from between the number of CT scans that it is
Teasdale, etal30) feasible to carry out and the likelihood that J
Indicationsforreferraltoneurosurgiialunit the investigation will contribute to manage- Ne
WitChoomutappreerlsiismtiinnagryafcteormrpeustusecdittaotmioongraphy: ment? uro
Deterioratingconsciousnessorprogressivefocalneurologi.caldeficits Guidelines for selection ofpatients for CT l N
Openinjury: depressedfractureofvaultorbasalskullfractture were first promulgated a decade ago, when e
PatientsfulfilscriteriaforCTinageneralhospitalwhentIhiscannotbeperformedwithina scanners were largely restricted to neuro- u
reasonabletime-forexample,threetofourhours ro
Aftercomputedtomographyingeneralhospital: surgical units.5051 More recently the increas- su
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Indicationsforcomputedtomographyingemeralhospitals ing of the criteria for scanning (table 5).3° sy
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Fullconsciousnessbutwithaskullfracture h
Confusionpersistingafterinitialassessmentandresuscitation Unfortunately, the opportunity provided by ia
Unstablesystemicstateprecludingtransfertoneurosurgery the availability of CT52 in many hospitals is try
Diagnosisuncertain woifttehnhneoatdtiunrjnuerdy tboectahueseadavcacnetsasgetoofthpeatsiceannt-s : firs
ner is limited to the normal working day, t p
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whereas most injuries occur at nights and at b
weekends. When this is the case, neurologists lish
during the first hciur and then afterwards andneurosurgeons should press forthe estab- ed
according to progress. The findings are a lishment of an "out ofhours service" with, if as
valid guide to the ex,tent ofbrain damage only necessary, image transfer for consultation 10
when the patient iis adequately oxygenated with the neurosurgical unit. Without an .1
1
and has a normal bllood pressure. Any deteri- emergency service, the restricted availability 3
6
oration is a signal t() seek complications such of the CT scanner in a general hospital can /jn
as hypoxia, hypotension, or intracranial lead to inappropriate delay before the patient np
haematoma. is investigated and a delay in the diagnosis of .5
remediable intracranial complications.53 8.5
INVESTIGATION: RADXIOLOGY It is neither feasible nor desirable that all .5
2
Computed tomogr;aphy proved its clinical head injuries should undergo CT. Instead, 6
value rapidly in the diagnosis of intracranial there is now evidence from several studies on
complications after head injury.48 Despite its that the factors that identify the likelihood of 1
advantages in diaginosis, however, improve- a patient having either abnormal CT or a M
a
ment in the outcomLe ofhead injury occurred remediable intracranial lesion can be deduced y 1
only when the availtability ofCT was allied to from clinical features.'03'54 The key factors 9
9
peoarlliiceiresstaaigem,edpreatfeernaiLbsluyribnegfoirnevetshteigoatcicounrraetncaen acroensctihoeusdneepstsh, tahnedredsuurlattoifona sokfulallrteardaitoigornapohf 5. D
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ofneurological deterioration.38 Magnetic res- (fig 1) and, in a few cases, the presence of w
onance imaging is more sensitive to focal neurological signs. Whereas in the past, nlo
parenchymal abnorrmalities,749 but the greater when scanning required neurosurgical trans- ad
availability and practicability of CT make it fer, this could be advocated only in patients ed
still the mainstay of acute investigation of with both impaired consciousness and the fro
head injury, where iLts value in improving out- skull fracture-in whom the risk of m
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triage ofpatients; w:hat is the optimum match arrival at hospital are considered for CT (fig np
2).3° In the patient in a coma, this should fol- .b
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low transfer to the regional neurosurgical j.c
unit; in the patient with a coma score o
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rbeettuwrenento9noarnmdal14wiwthhoisneonceondtoittiwono dhooeusrsnootf on/
fq~ ~ ~ injSukryu,llscraandniiongrgasphhosulcdanbebecaormriitedteodutfrloocmalilnyi.- Janu
