ABSTRACT Minutes can make the dif...

ABSTRACT

Minutes can make the difference between life and death when patients with strict head injuries require surgery. Subdural, epidural and intracerebral hematomas and cerebral contusions and gunshot injurys are the pathologic entities rencountered most frequently during emergency surgery in patients with rigid head injuries. Neurosurgical team members many times use hyperventilation, mannitol and barbiturates, and sophisticated monitoring modalities to manage patients with accurate head injuries during and after surgery Although monitoring a patient's intracranial hurry (ICP) through a ventriculostomy catheter remains the most numerous widely used gauge of cerebral metabolism, neurosurgical teams also are using fiber-optic ICP monitoring catheters, cerebral children flow measurement probes, microdialysis catheters, jugular venous oxygen saturation catheters, and brain oxygen satisfy measurement electrodes. Coordinated teamwork from perioperative nurses, neurosurgeons, anesthesia care providers, and extremity department staff members helps render certain the best possible outcomes for patients who require surgery for management of peremptory head injuries. AORN J 63 (May 1996) 854-867

Head injuries are among the chiefly serious types of trauma seen in crisis departments (EDs) and ORs. A hardly any minutes, delay in treatment may conclusion in death or permanent disability. It is imperative that perioperative promotes be familiar with all aspects of the surgical management of patients with strict head injuries. This article reviews the basic principles of this management and provides information upon new modalities that are being used to treat patients with inexorable head injuries.

EPIDEMIOLOGY

Each year, approximately 500000 Americans are admitted to hospitals after sustaining traumatic head injuries that cause brain damage. Of this number, an estimated 75000 to 90000 die annually.[1] Approximately 10% of head injuries are classified as rigorous head injuries, which may be defined loosely as injuries that bring into view coma (ie, lack of answer to simple commands). Up to single in kind third of patients with cruel head injuries, excluding those who are dead upon arrival at hospitals, require turn of events craniotomy procedures.[2]

Historically, greatest in quantity discussions of the surgical management of patients with simple head injuries have excluded penetrating trauma. The rising incidence of gunshot anguishs (GSW) to the head indicates that patients with penetrating head injuries will account for a steadily expanding proportion of sudden [i]or[/i] unexpected occurrence craniotomy procedures.

PREOPERATIVE ASSESSMENT

Before a patient with a chaste head injury can undergo surgery neurosurgical team members must perform thorough, moreover rapid, neurologic and radiologic assessments of the patient's injuries.

Neurologic assessment. The patient's neurologic status forms the basis forward which all subsequent treatment decisions are made. The cornerstone of neurologic assessment is the Glasgow Coma Scale (GCS) The GC categorizes the severity of a patient's head injury according to assessing three responses (ie, vocal, inspection opening, motor responses). The patient's composite GC score may range from three (ie, no vocal reply no eye opening, no motor reply to 15 (ie, oriented to living body place, time, spontaneously opens vigilances obeys commands).[3] Neurosurgical team members also can use the GC to monitor the patient's postoperative progress

If the patient is comatose, examination of his or her pupillary light bent back is especially important. In the absence of orbital trauma, a dilated pupil that does not constrict in reply to light implies the air of increased intracranial pressure (ICP) and ongoing herniation of the patient's intracranial contentments from an expanding hematoma or other mass lesion. As the pupilloconstrictor fibers (Table 1) forward the periphery of the third cranial resolution become nonfunctional because of compression at swollen or displaced brain tissue, the ipsilateral (ie, forward the same side) pupil dilates. If caused at a mass lesion, this is a real neurosurgical emergency that requires immediate surgical intervention. Although all comatose patients require ready computerized tomography (CT) scans, unruffled greater haste is required for a patient with a unilaterally fixed and dilated pupil or other localizing signs (eg hemiparesis, unequal motor responses)

Table 1

GLOSSARY(1)

* Burr holes: greatest in number basic form of craniotomy used to suppress localized fluid collection beneath the dura mater or as a preliminary stair in the creation of a bone flap.

* Contralateral: Situated forward affecting, or pertaining to the opposite side.

* Craniotomy: Opening of the brain to expose the brain and intracranial structures

* Duraplasty: Repair of imperfections in the dura mater.

* Hypocapnia: Subnormal concentration of carbon dioxide in the blood

* Ipsilateral: Located upon affecting, or pertaining to the same side.

* Kocher-Cushing reflex: A compensatory rejoinder designed to provide adequate cerebral perfusion press in the presence of increasing intracranial pressure