Carotid injury secondary to blunt head trauma: case report

Internal carotid artery (ICA) injuries including dissection, pseudoaneurysm, occlusion, and carotid-cavernous fistula (CCF) are well-recognized as potential consequences of blunt head trauma. We discuss a patient with a basal skull fracture and several types of carotid injury who was managed conservatively with excellent outcome.

Head trauma in young athletes

Despite the most meticulous preparation for the most noncontact of sports, head injuries are a fact of daily life. Physicians should continue to strive to decrease the occurrence of these injuries by monitoring events for adherence to guidelines designed to reach this end. Contributing to policymaking, unannounced spot checks at practices and games, and appropriate on-site and follow-up care may help minimize the complications and sequelae of this injury.

Pathogenetic and therapeutic considerations of carotid-cavernous sinus fistulas

Carotid-cavernous sinus fistula (CCF) is a syndrome in which arteriovenous shunts exist between the carotid artery and the cavernous sinus. These shunts vary widely in pathogenesis, angiogram, haemodynamics and treatment. Several systems of classification in terms of either haemodynamics, aetiology and/or pathogenesis have been reported, but they are not comprehensive. A more comprehensive and simpler nomenclature of classification is now required. Fifty seven cases of CCFs were analyzed and were classified according to their pathogenesis, angiography and treatment modalities. There were 11 traumatic CCFs with direct shunts (T-D group), and 2 traumatic CCFs with indirect shunts (T-I group). Spontaneous CCFs were divided into three groups. There were 37 spontaneous CCFs caused by dural arteriovenous shunts that were naturally classified as being indirect shunts (SD-I group). There were 5 spontaneous CCFs caused by suspected connective tissue disorders, such as fibromuscular dysplasia, Ehlers-Danlos syndrome etc.; these had direct shunts. Care was needed to avoid dissection of the artery or complications due to the fragility of connective tissue (SC-D group). There were 2 spontaneous CCFs caused by the rupture of an inflaclinoid aneurysm without any background of connective tissue disorder; these had direct shunts (SA-D group). By this system of grouping and use of abbreviations, each case of CCF can be clearly delineated in terms of its pathogenesis and selection for appropriate treatment.

Management of trauma in the elderly patient

Injuries among the elderly are a common occurrence and, as the population ages, the elderly will constitute a prominent proportion of trauma patients. The elderly sustain the same injuries that younger people do; however, because of a variety of age-related processes, the elderly suffer more severe consequences from these injuries. Epidemiologic factors and physiologic processes are used to explain the "susceptibility" of the elderly population to traumatic injuries. Recommendations for initial resuscitation and management of specific injuries are presented along with general principles of injury prevention and rehabilitation. The socioeconomic cost of trauma in the elderly is discussed in terms of physical disabilities and financial burdens.

The effect of blood volume replacement on the mortality of head-injured patient

In 77 head-injured and transfused patients, the amount of blood volume replacement (BVR) and patient outcome were retrospectively analyzed. They were divided into four groups of intracranial lesion by initial CT; acute subdural hematoma (SDH) with or without other lesions, traumatic subarachnoid hemorrhage only, epidural hematoma only and all other lesions. Result shows SDH is the most vulnerable to massive transfusion and BVR more than 5000 ml was fatal. Patients with other lesions have high possibility of survival even if BVR amounts to 7000ml. It is concluded, for patients resuscitated with excessive amount of transfusion (> 5000 ml), follow up CT and some vigorous treatment such as administration of hypertonic solutions should be scheduled.

Conservative management of extradural haematomas

The personal experiences with a series of 57 conservatively treated extradural haematomas (EDH) are presented and the criteria for conservative management outlined. Main preconditions are absence of neurological deficit, close clinical supervision and repeated CT check-ups.

Management of closed head injury in the patient with maxillofacial trauma

Closed head injury (CHI) affects approximately one in five patients who sustain facial fractures. The effects can range from simple loss of consciousness to coma and death. The high incidence of CHI in the facial trauma population and the potential for mortality and neurologic morbidity make it a distinct concern of the practicing oral and maxillofacial surgeon. This article discusses the evaluation, monitoring, and management of CHI and includes special consideration of the treatment of maxillofacial injuries in these patients.

[The course of intracranial pressure during respirator weaning after severe craniocerebral trauma]

To analyze the characteristics of hemodynamic parameters and cerebral dynamics, the courses of intracranial pressure (ICP), cerebral perfusion pressure (CPP), mean arterial blood pressure (MAP) and PaCO2 were analyzed retrospectively in 29 patients with severe head injury, comparing periods before and after the ventilatory mode was changed from controlled mechanical ventilation to spontaneous breathing with continuous positive airway pressure. Measurements were done before and after changing of the ventilation. Patients were allocated either to group I (n = 22, ICP remained stable: 18 +/- 2 mm Hg in both periods of observation) or group II (n = 7, ICP increased from 25 +/- 3 mm Hg to 33 +/- 4 mm Hg, P < 0.05). While changes of MAP did not reach significant levels in either group, concomitant changes in CCP appeared in group II (67 +/- 2 mm Hg to 60 +/- 2 mm Hg). Based on the observation of relatively high incidence of ICP increases and deterioration of CPP during weaning from ventilator, it is recommended that continuous ICP monitoring should be continued.