tial assessment if CT is to be carried out. A ary
skull radiograph, however, retains an impor- 2
-1:10f^) tant place in the investigation ofpatients who 5, 2
are fully conscious, in whom the finding of a 0
2
skull fracture raises the risk of intracranial 3
0.2 complications by more than 200-fold. by
Computed tomography should be performed g
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ifa skull fracture is present. The use ofCT in e
*i10000 s
'~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~...... all cases is unjustified, because ofthe greater t. P
radiation exposure (some twofold) and the ro
greater cost (twofold to fourfold) compared te
with a skull radiograph. cte
Skull radiographs still have value in the d
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Headinjury 531
Figure2 Flowchartfor
managementofpatients Patientfully Patientwith impaired consciousness or Patientincomaorwith J
withheadinjuryaccording conscious neurological signs deteriorating consciousness N
tolevelofconsciousness, e
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Observation Observe in hospital until Referto /jnn
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skull radiographs include high or medium dealing with head injuries should have an 1
velocity impact with a broad hard surface55 established policy, clearly displayed and Ma
and association with other features such as widely known. Table 6 shows the accepted y 1
post-traumatic amnesia, leakage of CSF, or indications for admission. Patients who are 9
9
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patient, radiographs should also include films of a relative or responsible adult who should ow
ofthe cervical spine, chest, and of any areas be given a list ofinstructions in the form ofa nlo
suspected ofassociated fractures. "warning card" about what to observe and a
d
what to do. In such low risk cases, admission e
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CLINICALOBSERVATION to hospital confers no advantage when a fro
The twin purposes ofobservation and moni- haematoma does develop.58 m
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intensity of observation and monitoring is two hours. Cardiovascular respiratory and np
determined bythe extent ofanyexistingbrain other "vital functions" can be assessed by .bm
damFoargethaendpatthieenpterwcehioveidsrciosnksocfidoeutseraionrdatwiohno. mcuasdteomainrtyercmliitntiecnatllym.etThhoedsmowirteh sreevceorredintghse j.co
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vation. At least four out of five patients are will fail to disclose important deviations from Ja
discharged for observation at home and the values that ensure satisfactory cerebral nu
proportion of patients admitted can be perfusion and oxygenation and the greater ary
reduced further without adverse effects.5657 the indication for continuous and invasive 2
Every accident and emergency department methods. 5, 2
0
2
3
b
y
Table 7 Monitoringtechniquesandinvestigations usedin g
patientswithsevereheadinjury (fromDellaCarte59) u
Table6 Indicationsforadmissionforobservationofheadinjuries e
s
Thefolowinglistofindicationsforadmissionofpatientswithheadinjuriesshouldbedisplayedinacci- Routine Selective t. P
dentandemergencydepartments Glasgowcomascore Intracranialpressure ro
Confusionoranyotherdepressionofconsciousnessatthetimeoftheexamination TPuepmiplesrature CCeenrterbarlalvepenrofuuss/ipounlpmroensasruyreartery tec
Skullfracture Arterial02saturation pressure te
Neurologicalsymptoms,orsigns,orboth EndtidalCO2 Electroencephalogram d
Difficultyinassessingthepatient-forexample,becauseofingestionofalcohol,epilepsy,or Arterialbloodpressure Jugularbulb02saturation b
LBraicoetkfhaoefmrnameersdeiisacpaoanlfstcierobnltderiaatduiumolnatswttiohtashtufpcuellrlovurideseccootvnhesercypiaoitsuisnenonettssna.encdCehsositalhrdeirrleysnoacaniraeilnadplirscooabtdliifeofnmiscfuolrtatdomaisssseisson Electrolytes/haematology TCrTa(:n2s4ochnr-a7an2dihma)il;siDsfiooipnnpt;lraepcorrsatnoipaelrative y cop
Iftinhjeurpyat"iweanrtniisngtocabred"obisnetrovtehdeocuatrseiodfeahorsepsiptoanlsihbeleoprersshoenshould be discharged with a head pdreteesrsiuorreatisiornaioscecd;urisfclinical yrig
h
t.
