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Address to which opinions and comments should be directed : Secretariat of the Japan Society of Neurotraumatology, c/oDepartment of Neurosurgery, The Jikei University School of Medicine, 3258 Nishi-Shinbashi, Minatoku, Tokyo1058461, Japan. TEL: 81334331111; FAX: 81334596412; E-mail: neurotrauma jikei.ac.jp.

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Neurol Med Chir (Tokyo ) 52, 1 30, 2012

Guidelines for the Management of Severe Head Injury,2nd Edition

Guidelines from the Guidelines Committeeon the Management of Severe Head Injury,

the Japan Society of Neurotraumatology

The guidelines are officially approved by the Japan Neurosurgical Society

Members of the Guidelines Committee on the Management of Severe HeadInjury contributed to the 2nd Japanese version:Chairman Minoru S HIGEMORIMembers Toshiaki A BE , Tohru A RUGA , Takeki O GAWA , Hiroshi O KUDERA ,

Junichi O NO , Takehide O NUMA , Yoichi K ATAYAMA ,Nobuyuki K AWAI , Tatsuro K AWAMATA , Eiji K OHMURA ,Toshisuke S AKAKI , Tetsuya S AKAMOTO , Tatsuya S ASAKI ,Akira S ATO , Toshiyuki S HIOGAI , Katsuji S HIMA , Kazuo S UGIURA ,Yoshio T AKASATO , Takashi T OKUTOMI , Hiroki T OMITA ,Izumi T OYODA , Seigo N AGAO , Hiroshi N AKAMURA ,Young-soo P ARK , Mitsunori M ATSUMAE , Tamotsu M IKI ,Yasushi M IYAKE , Hisayuki M URAI , Shigeyuki M URAKAMI ,Akira Y AMAURA , Tarumi Y AMAKI , Kazuo Y AMADA , andToshiki Y OSHIMINE

Foreword

In 1998, the Guidelines Committee on the Management of Severe Head Injury was established by theJapan Society of Neurotraumatology, and performed a critical review of national and international stu-dies published over the past 10 years. The guidelines were first published in 2000 based on the results ofthis literature review and the Committee consensus, and the 2nd revised edition was published in 2006.This English version of the 2nd edition of the guidelines is intended to promote its concepts and useworldwide.

Key words: head injury, traumatic brain injury, neurotrauma, guidelines, management

INTRODUCTION

On the Revision (2nd Edition) of theGuidelines for the Treatment and

Management of Severe Head Injuries

The Guidelines for the Treatment and Managementof Severe Head Injuries (1st edition) were published

in 2000. Prior to this, there had been various con-troversies over the significance of creating guide-lines, but the basic consensus considered that main-taining the ``quality of medical care'' constantly atan appropriate level (standardization of diagnosis,treatment, and management) is the most important


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Neurol Med Chir (Tokyo ) 52, January, 2012

Guidelines for Management of Severe Head Injury

Target patientsSevere head injuries primarily dealt with in these

guidelines are closed head injuries in adults with aGlasgow Coma Scale (GCS) score of 8 or less afterresuscitation (Note; GCS scores 8 are consideredto correspond to Japan Coma Scale [JCS] scores

30). Patients in whom the GCS score after resusci-tation is 9 or above but deteriorate to 8 or less afteradmission due to secondary brain damage are alsoincluded. Concerning children and elderly patients,only those points of management that are supportedwith references at present are mentioned. Multiplehead injuries and head injuries complicated by spi-nal cord injury were excluded from this edition, be-cause these conditions are more complex and needdifferent approaches from simple head injuries.

On using these guidelinesThese guidelines were prepared to serve academic

purposes and for use by primary care physiciansdealing with severe head injuries such as neurosur-geons and emergency care physicians. These guide-lines were also meant to be easy to understand byphysicians in general, nurses, allied health profes-sionals and paramedics such as emergency medicaltechnicians.

In addition to first aid before arrival at thehospital, resuscitation and management in the inten-sive care unit (ICU), many items including indica-tions to surgical treatment and analysis of thepresent status of special treatment methods, such asbarbiturate therapy and hypothermia, were evaluat-ed. According to similar guidelines in the USA, only3 of these statements were supported by clear andsufficient scientific evidence. They were the follow-ing: 1) Prolonged hyperventilation should be avoid-ed in patients with a normal intracranial pressure(ICP); 2) Glucocorticoid administration provides nobenefit to patients with head injuries; and 3) Ad-ministration of phenytoin, carbamazepine, orphenobarbital is expected to have no inhibitory ef-fect on the occurrence of late epilepsy. These andother items should be taken as experts' recommen-

dations. Therefore, we hope that users of theseguidelines do not unconditionally follow them inmanaging severe head injuries, always rememberingthat many issues remain unresolved, and that newscientific results continue to contribute to futureprogress in medicine.

Also, the guidelines may be used as a reference onmaking decisions in medical controversies andlawsuits, but as the best treatment changes day byday, whether each item of the guidelines should befollowed is left to the decision of individual physi-cians, and they are not intended to restrict rigidly

the medical actions that have to be taken.The specific types of treatment recommended in

these guidelines, such as ``follow-up by computedtomography (CT) is important,'' even being recog-nized as the best practice today, are not necessarilycovered by medical insurance.

Future developmentThese guidelines are the result of analyzing the

status of this problem in Japan as of October 1999,and their constant revision according to the futuredevelopment of medical science and care is antici-pated. In addition, an inclusion of the evaluation ofmultiple injuries and brain injuries complicated byspinal cord injury is desirable in the future.

Course of the Creation of theGuidelines (1st Edition)

Establishment and general rules followed by thepreparatory committee in the creation of Guide-lines for the Treatment and Management of SevereHead Injuries

At the Organizers' Meeting of the 21st AnnualMeeting of the Japan Society of Neurotraumatology(March 25, 1998), it was decided to create the Guide-lines for the Treatment and Management of SevereHead Injuries. Adults with closed head injuries anda GCS score of 8 or less were regarded as the targetpopulation. The guidelines were confirmed to be ex-clusively for academic purposes and would not regu-late or restrict the contents or principles of treat-ment and management at individual medical institu-tions. In addition to pre-hospital care, resuscitation,and ICU management, the present status of indica-tions for surgical and special types of treatment suchas barbiturate therapy and hypothermia treatmentwould be analyzed. Japanese studies published overthe past 10 years would be exhaustively reviewed,and differences compared with the contents of simi-lar guidelines in the United States and Europewould be evaluated.

First meeting of the executive committee for thecreation of Guidelines for the Treatment andManagement of Severe Head Injuries (December12, 1998)

The guidelines were clearly intended to be con-tinuously revised after publication. The guidelineswould be presented as a consensus of experts orcombined with evidence. The guidelines would bedrafted in an easy-to-read and easy-to-understandstyle. Multiple injuries would be excluded.


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Second meeting of the executive committee for thecreation of Guidelines for the Treatment andManagement of Severe Head Injuries (March 26,1999)

The initial guidelines would be restricted to closedhead injuries, and multiple injuries and injuries

complicated by cervical spinal cord injuries wouldbe excluded. The first edition would be created assoon as possible. References would be sorted ac-cording to topics and listed at the end of the guide-lines. The guidelines would be published after ap-proval by all organizers (executive committee mem-bers) of the Japan Society of Neurotraumatology.

Each executive committee member began toauthor the assigned parts of the guidelines in March1998, and the 1st draft was completed in October.On the basis of the discussion at the 1st meeting ofthe executive committee for the creation of theGuidelines for the Treatment and Management ofSevere Head Injuries in December the same year, a2nd draft was prepared in June 1999. It was decidedto itemize the contents as much as possible and to ar-range the items in the order of reliability using thefollowing expressions: 1, ... is desirable ; 2, ... is often(performed) ; 3, ... can be (performed) ; 4, ... may be (performed) ; 5, ... is undesirable ; and 6, ... may be regardedas a contraindication . In these guidelines, ``... isdesirable '' is the strongest positive expression, fol-lowed by ``... is often (performed) .''

The final draft was prepared in October 1999 byevaluating the opinions of all members of the execu-tive committee, and, after several sessions for edit-ing, the guidelines were published in September2000.

Course of Revision of the Guidelines

March 29, 2003 (during the 26th Annual Meetingof the Japan Society of Neurotraumatology), Nara

It was decided to start revising the Guidelines forthe Treatment and Management of Severe Head In-juries.

May 17, 2003 (during the Annual Meeting of theJapanese Congress of Neurological Surgeons),Osaka

Prior to the revision, it was decided to conduct aquestionnaire survey on the application of thepresent guidelines and collect suggestions for the re-vision at the facilities of the organizers of the JapanSociety of Neurotraumatology.

March 25, 2004 (during the 27th Annual Meetingof the Japan Society of Neurotraumatology), Tokyo

The results of the questionnaire survey were

reported, and the following was decided regardingthe revision procedure: The style of the presentguidelines would be maintained in the revision; Thenewly published references (Japanese and interna-tional sources) after the preparation of the existingguidelines would be evaluated; New items concern-

ing severe traumatic brain injury (TBI) in childrenand elderly people would be added; In addition to se-vere injuries, mild injuries that deteriorate into se-vere ones would also be mentioned; Contents men-tioned repeatedly in the current guidelines would beedited to avoid repetitions.

May 14, 2004 (during the Annual Meeting of theJapanese Congress of Neurological Surgeons),Tokushima

The topics and sections of the revised guidelinesdraft and the persons assigned to them were deter-mined.

October 6, 2004 (during the Annual Meeting of theJapan Neurosurgical Society), Nagoya

It was determined to submit the draft manuscriptof the Revised Guidelines for the Management of Se-vere Head Injuries to the secretariat of the Japan So-ciety of Neurotraumatology by the end of November2004.

