Management Of Severe Head Injury Research Articles

Surgical Management of Patients With Severe Head Injuries

ABSTRACT Minutes can make the difference between life and death when patients with severe head injuries require surgery. Subdural, epidural, and intracerebral hematomas and cerebral contusions and gunshot wounds are the pathologic entities encountered most frequently during emergency surgery in patients with severe head injuries. Neurosurgical team members frequently use hyperventilation, mannitol and barbiturates, and sophisticated monitoring modalities to manage patients with severe head injuries during and after surgery. Although monitoring a patient's intracranial pressure (ICP) through a ventriculostomy catheter remains the most widely used gauge of cerebral metabolism, neurosurgical teams also are using fiber-optic ICP monitoring catheters, cerebral blood flow measurement probes, microdialysls catheters, jugular venous oxygen saturation catheters, and brain oxygen content measurement electrodes. Coordinated teamwork by perioperative nurses, neurosurgeons, anesthesia care providers, and emergency department staff members helps ensure the best possible outcomes for patients who require surgery for management of severe head injuries. AORN J 63 (May 1996) 854–867.

Development of guidelines for the management of severe head injury.

Organized neurosurgery has taken a major step forward in developing guidelines for the management of severe head injury. This represents the first area in which neurosurgeons have tackled this difficult but important undertaking. The head injury guidelines, which are to be published soon, are evidenced-based, i.e., they are based upon published data rather than on expert opinion. The quality of data has been carefully analyzed and graded. The level of the recommendations, i.e., standard, guideline, or option, is based upon the strength of the data available. An attempt is made to provide a summary of the terminology and methodology used to develop guidelines. Arguments for and against practice guidelines are also summarized.

Early management of severe head injury in Northern Ireland

As part of a study into the management of major trauma, the early management of severe head injury in Northern Ireland was evaluated over a 12-month period. The injury severity score was used to define those patients considered to have severe head injury. There were 131 patients with severe head injury: 27 per cent were hypoxic and 18 per cent were hypotensive on admission to the primary hospital. Almost half had severe multiple injuries. Early endotracheal intubation was performed in 92 per cent of comatose patients, and adequate resuscitation (including laparotomy in some) was performed in 87 per cent of shocked patients transfered to the neurosurgical unit (NSU). Eighty patients were transferred to the NSU: 60 per cent were comatose, 68 per cent were intubated and ventilated, and 74 per cent were transferred by an anaesthetist. Two patients were in hypovolaemic shock after transfer and required laparotomy. Thirty-eight had evacuation of an acute intracranial haematoma; 26 of these would not have been classified as severe head injury by the Glasgow coma scale. The overall mortality rate was 38 per cent, and 24 per cent for those transferred to the NSU. We conclude that the early management of head injury in Northern Ireland is good, but there are problems, including pre-hospital oxygenation and delays in transfer.

Use of the Injury Severity Score in head injury

As part of a study of the early management of severe head injury, the use of the Glasgow Coma Score (GCS), Injury Severity Score (ISS) and TRISS was investigated. These injury scores were compared in correlating with outcome at one year as assessed by the Glasgow Outcome Score (GOS) and mortality. One hundred and thirty-one patients had a severe head injury, as defined by an ISS of 16 or higher, in whom the Abbreviated Injury Score (AIS) for craniocerebral injury was 3 or higher. Seventy-eight of these also fulfilled the accepted GCS definition of severe head injury (GCS less than 8 with no eye-opening). Thirty-eight had evacuation of an acute intracranial haematoma; 26 of these patients would not have been classified as severe head injury by GCS. The overall mortality rate was 38 per cent, and 24 per cent for those transferred to the neurosurgical unit. TRISS was slightly better than GCS for predicting outcome based on both GOS and mortality, however this difference was not significant. TRISS identified patients who died that are not considered as severe head injury by GCS. Use of TRISS allows the effects of systemic factors and other injuries to be taken into account when assessing severity of head injury.

Neurologic critical care and the management of severe head injury in the United States

Neurologic critical care and the management of severe head injury in the United States

Intensive care management of severe head injury

Intensive care management of severe head injury

Acute management of severe head injury

Acute management of severe head injury

Outcome prediction in early management of severe head injury: An experience in Malaysia

The outcome of 109 patients with severe head injury was studied in relation to clinical and computed tomographic (CT) criteria on admission, after resuscitation. Age, Glasgow Coma Score (GCS) and state of pupils strongly correlated with outcome. The presence of hypothalamic disturbances, hypoxia and hypotension were associated with an adverse outcome. The CT indicators associated with poor outcome were perimesencephalic cistern (PMC) obliteration, subarachnoid haemorrhage, diffuse axonal injury and acute subdural haematoma. The prognostic value of midline shift and mass effect were influenced by concomitant presence of diffuse brain injury. For the subset of patients aged < 20 years, with GCS 6-8 and patent PMC (n = 21), 71.4% correct predictions were made for a good outcome. For the subset of patients aged > 20 years, with GCS 3-5 and partial or complete obliteration of PMC (n = 28), 89.3% correct predictions were made for a poor outcome.

