XXV. Head Trauma (Don Marion Rusner Origin and
Evaluation of Plateau Wavews J. Neurosurg 60: 312-
324 1984)
A. Don't treat hypertension without thinking about
ICP. The brain may need that pressure for
perfusion in the face of an elevated ICP.
B. Goals in the management of head injured
patients
1. Identification and treatment of
concommitant injuries.
a. Head injured patients may have trauma
to other areas of the body that can
impact on ICP. These include tension
pneumothorax and pericardial
tamponade. If the combination of high
airway pressures and brain swelling
exists, think of pneumothorax and
mainstem intubation. In one case of a
head injured patient with unknown
tension pneumo, airway pressure rose
to 50-60 and CVP to 18-20. Blood was
present in the ET tube.
b. ET tubes placed in the field by
paramedics or by ER personnel may not
be in the correct location. Verify
correct positioning by auscultation
and/or direct larngoscopy upon patient
arrival. If a rush roller patient
appears blue upon arrival in the OR,
think esophageal instubation.
c. Cervical Spine fractures, basilar
skull fractures, avoid N2O
d. Prevention of Secondary brain injury
by maintaining cerebral oxygenation
and perfusion.
e. Patient's with a Glascow coma scale of
less than 7 may be routinely
intubated. If you intubate with sux,
you must follow with vec to prevent
bucking.
f. Treatment of ICP
C. If you pick up an intubated patient at the ICU
for transport to the OR, deepen the paralysis
and give judicious amounts of fentanyl.
D. PEEP and ICP - Waterfall
Tumors