January 21, 2005 (during the Annual Meeting ofthe Japan Society of Neurosurgical Emergency),Nagoya

It was determined to publish the main text of theRevised Guidelines for the Management of SevereHead Injuries with annotations in the Journal of the Japan Society of Neurotraumatology .

March 24, 2005 (during the Annual Meeting of theJapan Society of Neurotraumatology), Omiya

It was decided that the contents of the manuscriptshould be restricted to the minimum essentials onthe basis of the spirit described in the Introductionto the 1st Edition, and that representative committeemembers would perform final adjustments of the

style and contents.It was also determined that the contents be

itemized as far as possible and that the levels ofrecommendation be expressed in the order ofstrength (1 being the strongest recommendation/in-dication and 5 the weakest recommendation, whichis practically a contraindication) using the followingexpressions, similar to the current guidelines: 1, ... isdesirable ; 2, ... is often (performed) ; 3, ... can be (performed) ; 4, ... may be (performed) ; 5, ... is undesirable ;and 6, ... may be regarded as a contraindication .


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*Note 1: Authorized emergency care technicians can perform endotracheal intubation if there are specific instructionsgiven by a physician under on-line medical control.*Note 2: Emergency care technicians can perform electric defibrillation without specific instructions by a physician. Am-bulance crew members and firefighters other than emergency care technicians can also use an automated externaldefibrillator if they have completed the required training.*Note 3: There have been objections to classifying an injury as severe or deteriorating to severe, if the level of conscious-ness is 100 or above on the JCS score (Table 1) at the initial evaluation. Based on the criteria for triage at the scene, usingthe criteria proposed by the College of Surgeons Committee on Trauma, injuries with a GCS score (Table 2) of 13 or lessare graded as severe.

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CHAPTER 1: E MERGENCY CARE SYSTEM ANDN EUROSURGICAL DEPARTMENT (NEUROSURGEONS )

11. Pre-hospital CareThe objective of pre-hospital care is to minimize

secondary brain damage. For this purpose, it isdesirable to perform the treatment essential for lifesupport and promptly transport the patient to an ap-propriate medical facility based on the degree ofemergency and severity (``load and go'') as follows. i)Securing the airway (mandibular support); ii) correc-tion of hypoxia (administration of high concentra-tions of oxygen); iii) correction of hypotension (com-pression hemostasis); iv) protection of the neck(manual protection of the cervical spine or total spi-nal immobilization using a cervical collar or back-board); and v) first aid for additional injuries.

In Japan, pre-hospital care is performed exclusive-ly by ambulance crews belonging to local govern-ments. i) It is desirable that physicians working foran emergency (casualty) room or medical facility towhich the patient is transported give as much adviceto the ambulance crew as possible (on-line medicalcontrol). *Notes 1 and 2 Emergency care technicians(paramedics) can perform emergency medical treat-ment designated as specified medical actions (secur-ing the airway or a venous line using specializeddevices or equipment under the instructions of aphysician, but such specified medical actions arepresently permitted only in cardiopulmonary arrest.The contents of pre-hospital care performed forpatients with head injury not in cardiopulmonary ar-rest is limited to respiratory management to preventhypercapnia or hypoxemia (ambulances carry mo-nitoring equipment such as an electrocardiographyand SaO 2 monitor, a ventilator for assisted respira-tion with a demand valve, etc.) It is desirable for theLocal Medical Control Council to prepare and rev-iew guidelines for activities concerning the observa-tion of injured patients, their treatment, evaluationof severity and emergency, and selection of facilitiesto transport them to and conduct follow-up evalua-

tion with feedback and reeducation (off-line medicalcontrol).

Physicians on board an ambulance or helicoptercan be directly involved in pre-hospital care based

on one of the following methods: i) Ambulancecrews are stationed at hospitals and can be calledout with a physician; ii) An ambulance crewstationed near a hospital can pick up a physician atthe hospital when it is called out; iii) An ambulancecar or ambulance helicopter with a physician onboard can directly go to the accident site or take overhanding the patient from an ambulance crew duringtransport.

12. Criteria for Transport to Special Facilities,Transport Methods, and Information System121. Concerning all injury patients

It is important to abide by 3 principles: i) accurateevaluation of severity *Note 3 ; ii) appropriate selectionof the hospital to transfer to, and iii) prompt trans-port. For this, it is desirable to select the medical in-stitution according to the evaluation criteria for theseverity and emergency of injuries (advance off-linemedical control) (Fig. 1).

In emergencies requiring the fastest possibletransport time, it is necessary to evaluate the degreeof emergency and severity based on only visual in-spection, auscultation, and palpation (Fig. 2).122. For patients with head injuries/distur-bance of consciousness

Transport to an emergency hospital capable of in-vestigations, including CT, is desirable .

If symptoms of cerebral hernia in need of emer-gency treatment are detected, transport to a facilitywith a neurosurgeon (expert) is desirable . If the mini-mum resuscitation treatment such as securing theairway is necessary, it is desirable to perform it at thenearest medical facility and, then to transfer thepatient to a facility with an expert.

Patients with moderate or more severe distur-bance of consciousness (GCS scores 913) are often

transported to a facility with an expert, but transportto an expert is desirable if the GCS score is 38 (JCS


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Table 1 Japan Coma Scale (JCS) scores * (Ohta et al.;No Shinkei Geka , 1974)

Grade Consciousness level

1-digit code the patient is awake without any stimulation, andis:

1 almost fully conscious

2 unable to recognize time, place, and him/herself3 unable to recal l name or date of bir th2-digit code the patient can be aroused (then reverts to

previous state after cessation of stimulation)10 easily by being spoken to (or is responsive with

purposeful movements, phrases, or words) #

20 with loud voice or shaking of shoulders (or isalmost always responsive to very simple wordslike yes or no, or to movements) #

30 only by repeated mechanical stimuli3-digit code the patient cannot be aroused with any applied

mechanical stimuli, and:100 responds with movements to avoid the stimulus200 responds with slight movements including

decerebrate and decorticate posture300 does not respond at all except for change of

respiratory rate and rhythm

The 9-grade JCS has been more widely used in Japan as asimple and understandable coma scale compared with the15-grade Glasgow Coma Scale. *``R'' and ``I'' are addedto the grade to indicate restlessness and incontinence ofurine and feces, respectively: for example, 100-R and30-RI. #Criteria in parentheses are used in patients whocannot open their eyes for any reason.

Table 2 Glasgow Coma Scale (GCS) scores (Teasdale,Jennett; Lancet , 1974)

Eye opening (E) Best verbalresponse (V) Best motor response (M)

4. Spontaneous 5. Oriented 6. Obeying verbalcommands

3. To verbalcommand

4. Confusedconversation

5. Localizes pain

2. To pain 3. Inappropriatewords

4. Flexion/withdrawal topain

1 . None 2 . Incomprehensiblesounds

3. Abnormal flexion dueto pain (upper limbs)

1. None 2. Extension to pain(upper limbs)

1. None

GCS (315) E (14) V (15) M (16).

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scores 30300).If depressed fracture, optic canal fracture, space-

occupying intracranial lesion (such as an intracrani-al hematoma), etc., are observed, and if neurosurgi-cal treatment or management such as continuousICP monitoring is judged to be necessary, transfer toa facility with an expert is desirable.

If the patient has multiple injuries, transfer to afacility such as an emergency care center is desira-ble .

During transfer, it is desirable to continue thestabilization of respiratory and cardiovascular con-dition.

For transfer from a remote place, an ambulancewith a physician on board belonging to an expertfacility or emergency care center may be sent for the

patient.If there is no local medical facility matching theemergency or severity of the injury, the patient maybe transported to a facility such as a remote tertiarymedical institution using a helicopter, etc., bypass-ing the nearest medical facility (trauma bypass).

Information and communication devices such asFAX and the Internet should be used effectively totransfer the information related to the diagnosis andtreatment. CT images, etc., may be transferred inthis way, and an expert who can review them maygive instructions concerning transport to an expertfacility.

13. Role of Neurosurgeons in Team Care at anExpert Facility, etc.131. Secondary emergency care facilities

It is desirable that a neurosurgeon takes the initia-tive throughout the entire care of head injuries, in-cluding the initial diagnosis and treatment, and pre-and postoperative management.

It is desirable that there is a specialized room forinitial care, equipped for resuscitation, that thedepartments handling blood tests and transfusion,imaging diagnosis, and surgery are ready for im-mediate action, and that intensive postoperativecare can be performed.

Since there may be other complicating injuries, itis desirable that consultation with general surgeons,orthopedic surgeons, etc., is available.132. Tertiary emergency care facilities

Emergency care experts or trauma surgeons tendto take the lead, but the inclusion of a neurosurgeonin the care team is desirable .

In the initial diagnosis and treatment, it is desira-ble for the neurosurgeon to perform the treatment incooperation with an emergency care specialist until

the presence of other complicating injuries is ex-cluded.

It is desirable that the neurosurgeon is responsiblefor the performance of surgery and the postopera-tive management of head injuries.

In patients with multiple injuries including headinjuries, it is desirable that a neurosurgeon performsthe craniotomy, however the order of treatmentprocedures has to be determined and generalmanagement be performed in cooperation with aphysician in charge of the emergency/intensive care(the team leader).


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Fig. 1 Criteria for severity and emergency evaluation of injuries for emergency transport. Cited from the Criteria forSeverity and Emergency Evaluation of Injuries in the Report of the Committee on the Criteria for Severity and Emer-gency Evaluation of Injuries, Foundation of Ambulance Service Development and the figure on page 187 of the JapanPrehospital Trauma Evaluation and Care. JCS: Japan Coma Scale.