532 Teasdale
MONITORING the operating theatre, whereas the second can
Detailed continuous monitoring is needed in be carried out with a twist drill in the inten- J
all patients who are not obeying commands sive care unit. Although the techniques for N
e
ionrjuwrhieos h(taavbelea7)h.eaAdrteirnijaulrypraensdsuortehesrhosuelrdiobues mesosnairtiloyrirnegstirnitcrtaecdratnoialnepurreosssuurrgeicaarle innottennseicv-e urol N
monitored with indwelling arterial cannula to care, just as an overconcern about the head e
provide a continuous record. This will pro- injury in a comatose patient with multiple uro
vide access for intermittent measurements of injuries can be dangerous, so too can be an su
blood gases as indicated by the results ofcon- overnarrow focus on observing and treating rg
tinuous monitoring of arterial oxygen satura- intracranial pressure. Unless monitoring is P
s
tion usingpulse oximetry. An ECG shouldbe accompanied by the knowledge and experi- yc
monitored continuously and monitoring of ence necessary to appreciate the importance hia
central venous pressure or pulmonary artery of first considering the cause of raised pres- try
porcecsusrurreed moaryisbesuisnpdeicctaetde.d wIhnena svheontciklahtaesd esaurseybaecfcoesrsetaonyantdreuastemeonft,reapneadtoCfTtheanndeeodthfeorr : firs
patient, the measurement of end tidal CO, investigations needed to interpret intracranial t pu
waidtehquaaccyapofnovgenrtaiplhatiiosn,asuuspepflulemcehnetcekd tboy tthhee pmraeyssubreeofuitndwieniggsh,ebdenbeyfitasdvferrosme mefofneicttso.riTnhgusit blish
e
controls inbuiltintomodemventilatorsystems. it is inappropriate and harmful to attempt to d
The role of monitoring intracranial pres- lower intracranial pressure by medical mea- as
sure in head injuries is still controversial. sures when its primary cause is an expanding 1
0
Although it is not employed in all units deal- intracranial lesion requiring evacuation. It is .1
1
ing with severe head injuries, it has at least also crucial to be aware that an apparently 3
6
two clear benefits.42 The first is in providing satisfactory reduction of intracranial pres- /jn
an indication of severity of space occupying sure for instance, by hyperventilation or n
p
effects from a focal intracranial lesion. The barbiturate treatment - may be at the price of .5
8
second, when coupled with arterial pressure actually inducing cerebral ischaemia as a .5
measurements, is in calculating cerebral per- result ofvasoconstriction,36' or net lowering .5
2
fusion pressure, the critical determinant of ofcerebral perfusion pressure by concomitant 6
overall cerebral blood flow. All techniques are hypotension62 and result in a worse out- on
to a degree invasive, however, and have a risk come.63 1
M
of intracranial infection of 2%-8% and of Continuous monitoring of jugular venous a
causing intracranial haemorrhage (< 1%) and oxygen saturation can provide valuable infor- y 1
epilepsy (1%). mation when treating raised intracranial pres- 9
9
The value of monitoring intracranial pres- sure.64 A decrease in venous blood 5
sure in the management of a patient with an oxygenation indicates increased extraction . D
o
intracranial clot became established when it either due to reduction in blood flow or due w
n
became apparent that CT was showing many to an increase in metabolism. Conversely, lo
more focal lesions than could be expected to very high levels of venous oxygenation indi- ad
require evacuation.60 Deciding as soon as pos- cate cerebral hyperaemia. Jugular oxygen sat- ed
sible whether to evacuate a clot in a stable uration can be measured continuously with fro
patient minimises the risk of neurological indwelling fibre optic catheters but, at the m
deterioration and improves outcome. Certain present stage of development, readings have h
rCisTe ifneaitnutrreacsrasnhiaolwprsetsrsounrgecaonrdreblaytitohnemwsietlhvesa btoecbaeuseintaebrpnroertmeadlwivtahluecsonsciadnerarbelseultcauftrioomn ttp://jn
are indications for evacuation.4041 Such fea- technical factors. The catheter should be np