Clinical Anesthesia in Neurosurgery

Cerebral physiology and evaluation cerebral hemodynamics and metabolism physiology of intracranial pressure electrophysiologic monitoring effects of anesthetic agents on intracranial dynamics anesthetic management for neuroradiologic diagnostic procedures fluid and electrolyte balance in neurosurgical patients neurosurgical and related procedures the management of cerebrovascular disease posterior cranial fossa surgery brain tumours surgery of the spine peripheral nerve surgery pediatric neurologic surgery surgery for seizures pain therapy stereotactic surgery central nervous system trauma the management of head injury cardiovascular effects of severe head injury management of spinal cord trauma anesthetic management of patients with neurologic disease for non-neurosurgical procedures post-operative and intensive care post-anesthetic care neurosurgical intensive care hyperalimentation therapy following major brain insult cerebral death brain death.

Jugular bulb venous oxygen saturation in the management of severe head injury

Jugular bulb venous oxygen saturation in the management of severe head injury

Intensive Management of Severe Head Injury

Intensive management of patients with severe head injury offers the best hope of minimizing death and functional disability in a young, working population. Secondary neurologic insult can be decreased by cardiorespiratory support and ICP control from the outset. Rapid neurologic assessment, airway management, and support of circulation are the basis of emergency management for head injury. Patients with severe head injury require intensive care management for two major reasons: management of ICP and management of organ system dysfunction. Care should not be withheld because of initially grim (and inaccurate) prognostic assessment. Newer techniques for assessing the adequacy of cerebral circulation may allow refinement of management strategies in the future.

Acute Subdural Hematoma

In spite of major advances in the management of severe head injury (HI) acute subdural hematoma (ASDH) continues to be one of the most lethal of all intracranial injuries. Of 1,150 consecutive severe HI patients, 137 (12%) had ASDH. The following variables were assessed in regards to outcome morbidity/mortality from ASDH: mechanism of injury, age, sex, neurologic presentation, postoperative intracranial pressure (ICP), and timing from injury to operative evacuation of the ASDH. The only variables found to statistically correlate with outcome were presenting neurologic condition (p = 0.001) and elevated postoperative ICP greater than 45 mm Hg (p = 0.001). The timing from injury to operative evacuation of the ASDH in regards to outcome morbidity/mortality was not statistically significant even when examined at hourly intervals (p = 0.418).

Social work and the management of severe head injury

This article examines the role of the health social worker in the management of the psychosocial sequelae of head injury from the membership perspective. Data relative to the incidence and medical dimensions of head injury and its psychosocial sequelae are briefly reviewed. The social work definition of head injury as a social process, rather than a medical event, is explored. Social work interventions designed to help those affected by head injury to manage home and community life are examined.

Staffing provision for early head injury rehabilitation

A questionnaire was sent to seven rehabilitation units in the UK which were recognized for expertise in the early rehabilitation of head injury patients. Information was obtained about the type of patients treated in the units, the number of beds available and staffing levels. In addition, the consultants' opinions were sought on optimal staffing levels for a hypothetical 20-bed unit for the early management of severe head injury. There was a wide variation in the staffing levels in the different neurorehabilitation units. The average therapy time available varied from six to 24.6 hours per week. The views of the four consultants who gave opinions about optimal staffing levels were similar and paralleled the levels recommended by other professional bodies.

Useful ICP monitoring with subarachnoid catheter method in severe head injuries.

ICP in 233 patients with severe head injuries was monitored utilizing a subarachnoid catheter technique. The relationships between initial ICP and GCS, between initial ICP and GOS, between maximal ICP and GCS, and between maximal ICP and GOS were examined statistically. The correlation was significant in each case, but particularly so between maximal ICP and GOS. Thus morbidity and mortality may be dependent upon maximal ICP. Catheterization of the subarachnoid space presents little difficulty using a Tuohy needle for epidural anesthesia as an introducer. Though the catheter is very fine (1.0 mm in outer diameter), failure of waveform occurred in only 2.1% of all patients. The procedure can be easily performed at the bedside, is safe, inexpensive, and useful for the management of severe head injuries. Meningitis was recognized in 4.7% of all patients.

Barbiturates in the management of severe head injuries

Barbiturates in the management of severe head injuries

Prediction of outcome and the management of severe head injuries: the attitudes of neurosurgeons.

We gave a questionnaire to a multinational group of 59 neurosurgeons to discover their views about certain aspects of predictions of outcome after severe head injury. Although there was wide variation in the opinions expressed, a majority of clinicians agreed that estimations of prognosis are possible within 3 days of severe head injury, that these estimates influence some of their management decisions, and that computer predictions should be at least as reliable as those of an experienced clinician. The findings suggest that clinicians may be receptive to the use of computerized predictions of outcome, but also indicate that many other factors influence difficult clinical decisions.

Prediction of outcome and the management of severe head injuries

We gave a questionnaire to a multinational group of 59 neurosurgeons to discover their views about certain aspects of predictions of outcome after severe head injury. Although there was wide variation in the opinions expressed, a majority of clinicians agreed (a) that estimations of prognosis are possible within 3 days of severe head injury, (b) that these estimates influence some of their management decisions, and (c) that computer predictions should be at least as reliable as those of an experienced clinician. The findings suggest that clinicians may be receptive to the use of computerized predictions of outcome, but also indicate that many other factors influence difficult clinical decisions. (Neurosurgery 19:989-991, 1986)

High dose glucocorticoids in the management of severe head injury: Giannotta SL, Weiss MH, Apuzzo MLJ, et al Neurosurgery 15:496–501 Oct 1984

High dose glucocorticoids in the management of severe head injury: Giannotta SL, Weiss MH, Apuzzo MLJ, et al Neurosurgery 15:496–501 Oct 1984

Management of Severe Head Injury under Hypothermia

Management of Severe Head Injury under Hypothermia