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Fig. 2 Flow chart of load and go according to the Japan Prehospital Trauma Evaluation and Care (JPTEC TM ). Citedfrom the figure on page 11 of the JPTEC.

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It is desirable for neurosurgeons to play the samerole in the local medical service system as at the sec-ondary emergency care facility even at a hospital re-garded as a tertiary emergency care facility, if there

is no existing emergency/intensive care team.If a neurosurgeon cannot regularly participate in

the team, it is desirable for an emergency care physi-

cian or the team as a whole to perform the initialtreatment, the pre- and postoperative managementmaintaining contact with a surgeon (the neurosur-geon in-charge of the surgical treatment). If only

conservative treatment (including continuousmonitoring of the ICP) is performed, a neurosurgeonmay not be directly involved.

CHAPTER 2: I NITIAL TREATMENT TO PROTECT THE BRAIN

21. Initial Examination and Treatment of Inju-ries

Even if the possibility of simple injury of the headis considered high, it is desirable to perform thetreatment according to the JATEC TM until life-

threatening injuries at other sites are excluded.It is important in head injuries to minimize sec-

ondary brain damage due to extracranial as well asintracranial factors at the initial examination andtreatment. For this purpose, it is desirable to begin


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the primary assessment and resuscitation promptlyafter the arrival of the patient.

Preparations for the acceptance of patients are asfollows. i) It is desirable that a physician directlytakes telephone calls requesting the acceptance oftrauma patients. ii) Devices such as a resuscitation

set, portable X-ray machine, and diagnosticultrasound equipment are often prepared for the ini-tial examination and treatment. iii) It is desirable totake standard infection prevention measures.

Primary assessment and resuscitation to securestability of the general condition are as follows. i) Ifabnormality of physiologic parameters is detected atthe primary assessment, it is desirable to resuscitateimmediately. Resuscitation includes not onlycardiopulmonary resuscitation but also all types ofemergency treatment necessary to maintain life. ii)During the primary assessment, resuscitation isoften performed in the order of: airway, respiration,and circulation. iii) If the GCS score is 8 or less, it isdesirable to secure the airway by endotracheal intu-bation, etc. It is desirable to protect the cervicalspine while securing the airway. iv) It is desirable tomaintain sufficient oxygenation and ventilation. Inseverely injured patients, high-concentration oxyg-en administration and assisted ventilation are oftenperformed. v) It is desirable to start treatment imme-diately if a life-threatening thoracic injury is detect-ed. vi) If there is abnormal respiration or circulation,it is desirable to promptly perform chest and pelvicradiography and abdominal ultrasonography. Evenif there is no respiratory or cardiovascular abnor-mality, it is still desirable to perform the above imag-ing investigations if affected consciousness level isdetected. vii) If there are symptoms of shock, it isdesirable to give initially rapid 12 l infusion for ex-tracellular fluid supplementation and examineresponse, as well as to examine whether there is ob-structive shock (cardiac tamponade, tension pneu-mothorax). viii) On the primary assessment, it isdesirable to examine the following neurological clin-ical parameters, in particular: GCS, pupillary find-ings, and presence of focal deficit: hemiplegia, etc.

ix) If the GCS score is 8 or less, or if the GCS scorehas deteriorated rapidly by 2 or more, and anisocor-ia or hemiplegia (signs of cerebral hernia) is ob-served, it is desirable to contact immediately an ex-pert and perform a CT. x) Undressing is often neces-sary to search for life-threatening injuries. xi) If thepatient has a high fever, it is desirable to promptlydecrease the body temperature to the normal range.xii) If hypothermic patients are at risk of massivehemorrhage, it is desirable to warm them promptlyfor preservation of blood coagulation and hemostat-ic properties.

Reference: ABCDE approach: Airway, evaluationand securing the airway and protection of the cervi-cal spine; Breathing, respiratory evaluation andtreatment for life-threatening thoracic injuries; Cir-culation, cardiovascular evaluation, resuscitation,and hemostasis; Dysfunction of central nervous sys-

tem, evaluation of life-threatening disorders of thecentral nervous system; and Exposure and environ-mental control, undressing and body temperaturemanagement.

Secondary assessment for close examination ofthe injury includes followings. i) If there is severedisturbance of consciousness with a GCS score of 8or less, a rapid decrease in the level of conscious-ness, or signs of cerebral hernia are observed, CT isperformed at the beginning of the secondary assess-ment, and respiratory and cardiovascular manage-ment performed during the assessment. ii) It isdesirable to examine for the following in the sec-ondary assessment of the head: injuries anddepressed fractures concealed under the hair; spec-tacle hematoma (``raccoon'' eyes, ``Brillen'' hemato-ma) or Battle's sign due to cranial base fracture; ocu-lar or orbital injuries; and hemorrhage orcerebrospinal fluid leakage from the external audito-ry meatus or oronasal cavity. iii) In patients suspect-ed to have cranial base fracture, it is desirable to in-sert a gastric tube orally.

22. Securing the Airway and RespiratoryManagement221. Securing the airway

i) In all injury patients, securing the airway is the first priority . Reliable securing of the airway bytracheal intubation, in principle, is desirable if theGCS score is 8 or less, or if the best motor responseof the GCS score is 5 or less. ii) Endotracheal intuba-tion should be performed orally, in principle. If thepatient is non-responsive, apneic, or shows agonalrespiration, it is desirable to consider the conditionas an ``airway emergency'' and immediately performdirect-vision oral intubation. iii) If the condition isnot an ``airway emergency,'' prompt endotracheal

intubation using sedatives and muscle relaxants isoften performed , in principle. However, if intubationis expected to be difficult due to obesity, a shortneck, etc., nasal or endoscopic intubation is oftenselected . iv) Since many sedatives may causehypotension due to circulatory suppression, it isdesirable to administer them with caution. In con-sideration of the necessity for repeated evaluation ofneurological condition, the use of short-acting seda-tives (such as propofol) is desirable . v) It is desirableto avoid laryngeal distention or the use of depolariz-ing muscle relaxants (such as succinylcholine) under


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insufficient sedation, because that may cause an in-crease in the ICP. vi) If tracheal intubation isdifficult due to marked facial injury, etc., a surgicalprocedure to secure the airway such asthyrocricotomy is often selected. vii) The cervicalcollar should be removed if it interferes with laryn-

geal extension, but manual fixation of the cervicalspine in the median neutral position is desirable dur-ing laryngeal extension. Priority is given to securingthe airway and cervical spine fixation can besacrificed if necessary.222. Indications for securing the airway in in-jury patients

i) Airway obstruction: If securing the airway bythe manual technique is insufficient; possibility ofaspiration of blood or vomitus; and risk of airwaynarrowing due to hematoma, damage, etc. ii) Secur-ing the airway in anticipation of respiratorymanagement: apnea; hypoventilation and hypoxe-mia (not corrected by oxygen administration). iii) Se-vere hemorrhagic shock/cardiac arrest. iv) Decreasein the level of consciousness (GCS score 8), etc.223. Respiratory management

i) All patients with severe injuries are often ad-ministered high-concentration oxygen (at 1015l/min using a face mask with a reservoir) until itbecomes clear that there is no risk of death. Particu-larly, it is desirable to administer high-concentrationoxygen in patients with a problem regarding therespiration, circulation, or consciousness. ii) It isdesirable to perform respiratory management at ini-tial care with the following targets: arterial bloodoxygen saturation (SpO 2) 95%, arterial blood oxyg-en partial pressure (PaO 2) 80 mmHg; and arterialblood carbon dioxide partial pressure (PaCO 2) orend-tidal carbon dioxide tension (PetCO 2) 3035mmHg during a period of elevated ICP, 3545mmHg during a period of normal ICP, and PaCO 2may be temporarily controlled to 30 mmHg or lessduring the preparation for surgical decompression,etc. iii) It is desirable to treat the following condi-tions as soon as they are detected: flail chest, openpneumothorax, tension pneumothorax, massive

pneumothorax, and massive airway hemorrhage,etc.

23. Cardiovascular ManagementIt is desirable to give priority to the prevention of

shock and resuscitation over treatment for in-tracranial lesions.

If there are symptoms of shock, it is desirable togive 12 l of extracellular fluid supplement by rapidintravenous infusion as an initial therapy and to exa-mine the response. If the patient shows no responseor only a temporary response to the initial infusion

therapy, priority is often given to hemostatic proce-dures (surgery, trans-arterial embolization, etc.)

Before concluding that the condition is a neuro-genic shock, it is desirable to perform differential di-agnosis with the following conditions: i) hypoxemia(upper airway obstruction, pulmonary contusion,

atelectasis, central pulmonary edema); ii) hemor-rhagic shock due to injuries at other sites (thoraciccavity, abdominal cavity, retroperitoneal cavity), iii)obstructive shock (cardiac tamponade, tensionpneumothorax); and iv) blunt cardiac injury, etc.

Intraperitoneal fluid accumulation and cardiactamponade are often diagnosed promptly by focusedassessment with sonography for trauma.

The following are desirable as targets of circulato-ry management at the initial examination and treat-ment: i) Patients with uncomplicated head injuries:systolic blood pressure 90100 mmHg andhemoglobin 710 g/dl; ii) Patients with complicatedhead injuries: systolic blood pressure 120 mmHg,mean arterial blood pressure 90 mmHg, cerebralperfusion pressure (CPP) 6070 mmHg (if the ICPis measured), and hemoglobin 10 g/dl.

