CURRENT Essentials of Critical Care.pdf

Chapter 13 Neurology 193Head Injuries■ Essentials of Diagnosis• Manifestations depend on extent and location of injury: asymptomatic;headache, nausea, vomiting, or amnesia; lethargy, increasedsomnolence, transient loss of consciousness, confusion,or unresponsiveness; papilledema, pupillary changes, Battlesign, “raccoon eyes,” or focal neurologic signs• Primary injuries include skull fracture, concussion, cerebral contusion,intracranial hemorrhage, diffuse axonal injury• Secondary injuries include intracranial insults (intracranial hypertension,herniation, cerebral ischemia or infarction); systemicinsults (hypoxia, hypotension, electrolyte imbalances)• Complete neurological examination including Glasgow ComaScale and brain stem function• CT scan diagnostic; cerebral angiography identifies dissection,traumatic pseudoaneurysm, vasospasm• Assess for concomitant spinal injury; occurs in 6–8%■ Differential Diagnosis• Seizure, stroke, brain tumor• Hypoglycemia, neurosyphilis • Vasculitis■ Treatment• Stabilize spine• Monitor and protect airway; intubation indicated if GCS 8;fiberoptic guidance for intubation in cervical spine injuries• Monitor cardiac rhythm; fluid resuscitation for SBP 110 mmHg; avoid hypotonic solutions• Serial neurologic examination to monitor for decompensation• Stabilize with target PaCO 2 35–40 mm Hg, mean arterial bloodpressure 90 mm Hg, normal intravascular volume and electrolytes• Manage elevated intracranial pressure: monitor with ventriculostomy;removal of CSF, short-term hyperventilation, head elevation,sedation, correction of hyperthermia; barbiturate comaif maximal medical therapy failed• Surgical indications: failing medical management; prevent irreversibledamage if neurologically deteriorating; certain contusions,hematomas, foreign bodies■ PearlImproved outcomes associated with head trauma are due in part toearly recognition and prevention of disorders that cause secondarybrain injury.ReferenceGuidelines for the management of severe head injury, 2nd ed. Brain TraumaFoundation, 2000.