Page 1602 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 118: Head Injury 1121

sign of impending hemodynamic instability is a progressive decrease in
urine output despite volume replacement that appears to be adequate in • Dunham CM, Bosse MJ, Clancy TV, et al. Practice management
guidelines for the optimal timing of long-bone fracture stabili-
relation to the recognized injuries. Deterioration in the respiratory status
should prompt assessment for the presence of a pneumothorax, lung zation in polytrauma patients: the EAST practice management
guidelines work group. J Trauma. 2001;50:958.
contusion, or another type of subtle injury, such as a ruptured esopha-
gus with pleural effusion that may present later in the patient’s course. • Eastridge BJ, Salinas J, McManus JG, et al. Hypotension begins
Delayed cardiac decompensation without obvious blood loss should at 110 mm Hg: redefining “hypotension” with data. J Trauma.
warrant investigation for myocardial contusion, cardiac tamponade, or 2007;63:291-298.
tension pneumothorax. The latter condition may develop on institution • Miller PR, Moore PS, Mansell E, et al. External fixation or arterio-
of positive pressure ventilation in a patient who sustained a simple pneu- gram in bleeding pelvic fracture: initial therapy guided by markers
mothorax which was not treated by tube thoracostomy. Deterioration in of arterial hemorrhage. J Trauma. 2003;54:437.
hemodynamics and cardiorespiratory status may result from development • Offner PJ, De Souza AL, Moore EE, et al. Avoidance of abdomi-
of traumatic abdominal compartment syndrome in the ICU. Recognition nal compartment syndrome in damage control laparotomy after
of this syndrome requires prompt decompression of the abdomen and the trauma. Arch Surg. 2001;136:676.
intensivist should be alert to the conditions which result in abdominal
compartment syndrome so that it may be recognized early and treated • Riskin DJ, Tsai TC, Riskin L, Herandez-Boussard T, et al. Massive
promptly. Respiratory deterioration may also occur in spontaneously transfusion protocols: the role of aggressive resuscitation versus prod-
39
breathing patients who sustained a rupture of the diaphragm and in uct ratio in mortality reduction. J Am Coll Surg. 2009;209:198-205.
whom the abdominal viscera at first remained in the abdominal cavity but • Trunkey DD. Trauma. Sci Am. 1983;249-328.
later migrated above the diaphragm, causing respiratory compromise. For
these reasons, continuous close monitoring in an ICU setting is crucial to
improving survival of the multiply injured patient. REFERENCES
Diagnostic imaging is obtained as indicated. In most multiply injured Complete references available online at www.mhprofessional.com/hall
patients, these will include cervical spine x-rays (or more commonly CT
of the spine) if there is any suggestion of cervical spinal injury, a chest
x-ray, and an x-ray of the pelvis. Other radiologic investigations will CHAPTER Head Injury
be undertaken as indicated by the assessment, such as the presence of
deformity in an extremity warranting x-ray to confirm a fracture. 118 John M. Oropello
Nirav Mistry
DECIDING ON SURGICAL INTERVENTION Jamie S. Ullman

One of the most important decisions to be made in the emergency man-
agement of the trauma patient is whether or not surgical intervention is KEY POINTS
indicated. If the decision based on the initial assessment is that surgery is
not warranted, then continued observation in an intensive care setting is • Primary injury occurs at the moment of trauma and is the result
necessary for most multiply injured patients. This approach, combined of direct damage to brain tissue. All subsequent preventable brain
with a high index of suspicion, will minimize the risk of overlooking injuries are termed secondary injuries.
occult injuries, such as a subcapsular hepatic hematoma in a patient • Head trauma is associated with cervical spine injury and stabilization
who is stable initially, but later decompensates with decompression and of the spine (eg, cervical collar, log rolling) is maintained until the
hemorrhage from the hematoma. spine is cleared.
In considering the need for surgical intervention, the common emer-
gency indications are for thoracic, abdominal, and intracranial injuries. • Hypoxemia, hypotension, and raised intracranial pressure (ICP) are
the leading causes of death in severe traumatic brain injury (TBI)
For thoracic injuries, this includes an uncontrollable pneumothorax and are related to the severity of the brain injury as well as the
representing a major tracheobronchial injury, a massive hemothorax systemic complications.
usually representing laceration of a systemic artery (eg, intercostal or
internal mammary) or central pulmonary vessel, a widened mediasti- • Critical care of the TBI patient is centered on airway control,
num or other sign of aortic disruption, or signs of a ruptured esophagus, favoring early intubation, resuscitation, maintenance of homeosta-
cardiac tamponade, or air embolism. The hypovolemic patient who sis, early detection of neurosurgically treated complications, and
suddenly becomes asystolic or suffers electromechanical dissociation interpretation of information from bedside monitors to minimize
is also a candidate for emergency thoracotomy. The details of assess- disruption of cerebral perfusion, (oxygenation and nutrient
ment and management of these indications for thoracic surgery are supply) in order to prevent or limit secondary injury.
considered in Chap. 120. The indications for laparotomy in the multiply • Level II evidence supports a minimum systolic blood pressure of
injured patient are signs of perforation, or hemorrhage in general. Other 90 mm Hg. An SBP of <90 mm Hg must be avoided if possible, or
relative indications are discussed in more detail in Chap. 120. rapidly corrected.
The indication for surgical intervention in head injuries is usually a • Currently there is no evidence from controlled clinical trials to
change in level of consciousness secondary to a mass lesion requiring indicate an optimal CPP goal in terms of reducing secondary
evacuation or placement of an intracranial pressure monitoring device. ischemic injury or improving the neurological outcome; however,
published guidelines state as a level III recommendation that the
KEY REFERENCES treatment range for CPP should be 50 to 70 mm Hg. Maintaining
• American College of Surgeons Committee on Trauma. Advanced CPP >70 mm Hg has been associated with the development of
Trauma Life Support for Physicians. Chicago, IL: American acute respiratory distress syndrome (ARDS).
®
College of Surgeons; 2008. • TBI is the second highest risk factor for the development of venous
• Bickell WH, Wall MJ Jr, Pepe PE, et al. Immediate vs. delayed thromboembolism (VTE), second only to acute spinal cord injury
fluid resuscitation for hypotensive patients with penetrating torso and the incidence of deep venous thrombosis (DVT) 7 to 10 days
injuries. N Engl J Med. 1994;331:1105. after TBI is as high as 31.6% even with mechanical prophylaxis.

section10.indd 1121 1/20/2015 9:20:11 AM