tures are pronounced midline shift (1 cm), recalibrated at least every 12 hours against .b
m
loss ofvisualisation ofthe third ventricle and the findings of a co-oximeter on withdrawn j.c
perimesencephalic cisterns, and dilatation of blood samples and these should be repeated o
m
the ventricle contralateral to the lesion, par- to check any apparently abnormal values. In o/
ticularly the temporal horn. When CT fea- the presence of arterial hypoxaemia and n
tures leave doubt about the need for anaemia, it is probably preferable to deter- Ja
operation, continuous monitoring ofintracra- mine the absolute content ofblood and hence nu
nial pressure should be instituted and the the cerebral oxygen extraction rather than ary
lesion evacuated ifpressure is sustained above rely on saturation values. The precise values 2
5
20-25 mm Hg. Ifthe pressure remains below of venous saturation that are optimum are , 2
this level for 24 hours, then the likelihood of still being debated; values below 50%-60% 0
2
deterioration is very small. Intracranial pres- indicate excessive extraction and potential for 3
sure should be monitored after evacuation of ischaemia, at least regional, and values of by
an intracranial clot to provide an early warn- 85% indicatehyperaemia. g
u
ing ofthe development ofa recurrent or new Cerebral blood flow can be determined e
s
haematoma and because after evacuation ofa intermittently from a variety of techniques, t. P
subdural or intracerebral clot brain swelling but none ofthese has as yet found a place in ro
and raised pressure are frequent. routine management. An index of cerebral te
c
Intracranial pressure can be monitored by blood flow is provided by the velocity of te
insertion ofa fluidfilled catheterinto the ven- blood flow in the intracranial arteries and this d b
tricle or, increasingly, by insertion of a solid can be measured intermittently or continu- y
state fibre optic system into the CSF path- ously, typically in the middle cerebral artery, co
p
ways or direct into brain parenchyma. The using transcranial Doppler sonography.65 y
first usually requires a burr hole performed in This non-invasive technique also finds rig
h
t.
Headinjury 533
application in the care of patients with sub- way to improving an outcome by prevention
arachnoid haemorrhage and is becoming of secondary insults or minimisation of their J
increasingly available in neurosurgical units. consequences. Also, the greater understand- N
e
Changes inmeanvelocity orinindices ofpul- ing of the pathophysiology of injury that has uro
satility-the difference between systolic and come from animal experiments and clinical l N
diastolic flow velocities-aid the interpreta- observation in the past decade has enabled e
u
tion ofinformation from intracranial pressure the development ofmore rational policies for ro
measurements and cerebral oxygen extraction management and more appropriate targeted su
values. Velocity falls and pulsatility increases treatment in individual cases.66 This is rg
with reducing cerebral perfusion pressure and encompassed within the concept of neuro- Ps
blood flow. A high velocity can be due to intensive care, distinguished in its concepts yc
h
hyperaemia ornarrowing ofthevessels due to and techniques from general intensive care. ia
traumatic cerebralvasospasm. No longer is it satisfactory for patients with try
proSvtiuddeieisnfoofrmcaetrieobnralaboeluetctrbircaailnafcutnivcittiyoncainn htielaadtedinjinurythteo baebsseendcaeteod,fpaaprparloypsreida,teanndeuvreon-- : firs
patients who are unconscious either due to monitoringand investigation facilities. t pu
thehead injuryorbecause ofpharmacological blis
treatment. The potentials evoked by NON-OPERATIVE MANAGEMENT OFSEVERE h
e
sinodmeaxtoosfenisntoergyritsytiamnudlaatrieonprporgonvoisdtiecaallyusuesfeu-l THhEiAsDcIoNvJeUrRsYa range of techniques employed d as
ful but have not established a value in practi- to prevent and treat complications considered 1
0
cal care. When neuromuscular paralysis is to be liable to produce secondary damage. .1