In patients with hemorrhagic shock, it is desirableto perform promptly initial infusion therapy even ifthere are head injuries. However, intracranialhypertension may be exacerbated with the resolu-tion of shock due to rapid dilation of the cerebralvasculature.

To prevent hyperglycemia, a glucose-free solutionis desirable as extracellular fluid supplementationused for initial infusion therapy. Avoidance of infu-sion overload is desirable to prevent cerebral edema.Hypertonic saline or sodium lactate solutions maybe used to reduce the infusion volume and preventcerebral edema.

In the secondary assessment, in principle, headCT is performed after stabilization of the cardiovas-cular condition. At facilities that can simultaneouslyperform hemostatic procedures against shock andsurgery for head injuries, head CT may be performedpreoperatively in anticipation of simultaneous sur-gery if hemodynamics can be maintained by rapid

infusion.For the management of hypertension considered

to be Cushing's phenomenon, it is desirable to givepriority to the correction of intracranial rather thansystemic hypertension. There is no clear guidelineconcerning to what level hypertension may be per-missible.

It is desirable to use antihypertensive agents care-fully, because many of them dilate the cerebral vas-culature and exacerbate intracranial hypertension.The calcium-blocker diltiazem has been reported toexhibit a relatively mild effect on the ICP.


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Table 3 Computed tomography (CT) classification ofthe Traumatic Coma Data Bank (Marshall, et al.; J Neurosurg , 1991)

Category Definition

Diffuse injury I No visible intracranial pathology seen on CTDiffuse injury II Cisterns present with midline shift 05 mm

and/or:Lesion densities presentNo high or mixed density lesion 25 cm 3

Diffuse injury III(swelling)

Cisterns compressed or absent with midlineshift 05 mm, no high or mixed densitylesion 25 cm 3

Diffuse injury IV(shift)

Midline shift 5 mm, no high or mixeddensity lesion 25 cm 3

Evacuated masslesion

Any lesion surgically evacuated

Nonevacuatedmass lesion

High or mixed density lesion 25 cm 3, notsurgically evacuated

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24. Recognition and Treatment of Life-Threa-tening Brain Herniation

A GCS score of 8 or less, rapid exacerbation of theGCS score by 2 or more, anisocoria, hemiplegia, etc.,often indicate a life-threatening brain herniation.

A large space-occupying lesion, a 5-mm or greater

brain midline shift, and compression or disappear-ance of the basal cisterns often indicate life-threatening brain herniation.

Even if a life-threatening brain herniation is diag-nosed, it is desirable to give priority to the normaliza-tion of respiration and circulation if they are abnor-mal.

It is desirable to perform immediately emergencysurgery for life-threatening brain herniation due to aspace-occupying lesion.

With the following events, ultra-emergency trephi-nation or a small craniotomy may be performed atthe initial examination in the treatment room orICU: i) If the condition is considered to be extremelyurgent, so that there is no time for normalcraniotomy. ii) When further transfer of the patient

is decided to be impossible due to complicating inju-ries, etc.As a treatment for a life-threatening brain hernia-

tion, before surgery for the space-occupying lesion,a rapid drip infusion of mannitol at 0.251.0 g/kg isdesirable . When using mannitol, it is desirable to payattention to a possible decrease in the circulatingblood volume.

See the chapter on ICU management for othergeneral treatment for intracranial hypertension.

CHAPTER 3: ICU M ANAGEMENT31. Imaging Examinations and Monitoring311. Imaging evaluation

Neuroimaging evaluation on admission: CT, inparticular, is essential , because it provides very im-portant information concerning the selection of thetherapeutic strategy including the priority of treat-ment in cases of multiple injuries, judgment ofseverity, and prognosis.

CT: CT is very important for the early diagnosis ofdeteriorating brain edema or the appearance or en-largement of an intracranial hematoma. While im-portance should be given to changes in clinical con-dition, increased ICP, or reduced CPP, follow-up byCT is desirable .

Magnetic resonance (MR) imaging: Although MRimaging is not available at many facilities as anacute stage emergency examination, it is often moreuseful than CT, particularly regarding the following:i) Early diagnosis of parenchymal lesions of thebrain such as brain contusion, brain edema, andpetechial hemorrhages. ii) Diagnosis of cranial baselesions, which are difficult to be detected by CT dueto bone artifacts. iii) Diagnosis and pathological

analysis of diffuse brain injuries, particularly diffuseaxonal injury (Table 3).312. Monitoring

The following tends to be useful for specificmonitoring related to function of the brain andnerves (neuromonitoring): i) Physiological monitor-ing: electroencephalography (EEG); evoked poten-tials (auditory brainstem response, somatosensory e-voked potential, motor evoked potential, etc.), event-related potentials (P300), etc. ii) Monitoring of braincirculation and metabolism: ICP and CPP; cerebralblood flow (CBF), cerebral metabolic rate of oxygen,

and arteriovenous oxygen content difference; imag-ing studies of brain circulation and metabolism (sin-gle photon emission tomography, xenon-CT, dynam-ic CT, positron emission tomography, etc.; tran-scranial Doppler ultrasonography and color Dopplersonography; oxygen saturation at the bulb of thejugular vein (SjO 2) and transcranial monitoring ofoxygen saturation measured by near-infrared spec-troscopy, partial oxygen pressure in the cerebrospi-nal fluid or brain tissue; brain temperature (jugularvein blood temperature, brain parenchymal temper-ature, etc.); biochemical measurements of productsof energy metabolism, free radicals, cytokines, acid-base balance, etc., and microdialysis, etc. iii) Mul-timodality monitoring: Using a combination of i)and ii).

These monitoring techniques tend to be used for


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endotracheal intubation and controlled respiration.Blind hyperventilation should be avoided. Particu-

larly, it is desirable to avoid hyperventilation (PaCO 2 35 mmHg) without ICP monitoring within 24hours after injury.

During hyperventilation therapy, arterial blood

gas analysis or the measurement of the end-tidal par-tial carbon dioxide pressure is essential , andmonitoring of the ICP and SjO 2 is desirable .

Hyperventilation therapy is often initiated if theICP cannot be controlled at 20 mmHg or less bysedative or muscle relaxant administration,cerebrospinal fluid drainage, or the administrationof a hypertonic solution.

Hyperventilation therapy discontinuation isdesirable if the ICP can be controlled at 20 mmHgby other treatments.

If the ICP cannot be controlled to 20 mmHg or lesseven by reducing the PaCO 2 to 3035 mmHg, thePaCO 2 may be reduced to 2530 mmHg, but it isdesirable to discontinue hyperventilation at this lev-el as quickly as possible.

38. Mannitol, Glycerol, DiureticsIn patients showing or suspected to have ICP, the

appropriate administration of mannitol or glycerolis useful for the control of the ICP.

It is desirable for the plasma osmotic pressure be-fore administration to be 310 mOsm or less.

An effective dose is usually 0.251.0 g/kg.It is often suggested that repeated bolus adminis-

trations are more effective than continuous adminis-tration.

39. Barbiturate TherapyInitiation of barbiturate therapy may be consi-

dered if intracranial hypertension could not be con-trolled with maximum standard treatment. Usualdose: pentobarbital 25 mg/kg body weight orthiopental 210 mg/kg as a bolus, followed by con-tinuous infusion of pentobarbital 0.53 mg/kg/hr orthiopental 16 mg/kg/hr.

310. SteroidsWhile the negative view that glucocorticoids

(steroids) are ineffective for the treatment of head in-juries is shared by many researchers, prednisoloneor betamethasone may , in practice, be administeredintravenously.

Sufficient attention to gastrointestinal bleedingand hyperglycemia as side effects of steroids is alsonecessary.

311. Hypothermia (Brain Hypothermia)Although hypothermia reduces the ICP, it does

not improve the outcome.Hypothermia has unfavorable outcome in elderly

people, but tends to result in favorable outcome inchildren.

Hypothermia may increase the incidences of com-plications such as infection, arrhythmia, hypokale-

mia, and thrombocytopenia.Concerning hypothermia, no consensus has beenreached regarding the target body temperature, du-ration, temperature recovery method, patient selec-tion (except age), etc.

312. Therapeutic Procedures for Increased ICPFor ICP 1525 mmHg: i) Check the respiratory

condition, intubate the patient if necessary, andmaintain the SpO 2 at 95% or above. If respiration isweak, assisted ventilation is desirable . ii) It is desira-ble to elevate the head (by the cranial side of the bed).Caution not to flex the neck and impair venousreturn is necessary. iii) Intravenous administrationof high-osmotic pressure diuretics (mannitol) orglycerol is desirable . iv) Hyperventilation may beperformed to maintain the PaCO 2 at 3035 mmHg.

For ICP 2025 mmHg: If the ICP is difficult tocontrol even by i) to iv) in above, it is desirable to per-form CT again and advance to the next step. i) Bar-biturate (thiopental, pentobarbital, etc.) therapy maybe performed. ii) Hypothermia treatment may be ad-ministered. iii) External or internal decompressionmay be performed.

313. AntiepilepticsAntiepileptics are reported to be effective for the

treatment of early epilepsy, without significantdifference in the incidence of late epilepsy betweentreated and untreated patients. Many researcherssupport the view that antiepileptics are ineffective inpreventing epileptogenic foci development. Someresearchers have suggested that only zonisamide haspreventive effect.

Antiepileptics may be administered to the follow-ing patients: i) patients showing abnormalities onCT, particularly those found to have brain paren-

chymal injuries; ii) patients with early-onsetepilepsy; and iii) young patients.

Phenytoin, carbamazepine, zonisamide, andphenobarbital are often used. Many researchershold the view that valproic acid is a selective drugfor generalized epilepsy and is not suitable for thetreatment of traumatic epilepsy. Carbamazepine hasnot been sufficiently evaluated.

