الفهرس 
IntroductionOnly 14 pages are availabe for public view
 |  | from | 110 |  |  |
| | | from | 110 | | |
Abstract
The adopted approach is further Summary Guidelines for the management of severe head injury in adults. The importance of preventing and treating secondary
insults is emphasized and the principles on which treatment is based are reviewed.
Guidelines presented are of a pragmatic nature, based on consensus and expert opinion, covering the treatment from accident site to intensive care unit. Specific aspects pertaining to the conduct of clinical trials in head injury are highlighted.
The adopted approach is further discussed in relation to other approaches to the development of guidelines, such as evidence based analysis.
The management of patients with severe head injury is complex and requires a coordinated, comprehensive, and multidisciplinary approach. Central to the management of the head-injured patient is the prevention of secondary neuronal injury by avoiding hypotension and hypoxemia. Considering the enormous costs to society, we need to invest greater resources in the prevention of this pandemic.
• Always treat the greatest threat to life and avoid further harm.
• A falling or persistently reduced Glasgow Coma Scale (GCS) score and amnesia are associated with an increased risk of intracranial complications.
• Do NOT assume that signs and symptoms of a person’s injury are due to intoxication from alcohol or drugs.
• Initiate referral to the Emergency Department if there are signs and symptoms that are risk factors for acute intracranial complications of TBI.
• People who do not require further medical assessment must be provided with written information about when to seek medical help.
Coordinated trauma systems reduce mortality in serious injury, including serious neurotrauma.
1. Always address immediate life-threatening injuries and begin resuscitation using ATLS protocols.
a. Normal saline is the preferred crystalloid solution.
b. Blood products are preferred over albumin and hespan if colloids are necessary.
c. Consider recombinant Factor VIIa for life threatening intracranial bleeding.
d. Consider hyperventilation (goal PaCO2 30-35 mm Hg) to decrease ICP.
e. Antibiotics are unnecessary for isolated closed head injuries. Patients with open head injuries should receive 2 grams (child 50 mg/kg) cefazolin (Ancef) IV on admission and every 8 hours until wounds are closed.
f. Steroids provide no benefit to head injured patients.
2. Two most important factors to manage:
f. Hypotension: keep SBP > 90 mm Hg
g. Hypoxemia: keep SpO2 Sat > 93%
3. Document neurological examinations. These should include:
a. Glasgow Coma Score (GCS)
b. Size and reactivity of pupils
c. Presence of gross unilateral weakness, paraplegia, or quadriplegia
d. Interval changes while at your facility
4. Neurosurgeons in our hospital prefer to examine patients when they arrive. Avoid medications which cause long lasting sedation or paralysis.
*at no time should these preferences override the need for safe transport*
a. Vecuronium (Norcuron) 5-10 mg (child 0.1 mg/kg) IV is preferred for paralysis.
Avoid redosing within one hour of arrival in Balad.
b. Propofol (Diprivan) 5-10 mcg/kg/min IV is preferred for sedation.
c. Intermittent administration of narcotics is preferred over continuous intravenous drips for pain control.
5. If therapy for intracranial hypertension is needed prior to transfer:
a. Consider 23% NS 30 cc one time bolus IV over 15 minutes (child 0.5 cc/kg).
b. If 23% sodium chloride is unavailable, consider 3% NS 250-500 cc IV bolus (child 5 cc/kg) followed by continuous infusion 40 cc/h (child 5 cc/kg/hr).
c. If signs of herniation or severe edema are present, consider Mannitol 1 g/kg bolus IV, followed by 0.5 g/kg rapid IV push q4h.
*do not use mannitol in hypotensive or under resuscitated patients*
6. Antiepileptic medications for seizure prophylaxis:
a. Consider for all patients with intracranial hemorrhage, penetrating brain injury, seizure following the injury, or GCS 3-8.
b. Fosphenytoin (Cerebyx) is the preferred parenteral (IV or IM) medication:
i. Adults: load 1 gram IV over 10 minutes, followed by 100 mg IV q8h.
ii. Children: load 20 mg/kg over 10 minutes, followed by 2 mg/kg IV q8h.