1
employed to permit ventilatory treatment, Many of these complications are systemic- 3
6
however, there are advantages in continuous for example, hypotension, hypoxia, hyper- /jn
monitoring ofcerebral activity using a simpli- capnia, hypothermia, electrolyte imbalance- n
p
fieddevicesuchasacerebralfunctionmonitor. ratherthanintracranial. The need formeticu- .5
8
Monitoring with which staffare not famil- lous standards of management of severely .5
iar or which produces technically capricious injured or ill patients, and the methods .5
2
results is useless and even dangerous. The involved apply just as much to a serious head 6
o
increasing complexity of monitoring used in injury. As a general principle, such systemic n
the management ofpatients with serious head disturbances are both more common and 1
M
injury is a strong argument for concentrating more serious in their effects than intracranial a
such cases, and hence experience, in regional disturbances,67 even after the initial resuscita- y 1
neurosurgical centres, where the expertise to tion and emergency measures have been car- 9
9
carry outthe measurements and interpret and ried out.14 By contrast with the unanimity 5
act on their findings can be developed and about the importance ofthese factors, there is . D
o
sustained. still considerable variation of opinion about w
n
the employment of methods primarily aimed lo
at treating raised intracranial pressure and ad
e
Management oftraumatic braindamage brain swelling after head injury. This is partly d
The early scepticism, ifnot pessimism, about because such methods have not been shown fro
the prospects for recovery of a patient who by a randomised control trial to substantially m
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such victims can recover and make an inde- swelling and raised intracranial pressure may p
pendent recovery. The prospects for improv- be a consequence of brain damage, rather .bm
ing the outcome of such injuries have been than a primary factor in producing damage. j.c
considerably heightened by evidence from There is, nevertheless, an acceptance that the o
m
modem methods ofmonitoring ofthe occur- supervention of raised intracranial pressure, o/
rence of secondary insults, likely to exacer- reduction in cerebral perfusion pressure, and n
bate brain damage, that were not detected by ischaemia on an already damaged brain, with Ja
methods available a decade or more ago.'2 heightened vulnerability as a result ofinjury68 nu
a
Such insults worsen outcome" opening the cannotbe otherthanundesirable.69 ry
Ventilation of unconscious patients is 2
5
widely used (table 8). The aim should be to , 2
keep arterial oxygen saturation as close as 0
2
Table8 Indicationsforintubation andventilationofpatientswithrecentheadinjury possible to 100%, using increases in inspired 3
(fromGentlemanetal43) oxygen and positive end expired pressure by
Immediately: when necessary. Ventilation should be gu
VLCeoonstmsialoaf(tpnororotytoeincbsteuiyfvifenigcl,iaernnyocntyges(apalesarjkeuifdlneggx,eedsnobtyebyleooodpegnasiensg)):-thatis,Glasgowcomascore < 8 nadojrumsatledortsoligmhatilyntsauibnnorarmtaelri.alThCeOp,ractteincseioonf est. P
SpoHHnyytppaeonrxecaaoerumbsiihaayp((ePPraavcoeo2n2t<i>l9a6tkikPoPnaac)oanusaiirngorPa<co123k<P3a-5onkPoaxygen) heyqpueartvienngtilvaetnitoinlamtiuosnt bofe ahbeaanddoninejduriyn vwiietwh rotec
BefRSoiergsenpiitfrriacatanonsrtplyoyratdrerwthieytrhtiihonmriaotarinbgetcownesecniohuosspiltevaells,:evenifnotinacoma hoyfpotxhiea aevniddeinmcpeairQefd othuetcoremseultthiantgrecseulrte.b"r3a6l3 ted b
Bilaterallyfracturedmandible Hyperventilation should be employed only y
Copiousbleedingintomouth(forexample,fromskullbasefracture) c
Seizures briefly, not least because its effects are only o
p
Anintubatedpatientmustalsobeventilated;aimforPao2> 15kPa;Paco240-45kPa temporary. Hypotension, whether as a conse- y
Pao2=arterialoxygentension;Paco2=arterialco2tension. quence of hypovolaemia due to inadequate righ
t.