Since early epilepsy deteriorates brain injuries, itis desirable to avoid using antiepileptics. i) Since an-tiepileptics have a brain-protective effect, it is desira-ble to use them promptly in patients with brain inju-


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ries. ii) If antiepileptics are used, it is desirable tostart their administration within 24 hours after inju-ry and continue the therapy for 3 months until brainedema has subsided and cerebral circulation is stabi-lized. iii) Antiepileptic treatment is often continuedfor 2 years in patients with severe brain injuries.

Against late epilepsy: i) As in epilepsy in general,it is desirable to start administration of antiepilep-tics. ii) Phenytoin, carbamazepine, zonisamide, andphenobarbital, which are effective drugs for partialepilepsy, are often used. iii) During the administra-tion of antiepileptics, it is desirable to performperiodically EEG studies and check plasma drug lev-

els. iv) Traumatic epilepsy generally has a favorableprognosis and is resolved in 50% of the patients in 5years. However, as it develops into refractoryepilepsy in some patients, it is desirable to discon-tinue the administration of antiepileptics in seizure-free patients after careful evaluation.

314. NutritionEnteral or parenteral nutrition should be initiated

early in order to attain full caloric replacement byday 7 after injury.

Blood glucose level should be controlled withinthe range of 100200 mg/dl.

CHAPTER 4: SURGICAL INDICATIONS AND PROCEDURES

41. Closed Depressed Skull FractureWhether reduction of depressed fracture leads to

an improvement of neurological deficit or the inci-dence of traumatic epilepsy (late epilepsy) has notbeen established.

Indications: i) presence of 1-cm or greaterdepression or severe brain contusion; ii) presence ofesthetically unacceptable cranial deformity; and iii)compression of the venous sinuses, etc.

Methods: Elevation of depressed bone frag-ments or their repositioning by craniotomy.

42. Open Skull Depressed FractureIf there is dural damage (penetrating head injury),

it is important to promptly perform dural closure. Ifthere is no dural damage (non-penetrating head inju-ry), only sufficient irrigation, d ebridement, andclosure of the scalp wound are necessary.

Indications: i) Markedly contaminated wound;ii) severe contusion or comminuted fracture; iii) ex-posure of the brain parenchyma or situations sug-gestive of dural damage such as the leakage ofcerebrospinal fluid; iv) presence of bone fragmentsin the brain; v) uncontrollable hemorrhage related tobone fragments (damage of a venous sinus, etc.); vi)disorders of venous return due to compression of a

venous sinus by depressed bone fragments; vii) 1-cmor greater depression or severe brain contusion; andviii) esthetically unacceptable cranial deformity, etc.

Timing: Surgery within 24 hours is desirable .The infection rate clearly increases if surgery is per-formed more than 48 hours after injury.

Methods: i) Debridement: If the wound is con-taminated, specimens for culture should be taken. ii)Dural closure: Not only scalp closure by suturing butalso dural closure must be ensured (particularlywhen the wound is contaminated). If the duraldefect is large and difficult to close by suturing,

duraplasty using autologous grafts such as perioste-um, fascia, or aponeurosis should be performed (tis-sues with a rich blood supply are more resistant toinfection). iii) Timing of cranioplasty: If there is amarkedly contaminated wound, severe brain lacera-tion, or comminuted fracture, if surgery is per-formed after more than 4872 hours after injury, ifbone fragments are present in the brain, or if there isbrain protrusion, etc., two-stage surgery (removingcontaminated bone fragments first and performingcranioplasty later) should be considered . The timingof cranioplasty should be determined according tothe state of contamination and postoperative course.It should be performed after confirming adequatecontrol of infection.

43. Penetrating InjuriesPenetrating injuries may be caused by objects

used in daily life such as an umbrella, needle, andchopsticks, as well as a bullet, knife, and shard ofglass. The route of entry may be transcranial, tran-sorbital, transnasal, transbasal, etc.

Indications: All penetrating head injuries are in-dicated for surgical treatment, but a gunshot wound,which causes extensive brain damage, is often not re-garded as an indication.

Timing: Surgery should be performed as prompt-ly as possible. Angiography may be performedpreoperatively if damage of a venous sinus or arteryis strongly suspected.

Methods: i) Removal of the object penetratingthe brain before entry into the operation room mustusually be avoided . ii) It is desirable to perform acraniotomy in the area around the penetrating ob-ject and carefully remove the site of penetration us-ing a Luer bone nibbler or a drill. iii) Dural openingis often performed radially around the penetrationsite. iv) It is desirable to remove any subdural and in-


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tracerebral cloth and remove debris around thepenetrating object. v) Carefully remove the penetrat-ing object. Pay attention to the risk of damagingblood vessels. vi) It is desirable to perform tightclosure of the dura using the femoral fascia, etc. vii)If the wound is contaminated, cranioplasty should

be performed after sufficient control of infection ac-cording to the degree of contamination andpostoperative course. It is often performed 36months after injury.

Complications: Complications include meningi-tis, brain abscess, cerebrospinal fluid leakage, andtraumatic intracranial aneurysms.

44. Acute Epidural HematomaIndications for surgical intervention: i) Surgery

is indicated as a principle for acute epidural hemato-ma 12 cm in thickness, 2030 ml ( 1520 mlin the posterior fossa), or in the presence of con-comitant hematoma with different location. ii)Emergency craniotomy is indicated in the case of aprogressively worsening neurological deficit (in par-ticular, frequent neurological examinations and fol-low-up CT scanning are required within 24 hours ofthe injury). iii) Conservative management, with closeclinical observation, is reasonable if there is no neu-rological deficit.

Timing: Surgery performed as soon as possibleis desirable .

Methods: Craniotomy with hematoma evacua-tion is the principle.

45. Acute Subdural HematomaIndications for surgical intervention: i) Hemato-

ma 1 cm in thickness. ii) Hematoma with adefinite mass effect, or causing neurological deficit.iii) Rapidly progressing neurological deficit, even ifthe initial consciousness level was normal. iv) Sur-gery is usually not indicated if brainstem function isabsent for a long time. Surgery performed as soon aspossible is desirable .

Methods: Large craniotomy with hematomaevacuation is the principle . In some cases, a burrhole

or a small craniotomy is performed under localanesthesia, and decompression is attempted. A con-sensus has yet to be reached for external decompres-sion, with reports for and against its efficacy.

46. Intracerebral Hematoma, Brain ContusionIndications: i) Presence of any of the following

CT findings: hematoma (hyperdensity area) with adiameter of 3 cm or greater; diffuse contusion-in-duced edema; and disappearance of the basilar orperimesencephalic cisterns, etc. ii) Deterioration ofneurological condition. iii) Uncontrollable increase

in the ICP ( 30 mmHg): If the ICP is not monitored,decision is made according to criteria i) and ii)above. There is usually no indication for surgery if along time has passed since the complete arrest ofbrainstem functions.

Timing: i) If any of the criteria i)iii) above are

met, it is desirable to consider early surgery. ii) Inpatients with an initial GCS score of 9 or above, theearly performance of surgery is desirable if the neu-rological condition is progressively deteriorating.iii) In patients with hematoma of the temporal ortemporoparietal lobe, surgery may be considered be-fore neurological deterioration.

Methods: i) Hematoma evacuation by cranio-tomy is desirable . ii) If there is marked contusion-in-duced edema, contused brain tissue is often resected(internal decompression). iii) Indications of only ex-tensive decompression craniotomy or in combina-tion with hematoma removal and internal decom-pression may be evaluated. However, no consensushas been reached regarding the effectiveness of ex-ternal decompression. iv) Continuous cerebrospinalfluid drainage (from the ventricles or cisterns) is alsouseful for the treatment of contusion-induced ede-ma.

47. Diffuse Brain InjuriesDiffuse brain injuries such as those in patients

remaining comatose immediately after injurydespite the absence of a space-occupying lesion onCT should be treated conservatively, in principle.

48. Traumatic Cerebrovascular DisordersDue to the development of noninvasive and rapid

imaging modalities such as CT and MR imaging, in-stances of angiography performed in the initial stageof diagnosis and treatment of head injuries havebecome rare. This, however, has made the early di-agnosis of head and neck vascular injuries moredifficult. Traumatic cerebrovascular disorders areoften accompanied by intracranial lesions and mul-tiple injuries, and, if they are diagnosed, their treat-ment is often difficult.

481. Tests for the diagnosisIndications: Tests are indicated with conditions

suggesting a strong possibility of the presence oftraumatic cerebrovascular disorders as below arenoted: i) If the neurological condition is difficult toexplain based only on the TBI. ii) Delayed deteriora-tion of clinical condition cannot be explained by thetraumatic mechanism or the cerebral infarction de-tected by CT. iii) Thick, diffuse, severe subarachnoidhemorrhage or localized intense subarachnoidhemorrhage. iv) Neck injuries (fracture at or abovethe 5th cervical vertebra, fracture of the transverse


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process, hyperextension or hyperrotation of theneck, etc.). v) Cranial base fracture (fracture of theanterior cranial base reaching the medial 2/3 fromthe sphenoidal margin or the middle cranial basereaching the carotid canal). vi) Severe hemorrhagefrom the oral or nasal cavity or the external auditory

meatus that is difficult to stop.Timing: If the above indications are met, diag-nostic studies should be performed as soon as possi-ble.