Conservative management of epidural haematomas. Prospective study of 15 cases

Conservative management of epidural haematoma (EDH) depends on a balance between expansion and resorption rate of the clot. 15 patients with EDH whose CT scans demonstrated a small EDH and were asymptomatic or with minor symptoms or with a delayed diagnosis were treated conservatively. The thickness of haematoma ranged between 4.9-40.8 mm. In two patients, the haematoma extended from the posterior fossa to the supratentorial region. In 7 patients, additional intracranial pathology was detected. None of the patients had neurological deterioration on follow up. The second CT was performed on second day at the earliest, in fourth week at the latest. We conclude that the patients with EDH who are neurologically stable during the first 24 hours after trauma, with small EDH and with minor or no symptoms or signs, might be candidates for conservative management. An absolute precondition for conservative management is close supervision of the patient.

Current level of prehospital care in severe head injury--potential for improvement

The fact that 50-60% of cases with severe head injury result from traffic accidents underlines the great significance of emergency care and of its organization. Many patients with severe head injury are threatened from vital complications diagnosed with delay, or not at all, which plays a major role not only for survival but also for the quality of recovery and regaining of employment capabilities. Thus, the necessity of qualified and trained physicians with experience in emergency care is obvious. Emergency care can be divided into an early resuscitation phase of securing or reestablishment of general vital functions, and a following stabilisation phase with administration of measures directed towards the specific conditions underlying trauma. 1. Prevention and treatment of respiratory complications. In addition to classical emergency care measures, endotracheal suction might be employed. The most effective method for clearance of airways and, thus, securing of the cerebral oxygenation is endotracheal intubation. Early intubation provides also for control of the intracranial pressure by hyperventilation and administration of O2. Recently assistant ventilation is available as compared to the past when only controlled ventilation was possible. 2. Circulatory support. A major requirement for a sufficient cerebral perfusion is an adequate cerebral perfusion pressure making necessary early fluid substitution. In case the patient is in circulatory shock, shock-specific treatment may compete with adequate positioning of the patient. 3. Pharmacological treatment in the prehospital phase. Although dexamethasone has been reported to directly influence brain edema, its benefits in head injury are not clear. Currently conducted clinical studies using markedly higher doses may provide so far missing information.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessment of emergency care in trauma patients

There are many reasons for evaluation of an emergency care system, such as expenses (1.035 Bio. DM in 1985) and quality control. From January 1, 1987 to December 31, 1987 information on all patients seen by an emergency physician in the field have been recorded prospectively in a standard form by the Cologne emergency medical services. Cologne has 1,000,000 inhabitants and covers an area of 405 km2. The patients' status, diagnosis and therapeutic interventions were recorded. Trauma patients were further assessed as to time of accident, cause of accident, and trauma score. All trauma patients with a trauma score < 16 were followed up to their discharge from the hospital. In 1987, 2,073 trauma patients were treated. Overall mortality at the time of discharge was 9.2%. This result alone, however, is not sufficient for assessment of the trauma system. It is important to provide better information on the patient. The trauma evaluation score already used in the US became also a valid instrument in West-Germany. It shows a high correlation between survival and the patients' physiological status in the field. Standard curves could be established for comparing individual or regional trauma systems.

Management of intracranial hypertension in head injury: matching treatment with cause

Raised intracranial pressure (ICP) is common after head injury and strongly associated with mortality and morbidity. Empirical and prophylactic therapy with steroids and barbiturates has proved unsuccessful. Ideally, therapy should be targeted at the predominant cause of the increase in ICP. In head injury these may be (1) an increase in cerebral blood volume best treated by hyperventilation and hypnotic drugs. (2) an increase in brain water content best treated by osmotherapy and (3) increased CSF outflow resistance best treated by CSF drainage. This last cause seldom predominates in head injury. To determine whether it is possible to identify the best therapy in individual head injured patients, we are comparing osmotherapy (mannitol) and hypnotic drugs (thiopentone and gamma-hydroxybutyrate) in selected patients with severe head injury where it is possible to maintain standard conditions of ventilation and stable blood pressure and to measure ICP, CPP, brain electrical activity, PR ratio of the ICP wave form and cerebral AvDO2 before and during each of the two forms of therapy. Effective therapy means that ICP has been reduced to 20 mm Hg with preservation or improvement in CPP. 17 patients have been studied so far and 4 groups identified. Osmotherapy was superior to hypnotic in 5 cases, hypnotic superior to mannitol in 3 cases, both were effective in 5 cases and neither effective in 4 cases. Patients in whom hypnotics were superior tended to be younger, with diffuse rather than focal brain injury, had the highest levels of brain electrical activity prior to treatment and a higher PR ratio.(ABSTRACT TRUNCATED AT 250 WORDS)

