Neurosurgery notes/Trauma/Head Trauma general/Associated severe systemic injuries

Associated severe systemic injuries

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Head Trauma general

Intraabdominal injuries

  • Diagnosed
    • Diagnostic peritoneal lavage (DPL) looking for bloody fluid or
    • FAST (focused abdominal sonogram for trauma) are often used by trauma surgeons to assess for intra-abdominal hemorrhage.
  • If negative AND the patient is hemodynamically stable, the patient should be taken for cranial CT
  • If positive DPL OR positive FAST and/or hemodynamic instability may need to be rushed to the O.R. for emergent laparotomy by trauma surgeons without benefit of cerebral CT.
  • Neurosurgical management is difficult in these patients, and must be individualized.
  • These guidelines are offered:

      • Operating on patients in DIC is usually disastrous.

      • ❌ CAUTION: many patients with severe trauma may be in DIC (either due to systemic injuries, or directly related to severe head injury possibly because the brain is rich in thromboplastin).
      • At the least, check a PT/INR/PTT.

      If GCS> 8 (which implies at least localizing)

      • Operative neurosurgical intervention is probably not required
      • Utilize good neuroanesthesia techniques
        • Elevate head of bed,
        • Judicious administration of IV fluids,
        • Avoiding prophylactic hyperventilation
      • Obtain a head CT scan immediately post-op

      If patient has focal neurologic deficit,

      • An exploratory burr hole should be placed in the O.R. simultaneously with the treatment of other injuries.
      • Placement is guided by the pre-op deficit

      If there is severe head injury (GCS ≤ 8) without localizing signs, or if initial burr hole is negative, or if there is no pre-op neuro exam,

      • Measure the ICP:
        • Insert a ventriculostomy catheter
          • If the lateral ventricle cannot be entered after 3 passes, it may be completely compressed or it may be displaced,
          • Instead use an
            • Intraparenchymal fiberoptic monitor
            • Subarachnoid bolt
        • Normal ICP:
          • Unlikely that a surgical lesion exists.
          • Manage ICP medically and, if an IVC was inserted, with CSF drainage
        • Elevated ICP (≥ 20mm Hg):
          • Inject 3–4 cc of air into ventricles through IVC, then obtain portable intraoperative AP skull X-ray (intraoperative pneumoencephalogram) to determine if there is any midline shift.
          • If there is mass effect with ≥ 5mm of midline shift, explore surgically with burr hole(s) on the side opposite the direction of shift.
            • Routine use of exploratory burr holes for children with GCS=3 has been found not to be justified
          • If no mass effect, intracranial hypertension is managed medically and with CSF drainage

Fat embolism syndrome

  • Most often seen after a long bone fracture
    • Femoral: most common
    • Clavicular
    • Tibial
    • Isolated skull fracture: rare
  • Although almost all patients have pulmonary fat emboli at autopsy, the syndrome is usually mild or subclinical, only ≈ 10–20% of cases are severe, and the fulminant form leading to multiple organ failure is rare.
  • Clinical findings usually appear within 12–72 hrs of injury
  • Classic clinical triad of: (not always present)
    • Acute respiratory failure:
      • Including
        • Hypoxemia
        • Tachypnea
        • Dyspnea
      • Diffuse pulmonary infiltrates (usually seen as bilateral fluffy infiltrates).
        • May be the only manifestation of fat emboli in up to 75% of cases
    • Global neurologic dysfunction:
      • May include confusion (PaO2 usually not low enough to account for these changes), lethargy, seizures
    • Petechial rash:
      • Seen ≈ 24–72 hrs after the fracture, usually over thorax
  • Other possible findings include:
    • Pyrexia
    • Retinal fat emboli
  • No specific test for fat embolism syndrome (FES).
    • The following have been proposed, but have poor sensitivity and specificity:
      • Fat globules in the urine (positive in ≈ one–third)
      • Serum,
      • Serum lipase activity.
      • Bronchoalveolar lavage >5% of cells in the washings staining for neutral fat with red oil.
    • Nonspecific tests include ABG (findings: hypoxemia, hypocarbia from hyperventilation, respiratory alkalosis).
  • Treatment
    • Pulmonary support with oxygen, and mechanical ventilation if necessary including use of PEEP.
    • The use of steroids is controversial.
    • Ethyl alcohol (to decrease serum lipase activity) and heparin have not been shown to be of benefit.
    • Early operative fixation of long bone fractures may reduce the incidence of FES.
  • Outcome
    • Usually related more to the underlying injuries.
    • Although FES itself is usually compatible with good recovery, 10% mortality is usually quoted

Indirect optic nerve injury

  • General information
    • ≈ 5% of head trauma patients manifest an associated injury to some portion of the visual system.
    • Approximately 0.5–1.5% of head trauma patients will sustain indirect injury (as opposed to penetrating trauma) to the optic nerve,
  • Due to
    • Ipsilateral blow to the head (usually frontal, occasionally temporal, rarely occipital).
  • The optic nerve may be divided into 4 segments:
    • Intraocular (1mm in length)
    • Intraorbital (25–30mm)
    • Intracanalicular (10mm)
      • Most common one damaged with closed head injuries
    • Intracranial (10mm)
  • Funduscopic
    • Abnormalities visible on initial exam indicates
      • Anterior injuries
        • Injury to the intraocular segment (optic disc) or the 10–15mm of the intraorbital segment immediately behind the globe where the central retinal artery is contained within the optic nerve
      • Posterior injuries
        • Occurring posterior to this but anterior to the chiasm
        • Take 4–8 weeks to show signs of disc pallor and loss of the retinal nerve fiber layer.
  • Treatment
    • No prospective study has been carried out.
    • Optic nerve decompression has been advocated for indirect optic nerve injury;
      • Results are not clearly better than expectant management
      • Exception: Documented delayed visual loss appears to be a strong indication for surgery.
    • Transethmoidal is the accepted route, and is usually done within 1–3 weeks from the trauma.
    • The use of “megadose steroids” may be appropriate as an adjunct to diagnosis and treatment.

Posttraumatic hypopituitarism

  • Trauma is a rare cause of hypopituitarism.
  • After
    • Closed head injury
      • With or without basilar skull fracture
    • Penetrating trauma.
  • When it occurs
    • 100% deficient growth hormone and gonadotropin,
    • 95% had corticotropin deficiency,
    • 85% had reduced TSH,
    • 63% had elevated PRL.
    • 40% had transient or permanent DI.