Cranial Trauma

1. Cranial Trauma Gabriel C. Tender, MD Assistant Professor of Clinical Neurosurgery Louisiana State University in New Orleans

2. 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)

3. Patient #1

4. Patient #1

5. Patient #2 • Involved in football accident • GCS 10 – E2 V3 M5 • Localize pain on R, not moving L side as much

6. Patient #2

7. Patient #2

8. Patient #3 • Involved in high-speed MVA • Sedated and intubated in the field • Initial GCS 7 before sedation – E1 V1 M5

9. Patient #3

10. Cranial Trauma • What is the most important factor on physical examination? • Level of consciousness

11. 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)

12. Mild Head Injury

13. Orders for minor/moderate CHI

14. Mild Head Injury

15. 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

16. General Initial Assessment

17. 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

18. Exploratory Burrholes

19. Head CT

20. CT evaluation – midline shift

21. CT evaluation – the basal cisterns

22. Head CT

24. Epidural Hematoma (EDH)

25. Acute Subdural Hematoma (SDH)

26. Parenchimal Lesions (Contusions)

27. Posterior Fossa Lesions

28. Cranial Fractures

29. ICP Monitoring

30. 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)

31. Ventriculostomy

32. Ventriculostomy

35. ICP monitors

36. ICP monitors – Integra (Licox) • Monitors both ICP and PaO2 • Is more difficult to insert and maintain • Has more drift

37. 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

38. ICP monitors – Codman • Monitors ICP only • Is easy to insert and maintain • Has less drift

39. 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)

40. When to treat increased ICP?

41. Increased ICP Treatment - Hyperventilation

42. Increased ICP Treatment - Hyperventilation

43. Increased ICP Treatment - Mannitol

44. No steroids for TBI!

45. Barbiturate Coma

46. ICP treatment

47. ICP treatment

48. Nutrition

49. Posttraumatic Seizures