534 Teasdale
fluid replacement, or the use of sedative and safety margin is likely to depend on the
depressant drugs mustbe avoided. patient receiving effective neurocritical care. J
When raised intracranial pressure occurs Certainly, this will be necessary in the trials N
e
wanady soibmsptlreucctaiuosne,s saubcnhoramsanlecbkrepaostihtiinogn,paaitr-- ntreaetdioendotfo sdeevteerremliynienjeuffriecdacpyatainednttsheincoanpcperno-- urol N
terns, fever, and seizures, have been excluded priate facilities shouldbe encouraged. e
u
and a surgically remediable intracranial lesion ro
occupying space has been ruled out, two ANTICONVULSANTS su
principal approaches to treatment are The frequency of seizures (5%), both in the rg
employed. The first is the use of osmotic acute and late phase after head injury73 has P
s
diuretics such as mannitol with a view to prompted the use ofanticonvulsant drugs as a yc
withdrawing fluid from either the normal prophylactic measure rather than as a hia
brain or areas of brain oedema. The usual response to a declared epileptic event. It was try
satdajrutsitngmendtoseasidset0-e5rmgi/nkegdbboydythweeiegffhetctswiotnh hsuoppperdesstihoatn opfrospehiyzluarcetiecventtrseawtomuelndt laenaddttohea : firs
intracranial pressure and cerebral perfusion reduced occurrence of late continuing t p
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pfrreussseumried.e tAoddsiutsitoanianlthemeoassmuorteisc griandcileundte, cseaiszeurefso.rTsriuaclhs hlaatvee sephiolewpnsyt.h74at75thiOsnies nsottudtyh,e blish
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infusion ofcolloid to maintain circulatingvol- however, has shown a clear reduction in d
ume, and the avoidance of hyperosmolarity seizures but only in the first week after as
(serum osmolarity more than 320 mmol/l). injury. The precise level of risk of seizures 1
0
The alternative is to use sedative or hypnotic that merits treatment remains debated; like .1
drugs such as propofol or thiopentone to most British neurosurgeons, I prefer to with- 13
6
reduce cerebral metabolism and hence induce hold treatment until such time that a seizure /jn
a fall inblood flow andbloodvolume. occurs. n
p
Mannitol is considered to be most effective .5
8
in raised pressure due to focal space occupy- ANTIBIOTICS .5
ing lesions whereas sedatives are more appro- There is controversy also about the use of .5
2
priate in patients with raised intracranial antibiotics in the prophylaxis of infection in 6
pressure due to vascular dilatation-typically patients with an open injury, particularly due on
children with preserved cerebrovascular CO2 to a fracture at the base ofthe skull resulting 1
activity and cerebral electrical activity.65 In all in CSF rhinorrhea, or otorrhea, or intracra- M
a
circumstances, care must be taken to avoid nial air. One school ofthought argues thatthe y 1
hypotension and it is sometimes more appro- use of broad spectrum antibiotics does not 9
9
priate to maintain cerebral perfusion pressure reduce infection and simply promotes the 5
by raising blood pressure pharmacologically occurrence ofantibiotic resistant bacteria. On . D
o
thanto strive to reduce intracranial pressure. the other hand, I believe that there is reason- w
able recent evidence77 to support the longsus- nlo
DRUGTREATMENT OF HEAD INJURY: pected value ofprophylaxis with penicillin or ad
NEUROPROTECTION allied agents, against pneumococcus, which is ed
Various agents have been used or are being the most common organism and which can fro
considered that aim to interfere with the mol- cause explosive and irreversible deterioration. m
ileancrjuulraypr.r,7o0bcieNosocsehnseemihicanasvlo,ylevcteeldlbuelieanrn, starhnaoduwmmnaitccirlcoevarablsrycauit-no MOPoEsRtATiInOtrNaScrIaNniHaElAhDaIeNmJaUtRoYmas after a head http://jn
be of benefit. This is particularly true of injury are intradural-subdural, intracerebral, np
steroids. After many years of debate, several or both. Effective operative management of .b
m
