1. Head injuries and raised intracranial pressure
Chapter 25

2. Remember Airway – ET intubation CPP – Maintain MAP
Prevent secondary brain injury
Triad of head, facial and neck injuries

3. Signs and symptoms of raised intracranial pressure
Early
Late
Thus hypovolaemic shock may be masked by cerebral ischaemia reflex

4. Treatment of high intracranial pressure
Remove space-occupying lesions – Not you
Drain CSF – Not you
Decrease intracranial blood volume – You
Prevent arterial vasodilatation
Ventilation
Decrease oxygen consumption
Prevent venous congestion
Prevent Brain Oedema – You
CPP
Fluids

5. Cerebral Perfusion Pressure CPP
CPP = MAP – ICP
Cerebral outoregulation blunted
CPP = 60 TO 70 mmHg
Bedside – For each 10 cm vertical elevation of the head (ear) above the heart (middle of upper arm) , the cerebral perfusion pressure decreases by about 7 mmHg

6. CPP Increasing MAP , Decreasing VP Decrease brain volume
Oedema
Ventricular drain
Decrease Oxygen consumption
Induced/permissive hypothermia
Sodium thiopental
Systemic homeostasis BP
Adrenaline
Dobutamine
Phenylephrine

7. CPP Systemic homeostasis Diabetes insipidus Cerebral salt wasting
Diuresis, hypernatraemia, low urine osmol
Cerebral salt wasting
Diuresis, hyponatraemia, high urine osmol
Coagulation
Temperature
Cardiac manifestations

8. Fluid therapy Avoid hypotonic fluids
Maintain normal to high plasma osmolality
Hyperglycemia worsens TBI
Glucose containing fluids contraindicated
Treat hyperglycemia
Brain oxygenation
Hct 30 , Cardiac output , Oxygen

9. Treatment of brain oedema
Glucocorticoids
Infection and tumours
Osmotic agents
Mannitol

10. Anaesthetic management
Other injuries
RSI
Ketamine
Suxamethonium
Low normal CO2 , 35 mmHg
Intubation response
Positioning NB!!!!!

11. Anaesthetic management
Positioning
15 degrees
Not anti-trendellenburg
Head neutral position
No hyperextension
No rotation

12. Anaesthetic management
Mayfield head clamp
Air embolism
CPP
Avoid N2O , Vapour MAC < 1
Muscle relaxation
Fluids
ECG neurogenic changes

13. Anaesthetic management
Hyponatreamia
ADH
oliguria
Cerebral salt wasting
Diuresis
Diabetes Insipidus
Hypernatreamia, diuresis, low urine osmol
Extubation