Highlighted to the critical role of an anaesthetist in the management of a pt with Head injury.

1. ROLE OF ANAESTHESIOLOGIST IN
THE MANAGEMENT OF HEAD INJURY
PATIENT
Chairperson
Prof. Dr. Munirul Islam
Head,Dept. Of Anaesthesia & Intensive Care;
Mymensingh Medical College & Hospital.
Presenter
Dr. Mehedi Hasan
D.A. Student
Mymensingh Medical College & Hospital
Session: July 2016-’18.

2. HEAD INJURY
 Any injury that results in trauma to the skull or
brain can be defined as a head injury.
 The terms traumatic brain injury and head
injury are often used interchangeably in the
medical literature.

3. CLASSIFICATION OF
HEAD INJURY
 Scalp
Hematoma Laceration Avulsion
 Skull Fracture
Linear Depressed Compound Basilar
 Brain Injury
Contusion Laceration Penetrating
 Vascular Injury
EDH SDH SAH IVH

4. MANAGEMENT OF HEAD INJURY
PATIENT
 Management of a patient with head injury can
be categorized in two ways. Those are-
 1. Conservative or medical and
 2. Interventional or surgical.
 The managent of a patient with head injury
starts with clinical assessment which indicates
the modality of treatment.

5. MANAGEMENT OF
HEAD INJURY PATIENT
(CONTD.)
 As a critical care or intensive care personnel, an
anaesthesiologist takes decision in association
with a neuromedicine or neurosurgery specialist
whether the management plan will be,
conservative or interventional as well as assess
and resuscitate the patient needfully.

6. ASSESSMENT
 Assessment should be done under these three
headings.
1. Mechanism of injury:
Blunt Vs Penetrating
2. Morphology:
Scalp: laceration, haematomas
Skull: linear, depressed or basilar fractures
Intracranial: haematomas, contusions and
diffuse axonal injury.

7. ASSESSMENT (CONTD.)
3. Glasgow Coma Scale:
 Minor head injury: GCS 15 with no loss of consciousness
(LOC);
 Mild head injury: GCS 14 or 15 with LOC;
 Moderate head injury: GCS 9–13;
 Severe head injury: GCS 3–8.
 Glasgow Coma Scale (GCS)
(The scale was published in 1974 by Graham
Teasdale and Bryan J. Jennett.)
It is a skeptical presentation of definite Neurological
Signs which aims to give a reliable and objective way of recording
the best eye, verbal & motor response to determine the
consciousness state of a person for initial as well as subsequent
assessment.

8. ASSESSMENT (CONTD.)
 Patient scoring eight or below are categorized as
unconscious and should be intubated and
ventilated in the acute phase.
 The GCS is not linear because it is calculated from
the best response thereby lateralizing signs such
as limb deficit and pupillary responses should be
documented simultaneously.

9. VASCULAR STRUCTURES INVOLVED IN
BRAIN INJURIES

10. HEAD INJURY MANAGEMENT
 Nonoperative
Seen in absence of significant intracranial mass lesion.
Typically consists of assessment and/or treatment of
intracranial pressure (ICP).
 Operative
Typically required when a significant intracranial mass
lesion is present.
Decompressive craniectomy or brain resection is less
common.

11. HEAD INJURY MANAGEMENT (CONTD.)
 Mild head injuries : Analgesics and close monitoring for
potential complications such as intracranial haemorrhage.
 Moderate and Severe head injuries: There is
significant secondary injury :
 Prevention of hypoxia: Oxygen therapy
 Control of elevated intracranial pressure: Mannitol, hyper-
ventilation, CSF diversion, hypothermia,

12. HEAD INJURY MANAGEMENT (CONTD.)
hypertonic saline, barbiturate coma, decompressive
craniectomies etc.
 Maitenance of perfusion: Ringer’s lactate, paediatric
saline, monitoring of blood pressure, vasopressors.
 Seizures: Anticonvulsants.
 Agitation: Paralytics, sedatives.
 Nutrition: Enteral or parenteral feeding.
 Correction of dyselectrolytaemia: Hyponatraemia,
hypomagnesaemia.

