Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
ABCDE of trauma
Airway management
Airway management techniques
Ventilation (breathing) management
Circulatory management
Circulatory resuscitation measures
Secondary surgery
Chest trauma
Abdominal trauma
Head trauma
Spinal trauma
Neurological trauma
Limb trauma
Special trauma cases
Transport of critically ill patients
Trauma response
Activation plan for trauma team
Primary Trauma Care Manual | Head trauma
 

 

Delay in the early assessment of head-injured patients can have devastating consequence in terms of survival and patient outcome. Hypoxia and hypotension double the mortality of head-injured patients.

The following conditions are potentially life-threatening, but difficult to treat in district hospitals. It is important to treat what you can, within your expertise and resources, and to triage casualties carefully.

ACUTE EXTRADURAL

Classically, the signs consist of:

:: Loss of consciousness following a lucid interval, with rapid deterioration
:: Middle meningeal artery bleeding with rapid raising of intracranial pressure
:: Development of hemiparesis on the opposite side of the impact area with a dilating pupil on the same side, with rapid deterioration.

ACUTE SUBDURAL HAEMATOMA

Acute subdural haematoma (clotted blood in the subdural space accompanied by severe contusion of the underlying brain) occurs from the tearing of bridging veins between the cortex and the dura.

Management is surgical and every effort should be made to do burr hole decompressions. The diagnosis can be made on history and examination.

The conditions below should be treated with more conservative medical management, as neurosurgery usually does not improve the outcome.

BASE-OF-SKULL FRACTURES


Bruising of the eyelids (Racoon eyes) or over the mastoid process (Battle’s sign); cerebrospinal fluid (CSF) leak from ears and/or nose.

CEREBRAL CONCUSSION

Cerebral concussion with temporary altered consciousness.

DEPRESSED SKULL FRACTURE

A depressed skull fracture is an impaction of fragmented skull that may result in penetration of the underlying dura and brain.

INTRACEREBRAL HAEMATOMA

Intracerebral haematoma may result from acute injury or progressive damage secondary to contusion.

Alteration of consciousness is the hallmark of brain injury.

COMMON ERRORS

The most common errors in head injury evaluation and resuscitation are:

:: Failure to perform ABC and prioritize management
:: Failure to look beyond the obvious head injury
:: Failure to assess the baseline neurological examination
:: Failure to re-evaluate a patient who deteriorates.


MANAGEMENT

Stabilize the Airway, Breathing and Circulation and immobilize the cervical spine, if possible. Vital signs of important indicators in the patient’s neurological status must be monitored and recorded frequently. Undertake a Glasgow Coma Scale (GCS) evaluation.

Chart

Never assume that alcohol is the cause of drowsiness in a confused patient.

Remember:

:: Severe head injury: GCS of 8 or less
:: Moderate head injury: GCS between 9 and 12
:: Minor head injury: GCS between 13 and 15.

Deterioration may occur due to bleeding:

:: Unequal or dilated pupils may indicate an increase in intracranial
pressure
:: Head or brain injury is never the cause of hypotension in the adult
trauma patient
:: Sedation should be avoided as it not only interferes with the state of
consciousness, but will promote hypercarbia (slow breathing with
retention of CO2)
:: The Cushing response is a specific response to a lethal rise in intracranial pressure. This is a late and poor prognostic sign. The hallmarks are:
Bradycardia
Hypertension
Decreased respiratory rate.
 

Basic medical management

Basic medical management for severe head injuries includes:

:: Intubation and moderate hyperventilation, producing moderate hypocapnia (PCO2 to 4.5–5 Kpa)
This will temporarily reduce both intracranial blood volume and
intracranial pressure
Hypoxia and hypoventilation may kill patients
 
:: Sedation with possible paralysis
:: Moderate IV fluid input with diuresis: i.e. do not overload
:: Nurse head up 20%
 
:: Prevent hyperthermia.

Caution: Never transport a patient with a suspected cervical spine injury in the sitting or prone position; always make sure the patient is stabilized before transferring.



Top of Page