trials at various doses have failed to show these lesions demands more access than can j.c
beneficial effects and even adverse conse- be achieved by a burr hole and requires o
m
wqiutehnctehse bheanveefitbeoefnstneortoeidd.s71inTbhriasincsonwterlalsitnsg naenudrosfaucrigliitciaesl. aWnidtnheueraoralnyaersetfheertrialc efxoprerCtiTs,e on/
due to tumour and highlights the mechanistic there now should be very few, if any, occa- Ja
differences inthe processes. sions that a non-neurosurgeon needs to con- nu
The increased understanding of traumatic template intracranial surgery-even for the ary
and ischaemic brain damage that has come simpler but much more rare solitary 2
pforionmteidntteonsetheresiemaprocrhtainncereocfentmeycehaarnsishmass edxettreacdtuerdalorhasetmroantgolmyas.usWphecetneda,haaelamragteobmoaluiss 5, 20
such as increased intracellular calcium, exci- of mannitol-for example, 1 g/kg-can "buy 23
totoxicity from excessive glutamate and other time" for transferto the neurosurgical operat- by
excitatory amino acids, and lipid peroxida- ingtheatre. g
u
tion.72 There are promising indications from Intracerebral contusions and smaller e
s
eoxfpneeruirmoepnrtoatlecsttiuvdeiedsroufgsb-enceaflictifurmomiona crhaanng-e hSaoemmeatosmuarsgeocnasn pfoasveourdiffaicultcondseecrivsaitoinsv.e t. Pro
nel antagonists, glutamate receptor blocking approach: intracranial pressure is monitored te
agents and antioxidants-and also hypother- and if raised, especially if cerebral perfusion cte
pmliaa.nnedC.linical studies are underway or purseesdsuarnedisoperreadtuicoend,pemrefdoircmaeld moenltyhoidfstheasree d by
Most neuroprotective agents have side fail. Although a conservative approach may co
effects on cardiovascular and CNS function be reasonable initially, ifintracranial pressure py
and the achievement ofan acceptable efficacy is raised and the CT shows a focal space rig
h
t.
Headinjury 535
occupying, mass effect, operation should be lie with the staff of the referring hospital.
preferred. Evacuation does not risk injury to Before transfer, the patient must be rendered J
surrounding recoverable brain tissue-areas stable; life threatening extracranial injuries N
e
of low CT density adjacent to a contusion demand priority.84 If there is any concern uro
identify cytotoxic oedema inirreversibly dam- about airway or oxygenation, intubation and l N
aged brain; evacuation of a mass lesion will ventilation should be established. The staff e
u
alwaysbe a more secure method ofimproving accompanying the patient should be experi- ro
intracranial pressure-volume relations, and enced in the care ofthe unconscious injured su
fatal herniation can occur from local shift patient. The minimum is a doctor, preferably rg
P
while intracranial pressure is being "con- an anaesthetist or a doctor with anaesthetic s
trolled" medically. training and experience, and a trained nurse yc
h
Open injuries are less urgent indications for orparamedic. Theymust be familiarwith the ia
operation. Debridement and repair ofa com- patient's condition before the journey, with try
hpRoeoupuransidroofdfeipanrjbeuasrssyaeladvsoskikudulslllforfrarcamtciutnruiermeiisswueistsuhaiilnnlfye1cp2toi-so2tn4.- wtDhhueartinpcgraontcrgeaodnsuwprroerostngthadenurdreimnuegsqtturiabnpesmperoenrltti,abalnneedeindwteirdta.h- : first pu
poneduntil anyassociatedleakage ofCSFhas venous access, the ECG shouldbe monitored blis
persisted for several days, at which time the continuously as should the blood pressure h
e
frontal lobe swelling, due to the contusions and arterial oxygen saturation by pulse d
a
customary in such cases, has subsided. There oximetry. The monitoring equipment should s
is a trend for early (< 12 hours) operation in preferably have the ability to display trends, 10
craniofacial injury, the optimum time for cor- to store data, and to print hard copy for later .1
1
recting deformity, but this should be avoided analysis. Facilities must be available to re- 3
6
if an associated head injury is any more than position or replace an endotracheal tube to /jn