13. PRIMARY RESUSCITATION
AIRWAY
Maintain SPO2 > 90%
Maintain PaO2 > 60mmHg
BREATHING
Maintain PCO2 35-40mmHg
Obtain CXR
Check ABG
CIRCULATION
Prevent hypotension
Aim SBP> 90mmHg
Resuscitation with isotonic cystalloid
Inotropes (adrenaline) if needed

14. PRIMARY RESUSCITATION
(CONTD.)
Indication for intubation
Unable to maintain
airway
GCS ≤ 8
Loss of protective
laryngeal reflexes
Unstable facial bone #
Bleeding into mouth
Seizures
Ventilatory insufficiency
Spontaneous
hyperventilation
Irregular respiration

15. HEAD INJURY MANAGEMENT
(CONTD.)
Monroe-Kellie doctrine:
The Monroe-Kellie hypothesis states that the
cranial compartment is incompressible, and the volume
inside the cranium is fixed. The cranium and its
constituents (blood, CSF, and brain tissue) create a state
of volume equilibrium, such that any increase in volume
of one of the cranial constituents must be compensated
by a decrease in volume of another.

16. HEAD INJURY MANAGEMENT
(CONTD.)
Intra-cranial pressure(ICP)
Intracranial pressure (ICP) is the pressure inside
the skull and thus in the brain tissue and cerebrospinal
fluid (CSF). ICP is measured in millimeters of mercury
(mmHg) and, at rest, is normally 7–15 mmHg for
a supine adult.

17. ICP MONITOR

18. HEAD INJURY MANAGEMENT
(CONTD.)
CPP = MAP – ICP
CPP- Cerebral perfusion pressure
MAP- Mean arterial pressure
 Normal CPP > 50 mm Hg
 Autoregulatory mechanisms maintain CBF at CPP’s
down to 40 mm Hg

19. THERAPY FOR INTRACRANIAL
HYPERTENSION
 First tier
Positioning
Ventricular drainage
Osmotic diuresis
Hyperventilation
 Second tier
Sedation
Neuromuscular blockade
Hypothermia

20. TREATMENT
 Medical management of raised intracranial
pressure > 20-25 mm Hg :
 Position head up 30º
 Avoid obstruction of venous drainage from head
keeping head in midline and cervical immobilization
collar should not obstruct venous return from the
head.
 Sedation +/– muscle relaxant.
 Diuretics like frusemide, mannitol (0.5-1 gm/kg bd-
tds) to reduce cerebral swelling.

21. MANAGEMENT OF HEAD INJURY
Resuscitation of Blood Pressure and
Oxygenation:
Hypotension (SBP<90mmHg) or hypoxia (apnea,
cyanosis or PO2<60mmHg) should be avoided.
MAP should be maintained >90mmHg throughout
treatment to maintain CPP >70mmHg

22. MANAGEMENT OF HEAD INJURY
(CONTD.)
Hyperventilation
Hyperventilation decreases CBF: Hyperventilating to
PCO2 26mmHg decreases CBF by 31% and CBV by 7% thus
maintaining normal ICP.
CBF 90% of control at 4 hours of hyperventilation.

23. NON-OPERATIVE MANAGEMENT
OF HEAD INJURY (STRATEGIC
OVERVIEW)
So, in a nutshell anaesthesiologist should do the
following while managing a patient of head injury
conservatively-
 Management of intense pain by opioid analgesic
(preferably Remifentanyl (1µgm/kg I/V bolus & 0.05-
2µgm/kg infusion),
 Maintain BG between 5.5-8 mmol/L,
 Osmotic diuresis by Mannitol(0.5-1gm/kg),

24. NON-OPERATIVE MANAGEMENT
OF HEAD INJURY (STRATEGIC
OVERVIEW)CONTD.
 Control epleptiform activity with appropriate anti-convulsant
therapy,
 Prevent coughing with sedation.
 Maintain a core body temp. between 36-37ºC,
 Avoid volume depletion/overload,
 Ventilate aiming to reduce PaCO₂ to 34mmHg,
 Hypnotic infusion and close observation.

25. ANAESTHESIOLOGIST &
SURGICAL INTERVENTION OF
HEAD INJURY
 A patient with head injury needs surgical intervention if
evacuation of a subdural, extra-dural or intracerebral
haematoma is needed. Anaesthesiologists play role in
this situation as a team leader and manage the patient
in every aspect of surgery.

26. OPERATIVE MANAGEMENT
 Types of mass lesions
Epidural hematoma
Subdural hematoma
Cerebral contusion
 Decompressive craniectomy/brain
resection.

27. ANAESTHESIOLOGIST & SURGICAL
INTERVENTION OF HEAD INJURY
(CONTD.)
 Anaesthesiologists play critical role during induction
of anaesthesia, positioning of patient, take measure
to prevent excessive heat loss, maintanance of
anaesthesia, fluid therapy, supplementary drug
therapy, monitoring during anaesthesia, apply
techniques to reduce intra-cranial pressure and
normotensive BP, recovery of anaesthesia & post-
operative care.