Methods: MR anghiography or cerebral an-giography is desirable . Cerebral angiography is con-sidered to be the gold standard, because the cervicalto intracranial blood vessels can be examined, andendovascular treatment can be immediately initiat-ed. Although there are limitations concerning the di-agnostic power, simple tests that can be performedat the bedside, such as cervical and transcranialDoppler sonography, may also be useful.482. Treatment

Indications: Treatment is indicated when bleed-ing (vascular rupture, arteriovenous fistula, traumat-ic aneurysm, etc.) or non-bleeding head and neckvascular lesions (wall irregularity, narrowing, ob-struction, etc., of vessels) are detected by the studies.

Timing: It is desirable to initiate treatment assoon as possible.

Methods: i) Since life-threatening bleeding mayoccur from traumatic vascular lesions, early treat-ment should be considered. Direct surgery or en-dovascular treatment is selected depending on thesituation, but their combination is often effective. Incarotid-cavernous fistula, if massive nasal bleedingpersists or if a large shunt induces a significant``steal'' phenomenon, making the peripheralcerebral circulation unsatisfactory, it is desirable toattempt its closure as soon as possible by endovascu-lar treatment. ii) In non-bleeding lesions, it is desira-ble to initiate heparin administration to prevent newcerebral infarction. However, if there is a possibilityof intracranial hemorrhage or an increase in hemor-rhage due to multiple injuries, administration isoften started after stabilization of the condition. In

the subacute period, administration of an antiplate-let agent should be considered.483. Comments

Traumatic cerebrovascular disorders associatedwith neck injury are often obstructive and multipleor bilateral.

Cerebrovascular disorders may also occur duringsports or chiropractics. Physical characteristicssuch as a flexible or long neck are considered to berisk factors for vascular disorders due to neck inju-ries.

Cerebrovascular disorders caused by shearing in-

jury have been reported to be common in theperipheral part of the anterior cerebral artery or cer-vical vessels.

49. Traumatic Cerebrospinal Fluid LeakageTraumatic cerebrospinal fluid leakage stops spon-

taneously within 13 weeks in 5080% of patients.Spontaneous healing of recurrent or delayed cases israre. Even after spontaneous resolution, there is arisk of future recurrent cerebrospinal fluid leakageand complication by meningitis.

Indications: i) Persistent cerebrospinal fluidleakage that cannot be stopped by conservative treat-ment in 13 weeks. ii) Recurrent or delayedcerebrospinal fluid leakage

Timing: i) Surgery is generally performed afterconservative treatment. ii) Surgery should beplanned promptly for recurrent or delayed cases.

Methods: i) Duraplasty (closure of the ruptureddura mater by suturing, repair of the ruptured duramater using fascia or periosteum, etc.) is performedby craniotomy. It is often carried out starting in-tradurally. ii) There are also reports recommendingtransnasal endoscopic repair as the first choice.

410. Fracture of the Optic Canal, Optic NerveInjury

Traumatic optic nerve injury may occur withoutfracture of the optic canal.4101. Injury mechanisms

Primary injury: Direct damage to the optic nerveper se (optic canal fracture).

Secondary injury: Delayed damage of the opticnerve due to circulation disorder or edema.4102. Treatment

Conservative treatment by drug therapy primarilyusing steroids.

Surgical treatment primarily by optic canal de-compression.

Indications: i) Surgery is often indicated forpatients who have light perception preserved, clearevidence of fracture, and visual impairment. ii)Patients initially with only mild visual impairment

are often treated surgically if they show fracture andprogressive visual impairment. iii) Patients com-pletely blind immediately after injury are usuallyconsidered to have no surgical indications.

Timing: i) Very early surgery: Decision to per-form surgery may be made after administeringsteroids and evaluating recovery after 4872 hours.ii) Early surgery: Surgery within 12 weeks after in-jury is desirable . iii) Surgery 30 days or more after in-jury is ineffective and undesirable .

Surgical procedure: Optic canal decompression


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411. Anesthesia and Antibiotics4111. Anesthesia

It is desirable to perform intubation for the induc-tion of anesthesia under cricoid cartilage compres-sion on assuming a full stomach.

Anesthesia is often maintained using a venous

anesthetic, avoiding an inhalation anesthetic, whichmay increase the intracranial pressure.In severely injured patients, the first priority is

stabilization of hemodynamics, and exact obser-vance of the usual required dose of the anesthetic isunnecessary.

To protect the brain, a barbiturate is often selectedas the anesthetic.

If hypothermia (brain hypothermia) is started be-fore surgery, it is desirable to maintain the low braintemperature (body temperature).

It is desirable to control intraoperatively the CPPat 60 mmHg or above and the ICP at 20 mmHg or be-low.

During the operation, it is desirable to performfluid infusion using preparations not containing glu-cose and, if necessary, to avoid hyperglycemia by in-

travenous insulin injections.4112. Antibiotics

Since patients with severe head injuries have mar-kedly reduced biological defense abilities, i.e., areimmunocompromised, it is desirable to perform rou-tine administration of antibiotics from an early stage

of treatment.Antibiotic therapy may be empiric, specific, orprophylactic.

The Centers for Disease Control and Preventionguidelines recommend the use of 1st or 2nd genera-tion cephalosporins as empiric therapy.

Since the risks of pneumonia associated with con-trolled respiration and septicemia due to catheteri-zation are high, periodic culture tests are desirable .

Efforts to clarify the focus of infection, causativemicroorganism, and drug sensitivity and to initiatespecific therapy as early as possible are necessary.

Non-critical continuation of use of 3rd or 4thgeneration cephalosporins often induces the appear-ance of resistant strains including methicillin-resistant Staphylococcus aureus , and results in per-sistent infection.

CHAPTER 5: M ANAGEMENT OF CRANIOFACIAL INJURIES

51. Blow-out FractureIndications: Refractory diplopia and esthetical-

ly intolerable enophthalmos.Timing: i) Elective surgery (13 weeks after inju-

ry) is commonly performed. ii) Emergency surgery isnecessary in patients exhibiting an oculo-cardiacreflex (hypotension, bradycardia, nausea, and dizzi-ness due to the vagus reflex) (more often observed inyoung patients). iii) Acute-stage surgery is selectedfor patients in whom the eyes are completely im-mobilized in a downward position, exposing thewhite of the eye (called white-eyed blowout), thosewho show no eye movement on the forced tractiontest, those who exhibit enophthalmos immediatelyafter injury, etc. iv) Surgery within 2 weeks after in-jury is recommended in patients exhibiting diplopia

in the 1st ocular position, a positive forced tractiontest, constriction of the orbital contents on imagingstudies and those with large fractures.

Methods: i) Inferior wall orbitoplasty by thetrans-inferior palpebral approach is usually selected.ii) Trans-maxillary sinus reduction and inferior or-bital wall fixation has also been performed by theplacement of a balloon catheter in the maxillary si-nus.

52. Maxillofacial Injuries521. Zygomatic bone fracture5211. Fracture of the zygomatic arch

Indications: Lockjaw due to depression of thearch; skin depression at the zygomatic arch.

Timing: Surgery should be performed early af-ter injury. Adhesion becomes more severe in thechronic stage.

Methods: Reduction of the zygomatic arch un-der the temporal fascia by employing Gillies' proce-dure is a common treatment. In comminuted frac-ture, etc., fixation using miniplates is performed bydirect surgery.5212. Fracture of the zygomatic body

In zygomatic body fracture, the frontal process ofthe zygomatic bone, inferior orbital margin, zygo-

matic arch, and inferior zygomatic crest are frac-tured (tripod or tetrapod fracture), and the zygomat-ic bone is displaced.

Indications: Displacement of the zygomaticbody is expected to cause permanent facial deformi-ty.

Timing: Early surgery is desirable . Adhesionsbecome significant 2 weeks or more after injury.

Methods: The fracture line is exposed by inci-sion of the area lateral to the eyebrow, vestibule ofthe mouth, lower eyelid, etc., and the zygomaticbody is reduced and fixed. Rigid fixation using


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miniplates is often performed. In patients showingminor displacement, zygomatic bone fracture maybe treated by Gillies' blind reduction.522. Mandibular fracture

The objective of treatment is to restore occlusioneffective for mastication and normal jaw move-

ments. Intermaxillary fixation is usually performed.Treatment must not be performed only for fusion ofthe fractured bone.

Indications: Edentulous mandible, large dis-placements due to fracture, multiple fractures, man-dibulomaxillary fracture, open fracture, bonedefects, etc., are indications for invasive treatment.

Timing: Surgery should be performed early afterinjury. Reduction becomes difficult due to adhe-sions in the chronic stage.

Methods: Depressed soft tissues are surgicallyremoved, and fixation is performed using miniplatesor wires. Usually, intermaxillary fixation is re-quired.523. Maxillar fracture5231. Le Fort III fracture

Le Fort III fracture involves the orbit, nasal boneand ethmoid bone, and is often accompanied by an-terior cranial base fracture. Since the injury is alsooften complicated by brain injuries, it is treated asan old fracture in many patients.

Indications: Le Fort III fracture is an indicationfor surgery in all patients except those with severebrain injuries.

Timing: Surgery should be performed as soon as

possible after injury. In old Le Fort III injury, addi-tional techniques such as osteotomy may be necessa-ry .

Methods: After mobilization and reduction ofthe joint, reconstruction is performed in the occlud-ed state by intermaxillary fixation, and bone frag-

ments are then fixed using wires or miniplates.5232. Le Fort I and II fracturesThese fractures are often accompanied by frac-

tures of other facial bones. Le Fort II fracture may beaccompanied by cerebrospinal fluid leakage as aresult of cranial base fracture. These fractures areaccompanied by diplopia, ocular depression, in-fraorbital nerve injury, etc., because of the orbitalwall fracture. The objective of treatment is to restorethe facial morphology and dental occlusion.