Prehospital management of head injuries: international perspectives

The extent of disability and, therefore, the management of head injured patients before their arrival to the hospital should be influenced by a number of factors including: the age of the victim (children with comparable severity of head injury have less disability and lower mortality than persons over the age of 40); the type of injury (motor-vehicle accidents are the most frequent cause of head trauma in the U.S. and Canada); the decision to transfer the patient to either the nearest hospital or to a designated neurotrauma center (at several communities in the U.S. and Canada, recent analysis has demonstrated that the extent of disability and the mortality among head injured victims can be significantly decreased by their admission to specialized trauma units); elapsed time as another important factor (at least in one type of traumatic injury--acute subdural hemorrhage--it has been shown than an interval of less than 2 hours between the time of injury and the time of the craniotomy can significantly decrease both the mortality and the extent of neurological impairment among the survivors). A number of acute injury effects on endothelial, neuronal or glial cells could potentially be influenced by compounds that may be administered before the victim arrives to the hospital.(ABSTRACT TRUNCATED AT 250 WORDS)

The early management of head injury

Acute management involves triage, well directed investigation and timely surgical intervention when necessary. All are discussed in this review. Cerebral blood flow (CBF) and flow velocity assessment are among the other investigations mentioned. Other topics include paediatric head injury, cerebrospinal fluid (CSF) fistulae, stab wounds and post-traumatic epilepsy.

Adverse effects of prolonged hyperventilation in patients with severe head injury: a randomized clinical trial

There is still controversy over whether or not patients should be hyperventilated after traumatic brain injury, and a randomized trial has never been conducted. The theoretical advantages of hyperventilation are cerebral vasoconstriction for intracranial pressure (ICP) control and reversal of brain and cerebrospinal fluid (CSF) acidosis. Possible disadvantages include cerebral vasoconstriction to such an extent that cerebral ischemia ensues, and only a short-lived effect on CSF pH with a loss of HCO3-buffer from CSF. The latter disadvantage might be overcome by the addition of the buffer tromethamine (THAM), which has shown some promise in experimental and clinical use. Accordingly, a trial was performed with patients randomly assigned to receive normal ventilation (PaCO2 35 +/- 2 mm Hg (mean +/- standard deviation): control group), hyperventilation (PaCO2 25 +/- 2 mm Hg: HV group), or hyperventilation plus THAM (PaCO2 25 +/- 2 mm Hg: HV + THAM group). Stratification into subgroups of patients with motor scores of 1-3 and 4-5 took place. Outcome was assessed according to the Glasgow Outcome Scale at 3, 6, and 12 months. There were 41 patients in the control group, 36 in the HV group, and 36 in the HV + THAM group. The mean Glasgow Coma Scale score for each group was 5.7 +/- 1.7, 5.6 +/- 1.7, and 5.9 +/- 1.7, respectively; this score and other indicators of severity of injury were not significantly different. A 100% follow-up review was obtained. At 3 and 6 months after injury the number of patients with a favorable outcome (good or moderately disabled) was significantly (p less than 0.05) lower in the hyperventilated patients than in the control and HV + THAM groups. This occurred only in patients with a motor score of 4-5. At 12 months posttrauma this difference was not significant (p = 0.13). Biochemical data indicated that hyperventilation could not sustain alkalinization in the CSF, although THAM could. Accordingly, cerebral blood flow (CBF) was lower in the HV + THAM group than in the control and HV groups, but neither CBF nor arteriovenous difference of oxygen data indicated the occurrence of cerebral ischemia in any of the three groups. Although mean ICP could be kept well below 25 mm Hg in all three groups, the course of ICP was most stable in the HV + THAM group. It is concluded that prophylactic hyperventilation is deleterious in head-injured patients with motor scores of 4-5.(ABSTRACT TRUNCATED AT 400 WORDS)

Resuscitation fluid for a patient with head injury and hypovolemic shock

The resuscitation of a patient with severe closed head injury and hypovolemic shock is a commonly encountered clinical scenario. The optimal resuscitation formula remains controversial. Aggressive use of crystalloid solutions may worsen brain injury. Early use of mannitol or hypertonic agents may worsen hemorrhage and shock. The optimal approach to the resuscitation of a patient with head trauma and hypovolemic shock is reviewed and discussed. Recent experimental evidence suggests that the early inclusion of an agent such as mannitol in the resuscitation formula may be appropriate despite the evidence of shock. However, the controversy remains unresolved.

Management of head injury. Neurobehavioral outcome

Recent research on overall recovery from closed head injury has focused on improving the prediction of outcome and the influence of age. The aspects of long-term neurobehavioral sequelae and recovery, memory deficit after closed head injury, and language and speech disturbance after head injury are covered in this article.