minorormild severity. continueventilation ifthe oxygen supplyfails, np
to continue or replace intravenous treatment, .5
8
and to deal with cardiac arrest. With an .5
Where shouldheadinjuriesbetreated? appropriately equipped ambulance and ade- .5
2
Provision of care for head injuries needs to quately experienced staff, road transport will 6
o
incorporate the assessment and arrangement be appropriate for most transfers, air transfer n
for home observation of the minor injuries being needed only for inaccessible locations 1 M
that make up 80% of hospital attenders; orforverylongdistances.85 a
arrangements for admission and observation The preferred location for the definitive y 1
of mild and moderate injuries; CT, either and continued management of the severely 9
9
btreafnosrfeer;orandafftoerr tnheeurreossuusrcgiitcaatlion,refceornrtalinuainndg icennjturree,d paantidentneiusrotshuergriecgailonalintneeruvreonstuirognicails 5. D
o
care and definitive management of patients highly cost effective.86 Although district gen- w
n
with a severe head injury or a head injury eral hospitals can increasingly undertake CT, lo
a
combinedwith serious injuries elsewhere.78 and provide general intensive care, the temp- d
e
Facilities needed for initial assessment tation to retain severely injured patients in d
include staff trained and able to assess con- whom CT seems not to show a surgical com- fro
sciousness, to apply guidelines for skull radi- plication should be resisted. As stressed m
gsoiugoirnda.eplhiTynh,eestsoefionrmtuedrsiptsrecthbaeirtsgaefvianoidlrianbghlsoe,spaaittnadlaltloadtamipimpsel-sy nsaicbnaongvs,e,,ttotohcedaerecrxiypdeeorutotinseatnhndeeeindneteeeddrptrfoeotrirncteoepmrepparrteetshceCannT-- http://jn
n
within a district general hospital that deals sive "neuromonitoring", and to apply its p
with trauma cases. The arrangements for results, requires the build up and continua- .bm
cases needing admission to hospital will tion of expertise; experience depends Cn a j.c
depend on whether the hospital also contains case load of sufficient numbers that is likely om
a neurosurgical unit. If this is not so, it is to be found only in a regional centre. Acting o/
preferable for head injuries admitted for against this are the factors, professional pres- n
observation to be grouped together in a spe- tige and market forces, that lead to pressures Ja
n
cific short stay or observation unit where notto transfer such patients forneurosurgical u
a
expertise and experience can be maintained care but to manage them in general intensive ry
in assessment and, where necessary, referral care units in a general hospital. This limits 2
5
onwards; it is less satisfactory for patients to the employment ofcomprehensive neurocriti- , 2
be admitted for observation on acute surgical cal care and also divorces the victim's family 0
2
wards, whether general surgical or from the informed advice, counselling, sup- 3
b
orthopaedic. port, and follow up that should be available y
Transfer ofa patient both within a hospital in a specialised unit. gu
e
and from a districthospital to a neurosurgical The merits of "trauma centres" are cur- s
unit is fraught with hazard.1279 The distance rently under debate and investigation. t. P
travelled is less important than the risk of Proponents emphasise the benefits of early ro
changes in homeostasis developing insidi- multidisciplinary intervention in patients with te
c
ously, unnoticed and untreated, because of serious multiple injuries. Others point to the te
d
inadequate monitoring, equipment, or inex- very small proportion of accident victims b
perienced escort.458>82 Dedicated transfer requiring such intervention and the difficul- y c
teams, travellingfrom major centres to collect ties in selecting out such patients, in arrang- o
p
severely ill patients have been shown to be of ing for their transport to a dedicated single y
value83 but most often the responsibility will centre, and in the centre being adequately righ
t.