Indications: Le Fort I or II fracture is an indica-tion for surgery in all patients, in principle.

Timing: Surgery early after injury is desirable.Methods: Le Fort I: A transverse incision is

made in the vestibule of the mouth under intermaxil-lary fixation and bone fixation using wire orminiplates is performed at the margin of thepyriform aperture. Le Fort II: After performing inci-sion at the root of the nose, inferior orbital margin,or vestibule of the mouth, or, if the fracture is com-plex, performing coronal incision (bifrontotemporalincision), intermaxillary fixation and bone fixationare performed similarly to Le Fort I surgical tech-nique.

CHAPTER 6: M ANAGEMENT OF PEDIATRIC AND GERIATRIC PATIENTS

61. Severe TBI in Infants, Children, and Adoles-cents

These guidelines address key issues relating to themanagement of severe TBI in pediatric patients witha GCS score of 38. Pediatric is defined as 16 yearsof age.611. Prehospital management

The purpose of prehospital management is to

avoid secondary brain injury as much as possible. i)Hypoxia and hypotension should be avoided if pos-sible, and attempts should be made to correct themimmediately. ii) Supplementary oxygen should beadministered, securing airway to maintain ventila-tion. iii) Cervical spine should be protected to main-tain its stability. iv) Complicated injury should bemanaged immediately, if possible.

Comments: Prehospital hypoxia has a statisticallysignificant negative impact on outcome.612. Transportation to a special facility

i) Pediatric patients with TBI should be transport-

ed to an emergency facility, which has a neurosurgi-cal service and a CT scanner available at all times. Itshould have a pediatric service, if possible. ii) TBIpatients with GCS 913 should be directly transport-ed to a facility, which has both a neurosurgical and apediatric services. iii) Severe TBI patients with GCS38 should be directly transported either to an emer-gency center or a facility which has both a neurosur-

gical and a pediatric services.613. Evaluation on admission

i) Both hypoxia and hypotension are often to de-velop rapidly in a child during apnea, hypoventila-tion, and airway obstruction. ii) Paleness, inactivity,and/or tachycardia are often to be considered as clin-ical signs of shock. iii) Hypotension is often a latesign of shock, appearing after the above mentionedclinical signs. iv) Focal neurological deficit is rarelyrecognized even in patients with intracranial injury.v) Patients should be checked systematically, includ-ing the possibility of child abuse injury. Body tem-


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perature should be maintained.614. Primary care after admission

i) Management of general condition should takeprecedence over everything else. ii) Primary care in-cludes airway, ventilation, and circulation main-tenance. Hypoxia and hypotension should be avoid-

ed if possible, and attempts should be made to cor-rect it immediately. iii) Blood pressure should bemonitored frequently. Timely fluid administrationshould be provided to maintain systolic blood pres-sure in the normal range. iv) Airway should be se-cured in patients with GCS 9, or with hypoventila-tion. Initial therapy with 100% oxygen is appropri-ate in the resuscitation phase of care. v) Cervicalspine should be protected to maintain its stability.

Comments: i) Hypoxia is defined as apnea, cyano-sis, PaO 2 60 mmHg, or oxygen saturation 90%.ii) Hypoventilation is defined as ineffective respira-tory rate for age, shallow or irregular respirations,frequent periods of apnea, or registered hypercar-bia. iii) Normal respiratory rate is 3045/min in in-fant, 25/min in 3 years old, and 20/min over yearsold. iv) Lower limit of systolic blood pressure for agemay be estimated by the formula: 70 mmHg (2age in years). v) In children, hypotension is definedas systolic blood pressure below the fifth percentilefor age or by clinical signs of shock. vi) In patientswith clinical signs of shock, internal and spinal cordinjury should be evaluated. vii) If peripheral vascu-lar access is difficult, intraosseous infusion of fluidsis indicated. viii) Bolus injection of lactate Ringer'ssolution 20 ml/kg should be provided immediatelyafter diagnosis of shock. ix) Combination ofhypotension and hypoxia increase morbidity andmortality.615. Management in intensive care unit

Techniques and indications for ICP monitoring: i)ICP should be monitored in patients with severeTBI. ii) Ventricular catheter or catheter tip pressuretransducer device is an accurate and reliablemethod of monitoring ICP. iii) ICP monitoring is notroutinely indicated in patients with mild or moder-ate head injury. iv) ICP should be monitored in

patients with severe TBI, who receive barbituratetherapy or hypothermia therapy.

Comments: i) A ventriculostomy catheter devicealso allows therapeutic cerebrospinal fluid drainage.ii) Parenchymal ICP monitoring with fiber optic orstrain gauge catheter is reliable but has the potentialfor measurement drift. iii) ICP measurement datawith parenchymal ICP catheter correlate well withthose of a ventriculostomy catheter. iv) Overall safe-ty of ICP monitoring devices is excellent, with clini-cally significant complications, such as infection,occurring infrequently. v) In infants, even with nor-

mal CT findings, intracranial hypertension may bepotentially present. vi) ICP monitoring and/or ag-gressive ICP control are associated with favorableoutcome.

Threshold for treatment of intracranial hyperten-sion: i) Treatment for intracranial hypertension, de-

fined as pathologic elevation in ICP, should begin atICP 1520 mmHg. ii) Treatment of intracranialhypertension should be corroborated by monitoringdata of physiological variables, such as ICP, CPP,SjO 2, and cranial imaging.

CPP: i) In children with TBI, CPP 40 mmHg isdesirable to be maintained. ii) CPP between 40 and65 mmHg probably represents an age-related con-tinuum for the optimal treatment threshold.

Use of sedation and neuromuscular blockade:Sedatives, analgesics, and neuromuscular blockingagents are commonly used for emergency intuba-tion, ICP control, mechanical ventilation, and crani-al imaging. However, attention should be paid to un-favorable side effects, such as sedative-induceddecrease in arterial blood pressure.

Comments: i) Bolus injection of ketamine isreported to decrease ICP in patients with severeTBI, but may raise ICP. ii) Neuromuscular blockadehave been reported to reduce ICP, oxygen consump-tion, and energy consumption. iii) Propofol is not in-dicated for pediatric sedation as safety has not beenestablished.

CSF drainage to manage ICP: CSF drainage can beconsidered as an option in the management ofelevated ICP in children with severe closed head in-jury.

Comments: i) Drainage can be accomplished viaonly a ventriculostomy catheter or in combinationwith a lumbar drain. ii) Addition of lumbar drainageshould be considered as an option only in the case ofrefractory intracranial hypertension with a fun-ctioning ventriculostomy, open basal cisterns, andno evidence of a major mass lesion or shift on imag-ing studies.

Use of hyperosmolar therapy: i) Both mannitoland glycerol may be effective for control of ICP after

severe TBI. ii) Serum osmolarity should be main-tained below 310 mOsm/l with mannitol use. iii) Ef-fective bolus doses of mannitol range from 0.25 to1.0 g/kg of body weight. iv) Euvolemia should bemaintained by fluid replacement.

Comments: i) Acute tubular necrosis and renalfailure have been observed with mannitol adminis-tration with serum osmolarity levels 320 mOsm/l.Much higher levels of serum osmolarity (360mOsm/l) appear to be well tolerated in childrenwhen induced with hypertonic saline. ii) Hypertonicsaline is effective for control of increased ICP after


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severe TBI. iii) Effective doses as a continuous infu-sion of 3% saline range between 0.1 and 1.0ml/kg/hr.

Use of hyperventilation: i) Chronic prolongedhyperventilation therapy should be avoided. ii)Hyperventilation therapy (PaCO 2 of 3035 mmHg)

may be necessary for brief periods if there is acuteneurological deterioration or for longer periods ifthere is intracranial hypertension refractory to seda-tion, paralysis, cerebrospinal fluid drainage, and os-motic diuretics. iii) SjO 2, arterial jugular venous oxy-gen content differences, and ICP monitoring mayhelp to identify cerebral ischemia if hyperventila-tion, resulting in PaCO 2 values 30 mmHg, is neces-sary. iv) Prophylactic hyperventilation therapy dur-ing the first 24 hours after severe TBI should beavoided because it can compromise cerebral perfu-sion during a time when CBF is reduced.

Comments: i) Hyperventilation induces hypocap-nia, leading to cerebral vasoconstriction accompa-nied by a reduction in cerebral blood volume and adecrease in ICP. However, hyperventilation is asso-ciated with a risk of iatrogenic ischemia. ii)Cerebrovascular response to hyperventilation canbe extremely variable following TBI. CBF, SjO 2, orbrain tissue oxygen monitoring may be suggested tohelp identify cerebral ischemia in this setting. iii)Mild or prophylactic hyperventilation (PaCO 2 35mmHg) in children should be avoided. iv) Aggres-sive hyperventilation (PaCO 2 30 mmHg) may beconsidered as a second tier option in the setting ofrefractory intracranial hypertension.

Use of barbiturates in the control of intracranialhypertension: i) High-dose barbiturate therapy maybe considered in hemodynamically stable patientswith salvageable severe TBI and refractory in-tracranial hypertension. ii) If high-dose barbituratetherapy is used, appropriate hemodynamic monitor-ing and cardiovascular support are essential.

Comments: i) High-dose barbiturates are known toreduce ICP, but are also associated with increasedrisk of hypotension. ii) Monitoring of EEG patternsfor burst suppression is thought to be reflective of

therapeutic effect. iii) Therapeutic regimens(Nordby, 1984): protocol for thiopental: loadingdose, 1020 mg/kg; maintenance, 35 mg/kg/hr. iv)Barbiturates are effective in lowering ICP in select-ed cases of refractory intracranial hypertension inchildren with severe TBI. However, studies on theeffect of barbiturate therapy have not evaluated neu-rological outcome. v) Potential complications ofhigh-dose barbiturate therapy in infants and chil-dren with severe TBI mandate that its use be limited.vi) There is no evidence to support use of barbituratesfor prophylactic neuroprotective effects.