28. GENERAL PRINCIPLES
 A smooth anaesthetic technique is essential to avoid increase
in arterial & venous pressure and changes in CO₂
concentration.
 Maintanance of hypnosis with either an inhalational agent or
infusion of propofol.
 Patient must be tranferred to post-operative room with no
residual neuro-muscular blockade or opioid induced
respiratory depression as both produce critical increase in
ICP.

29. INDUCTION
 Induction should be smooth. Full doses of hypnotics,
analgesics & muscle relaxants should be used to avoid
coughing, straining or hypertension.
 Inhalational induction is appropriate for children.
 Thiopental & propofol reduce ICP and are suitable for
induction.
 All others agents e.g. Etomidate, BDZ decrease cerebral
metabolism & CBF but ketamine is an exception causing
increase in CBF and regarded unsuitable for neuro-
anaesthesia.

30. INTUBATION
 Suxamethonium causes a brief rise in ICP & can release
potassium from denervated muscle but after head injury its
ability to allow rapid airway control it is used as a muscle
relaxant of choice before tracheal intubation.
 Non-kinking tubes are traditionally used.
 After the tube is being fixed & secured the neck should be
flexed gently while listening the presence of breath sound
in both axillae.

31. POSITIONING
 There are 4 positions: supine, prone, park-bench and sitting. A
pin head-holding system is commonly used. Insertion of pins
is very stimulating and needs profound anaesthesia &
analgesia which is provided by continuous remifentanyl
infusion. Precautions to take for the different positions are as
follows-
Supine: Avoid excessive lateral rotation of the neck and
traction on the shoulder, which may cause strech injury of the
brachial plexus.

32. POSITIONING (CONTD.)
Prone: Ensure no pressure on the eyes, avoid horse-
shoe type head rest which is notorious in this respect.
Park bench: Place a large pad under the ribs in the
dependent axilla to avoid streching in the brachial plexus.
Sitting: The head must not be too flexed, which may
cause tetraparesis and venous and lymphatic obstruction
can cause severe tongue swelling.

33. MAINTANANCE OF
ANAESTHESIA
 The basis of anaesthesia for surgery with a head-injury
patient is ventilation of the lungs with air & oxygen to produce
a PaCO₂ of around 4.5kPa using either a volatile anaesthetic
agent or a propofol infusion supplemented by an opioid
analgesic.
 Sevoflurane is the volatile agent of choice & best avoiding
enflurane as it is associated with seizure activity at high
doses.
 The choice of neuro-muscular blocking agents depends
usually on personal preferences.
 Use of techniques permitting rapid recovery(e.g. Sevoflurane,
Propofol, Remifentanyl) are particularly valuable in this
situation.

34. FLUIDS
 There is no ideal isotonic I/V fluid for use in neurosurgery
but glucose contining fluids should be avoided.
 Though having relative hypotonicity Compound Sodium
Lactate (CSL) is now in use as large volume (>3L) of
isotonic 0.9% saline can produce hyperchloraemic metabolic
acidosis.
 So isotonic crystalloids are the standard maintanance fluid if
used carefully.

35. MONITORING
General monitoring:
Invasive cardiovascular monitoring, ECG & pulse
oximetry are mandatory.Regular estimation of ABG,glucose,
Na⁺ and monitoring of core temperature are also required to
optimise treatment strategies.
Cerebral monitoring:
Measurement of CPP,CBF,assessment of cerebral
oxygenation, ICP monitoring, transcranial Doppler
ultrasonography, jugular venous bulb oximetry are needed on
specific situations.

36. EXTUBATION & RECOVERY
 Stormy extubation with laryngospasm, coughing and
bucking are extremely unwanted during recovery of head
injury patient after surgical intervention. It is probably most
reliably avoided by deep extubation.
 If recovery is prolonged airway management can be
assisted by insertion of a laryngeal mask or simple Guedel
airway tube.
 Patient should be referred to post-operative room with no
residues of neuro muscular blockers and post-operative
use of opioid must be judicious.

37. POST-OPERATIVE CARE
 Post-operative care must be provided in a high
dependency unit.
 Fluid therapy is required to prevent ongoing losses.
 Neurosurgical patients are at high risk of DVT so low
molecular weight heparin should be started.
 Post-operative pain is best managed by opioid in
addition to paracetamol.

38. PEARL

39. TAKE HOME MESSAGE
An anaesthesiologist can play role, starting from
evaluation of patient, primary resuscitation, maintain normal
ICP, pain management and watchful observation when the
head injury patient is managed conservatively and during
surgical intervention to provide the best anaesthetic
techniques which ensure best possible patient safety and
favourable outcome is the duty of an ideal and skilled
anaesthesiologist.

40. tHaNk yOu