Severe Head Injury

• Primary injury: Biomechanical
Contusions, lacerations, diffuse vascular injuries, intracranial haemorrhage

Main objective as anaesthetists

• Prevent secondary injury from
Hypoxia
Hypercarbia
Hypotension
Hypertension (arterial/venous)
Hyperglycaemia
Raised intracranial pressure

Severe Head Injury - objectives(1)

• Monitor for neurological deterioration during other procedures
• Perform neuro-resuscitative measures when indicated
• All airway manipulation with cervical spine immobilisation
5 ­ 17% prevalance of cervical spine fractures in patients with severe head injuries

Severe Head Injury - objectives(2)

• Control oxygenation and ventilation
Aim for PaCO2 ~ 30 mmHg, no PEEP
• Optimise cerebral venous drainage
Keep paralysed, posture, avoid neck compression
• Maintain high “normal” cerebral perfusion pressure
• Maintain sedation
• Fluid resuscitation with isotonic fluids

Severe Head Injury - objectives(3)

• Correct anaemia: aim for ~ Hb 100gm/L
• Anaesthesia drugs ­ no cerebral vasodilators
• Seek neurosurgical advice early
• Don’t waste time
• Rapid diagnosis of intracranial pathology
• Immediate definitive management (surgical)

Management of Acute Elevations in ICP

• Hyperventilation
• Osmotherapy ­ Mannitol 0.5 - 1 gm/kg
• If hypertensive consider thiopentone/fentanyl
• Plan for urgent head CT
• Plan for definitive surgical procedure or insertion of ICP monitor
• Basic principles still apply

Indications for Intracranial Pressure monitoring

• Severe head injury
Defined as a GCS of 3 - 8 after CPR
And
• Abnormal CT scan with
• Contusions
• Haematomas
• Oedema
• Or compressed basal cisterns