Temperature control following severe pediatricTBI: i) Hyperthermia should be avoided in childrenwith severe TBI. ii) Hypothermia may be consideredin the setting of refractory intracranial hyperten-sion. iii) Appropriate hemodynamic monitoring maybe required, as well as monitoring of ICP and SjO 2.

Comments: Posttraumatic hyperthermia is de-fined as core body temperature 38.5 9 C.Decompressive craniectomy: Decompressive

craniectomy should be considered in pediatricpatients with severe TBI, diffuse cerebral swelling,and intracranial hypertension refractory to inten-sive medical management.

Comments: i) Decompressive craniectomy isreported to significantly reduce mean ICP in chil-dren with severe TBI and has a trend toward betterclinical outcome at 6 months after injury. ii) Inpatients who underwent bifrontal decompressivecraniectomy for severe TBI, favorable outcome wasmore frequent in pediatric than adult patients. iii) Assurgical techniques, unilateral fronto-temporo-parietal craniectomy for unilateral cerebral swellingor bilateral frontal craniectomy for bilateral cerebralswelling have been generally recommended. iv)Decompressive craniectomy should be consideredin the treatment of severe TBI and medically refrac-tory intracranial hypertension in infants and youngchildren with head trauma due to abuse. v) Decom-pressive craniectomy may be most appropriate inpatients meeting some or all of the following criter-ia: diffuse cerebral swelling on cranial CT imaging,within 48 hours of injury, no episodes of sustainedICP 40 mmHg before surgery, GCS 3 at somepoint subsequent to injury, secondary clinical de-terioration, and evolving cerebral herniation syn-drome.

Use of corticosteroids: The use of steroids is un-desirable for improving outcome or reducing ICP inpediatric patients with severe TBI.

Comments: i) Steroids are useful in reducingcerebral edema, attenuating free radical productionin experimental models of TBI. ii) Corticosteroidsdid not improve functional outcome in adult

patients with severe TBI. iii) Use of steroids sig-nificantly reduces endogenous cortisol production,and may have an associated increased risk of infec-tion in children.

Nutritional support: i) Nutritional support shouldbegin by 72 hours with full replacement by 7 days. ii)Replace 130160% of resting metabolism expendi-ture after TBI in pediatric patients.

Comments: i) Mean energy expenditure is report-ed to be significantly elevated in pediatric as well asadult patients with severe TBI. ii) Serum glucose lev-els should be tightly controlled even in pediatric


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patients with severe TBI. iii) Based on the adultguidelines, weight-specific nutritional supportshould be provided in pediatric patients with TBI.

Anti-convulsive prophylaxis: i) Prophylactic anti-convulsant therapy may be considered as a treat-ment option to prevent early posttraumatic seizures

(PTSs) in young pediatric patients and infants athigh risk for seizures following head injury. ii)Prophylactic use of anti-convulsant therapy is notrecommended for children with severe TBI forpreventing late PTS.

Comments: i) Infants and small children areknown to have lower seizure thresholds, leading to agreater risk of early PTS compared with adults aftersevere TBI. ii) In the acute period after severe TBI,seizures increase brain metabolic demands and ICP,and may lead to secondary brain injury resulting inunfavorable outcome. iii) PTSs are classified as early(occurring within 7 days) or late (occurring after 7days) following injury. The reported incidence ofearly PTS after severe TBI in children varies fromapproximately 2039%. iv) Children 2 years of agehave almost a three-fold greater risk of early PTScompared with older children up to 12 years of age.v) Majority of cases of early pediatric PTS occur wi-thin the first 24 hours after injury. vi) Among chil-dren 3 years old who had brain trauma and earlyPTS, 12% of infants and toddlers experienced latePTS, and risk of late PTS was significantly greateramong children 1 year of age compared with 2-and 3-year-old children. vii) Phenytoin has beenshown to reduce the incidence of early PTS in a sin-gle study of children with severe TBI. viii) Anticon-vulsant therapy to prevent the occurrence of earlyPTS in high risk children during the first week fol-lowing severe TBI is recommended as a treatmentoption.

Head elevation: i) The cranial part of the bed maybe elevated to approximately 1530 9 to control ICP,and the response of ICP and CPP monitored for ef-ficacy. ii) Cervical flexion should be avoided inpediatric patients with TBI to secure venous return.

Comments: i) Attention should be paid to instabil-

ity of the head in pediatric patients with TBI, be-cause of the relatively large cranium and short neck.ii) CPP should be monitored, if possible. iii) Headelevation 30 9 may result in a greater risk ofdecreased CPP in case of systemic hypotension.

62. Severe Head Injury in the Elderlyi) Main causes of severe traumatic brain injuriesin aged group are pedestrian traffic accidents andfalls in daily life. ii) Mortality rate increases withage. According to the JNTDB, the mortality rate inpatients aged over 70 years is over 70% with orwithout surgical treatment. iii) Incidence of focalbrain injuries such as acute subdural hematoma andbrain contusion is higher and that of acute epiduralhematoma is lower in the aged group. Higher inci-dence of multiple traumas is one of the poor prog-nostic factors in the aged group. iv) Intensive gener-al care is desirable in the aged group, because sys-temic complications are major causes (3540%) ofearly death. v) Individuals aged 50 years and olderare more likely to sustain progressive neurologicaldeterioration into coma after suffering acute sub-dural hematoma, contusion hematoma, or in-tracerebral hematoma. GCS at deterioration, not ini-tial GCS, has prognostic value. Early surgical inter-vention is indicated if patients deteriorate. Time be-tween injury and deterioration is less than 3 hours in80% of acute epidural or subdural hematomapatients, but is longer in brain contusion or in-tracerebral hematoma patients. vi) Surgical indica-tions for acute subdural hematoma: Surgical inter-vention may not be indicated in patients with GCS 3.With early and intensive treatment, patients withGCS 4 or more and independent before injury mayhave good prognosis even aged over 75 years. Inpatients with GCS 5 or less, hematoma irrigationwith trephination therapy might be more effectivethan external decompression. vii) Recovery fromhigher cortical dysfunction after TBI takes longer inthe aged group. Intensive treatment and care mightbe extended to the chronic phase in the elderly.

CHAPTER 7: M ANAGEMENT OF M ILD OR MODERATE HEAD INJURIESR ISK FACTORS FOR DETERIORATION

71. Predictive Factors of Deterioration: Find-ings Suggestive of Organic Intracranial Injury(Tables 4 and 5)

Disturbance of consciousness, disorientation, am-nesia, (a GCS score 15), or other neurological ab-normalities noted on evaluation.

Presence of any of the following if there are none

of the above findings: i) episode of loss of conscious-ness, amnesia, or disorientation after injury; ii) fre-quent vomiting or headache; iii) epileptic attack; iv)condition suggestive of depressed or cranial basefracture; v) head radiograph suggestive of fracture;vi) circumstances of injury suggestive of severe frac-ture (traffic accident, fall from a high place, etc.); vii)


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Table 4 Canadian Computed Tomography (CT) HeadRules for patients with minor head injury (adult) *

High risk (for neurological intervention)GCS score 15 at 2 hrs after injurySuspected open or depressed skull fractureAny sign of basal skull fracture

Vomiting 2 episodesAge 65 yrsMedium risk (for brain injury on CT)Amnesia before impact 30 minDangerous mechanism (pedestrian struck by motor

vehicle, occupant ejected from motor vehicle, fallfrom height 1 m or five stairs)

*Minor head injury is defined as witnessed loss of con-sciousness, definite amnesia, or witnessed disorientationin a patient with a Glasgow Coma Scale (GCS) score of1315.

Table 5 Request computed tomography (CT) immedi-ately (National Institute for Health and Clinical Excel-lence head injury guidelines)

1. All patients with any of the following risk factors:GCS 13GCS 13 or 14 at 2 hrs after the injury

Suspected open or depressed fractureAny sign of basal skull fracturePosttraumatic seizureFocal neurological deficitMore than one episode of vomiting (clinical judgment

should be used regarding the cause of vomiting inpatients aged 12 yrs)

Amnesia 30 min of events before impact (assessmentwill not be possible in pre-verbal children and is un-likely to be possible in any child aged 5 yrs)

2. CT should also be requested immediately in the follow-ing situations provided the patient has experiencedsome loss of consciousness or amnesia since the injury:

Age

65 yrsDangerous mechanism of injury: pedestrian struck by amotor vehicle, occupant ejected from a motor vehicleor fall from a height of greater than 1 m or five stairs (alower threshold for height of falls should be usedwhen dealing with infants and young children aged 5 yrs).

Coagulopathy

GCS: Glasgow Coma Scale.

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old age; viii) condition suggestive of blood clottingabnormalities such as a regular use of warfarin; andix) history of neurosurgical operation (ven-triculoperitoneal shunt, etc.)

72. Risk Factors of DeteriorationAirway obstruction (hypoxemia, increased ICP).Hypoxia and hypotension (exacerbation of brain

edema, decrease in CPP).Hyperglycemia.Underestimation of the injury mechanism.Overlooking of complicating injuries (cervical spi-

nal injury, cardiac tamponade, hemopneumothorax,lung contusion, intraperitoneal hemorrhage, pelvichemorrhage, etc.)

Delayed referral to an expert facility.

73. Methods of ManagementObservation of the respiratory condition, chest

auscultation.Checking of vital signs and continuous observa-

tion.

Adjustment of the b

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