A 25-year-old male presented with a severe head injury and large subdural hematoma. The appropriate next step is immediate surgical evacuation of the hematoma. A 40-year-old female with a 10-mm midline shift on CT is at increased risk due to ventricular compression seen on imaging. A 55-year-old male requires ICP monitoring post-craniectomy; administration of mannitol is indicated to manage elevated ICP.

1. Head Trauma: Assessment,
Management, and
Monitoring
M.UMAIR

2. Objectives of lecture
Recognize the associated injuries often seen in head trauma patients, such as intra-abdominal or
intrathoracic injuries, long bone fractures, and spinal injuries.
Identify the importance of diagnostic measures, including imaging techniques like computed
tomography (CT) scans, in assessing head trauma.
Discuss the surgical and anesthetic management strategies aimed at preventing secondary insults.
Understand the role of intracranial pressure (ICP) monitoring in patients with head trauma and
the treatment options for intracranial hypertension.
Describe the anesthetic considerations and challenges in airway management for head trauma
patients.
Explain the significance of fluid management and hypotension correction in optimizing patient
outcomes.
Recognize the importance of timely intervention, accurate diagnostic measures, and effective
management in improving outcomes for head trauma patients.

3. Introduction
Head trauma is a significant contributory factor in trauma-related deaths,
accounting for up to 50% of such cases.
Most head trauma patients are young and often have associated intra-abdominal or
intrathoracic injuries, long bone fractures, and/or spinal injuries.
The outcome of head injury depends not only on the initial neuronal damage but
also on the occurrence of secondary insults.

4. Initial Assessment of Head Trauma
Initial assessment plays a crucial role in head trauma patients.
Young patients with head trauma often have associated injuries, so a thorough
evaluation for other injuries is essential.
Intra-abdominal or intrathoracic injuries, long bone fractures, and spinal injuries
should be considered and managed accordingly

5. Diagnostic Measures for Head Trauma
The Glasgow Coma Scale (GCS) score is a reliable indicator of injury severity and
outcome in head trauma patients.
Imaging techniques, such as computed tomography (CT) scans, help identify specific
lesions, midline shift, and ventricular compression.
Greater than a 5-mm midline shift and ventricular compression on imaging are
associated with increased morbidity.

6. Midline Shift

7. Management of Head Trauma
The surgical and anesthetic management of head trauma patients aims to prevent secondary
insults.
Secondary insults include systemic factors like
 Hypoxemia
 Hypercapnia
 Hypotension
 Formation And Expansion Of Hematomas
 Sustained Intracranial Hypertension.
Prompt interventions, such as surgical treatments and decompressive craniotomy, may be
necessary to prevent further damage.

8. Monitoring Intracranial Pressure (ICP)
Monitoring ICP is crucial in patients with head trauma, especially those at risk of
intracranial hypertension.
Indications for ICP monitoring include
 Large Contusions
 Mass Lesions
 Intracerebral Hemorrhage
 Evidence Of Edema On Imaging Studies
Treatment options for intracranial hypertension include
 Moderate Hyperventilation
 Mannitol
 Pentobarbital, Or Propofol

9. Diagnostic Measures - Radiographic and
Clinical Findings
The choice between operative and medical management of head trauma depends on
radiographic and clinical findings.
Patients should be stabilized before performing diagnostic studies, and critically ill
patients should be closely monitored during these procedures.
Restless or uncooperative patients may require general anesthesia for imaging
studies

10. Anesthetic Considerations - Airway
Management
Airway management in head trauma patients can be challenging.
Ensuring airway patency and ventilation adequacy is crucial.
Techniques such as cricoid pressure and in-line stabilization are used during
intubation to maintain a neutral position of the head, unless cervical spine injury is
ruled out.

11. Fluid Management and Hypotension
Hypotension in head trauma patients is often related to associated injuries, such as
intra-abdominal injuries.
Correcting hypotension and controlling bleeding take precedence over radiographic
studies and definitive neurosurgical treatment.
Use appropriate fluid therapy, including colloid, crystalloid, and blood products as
necessary.

12. Conclusion and Key Points
Timely initial assessment, accurate diagnostic measures, and effective management
strategies are essential in head trauma cases.
Early intervention is crucial in preventing secondary insults and improving patient
outcomes.
Anesthetic care should focus on airway management, monitoring intracranial
pressure, and maintaining hemodynamic stability.

13. Reference
Morgan and Mikhail's clinical anesthesiology 5th edition chapter 27 Anesthesia for
neuro surgery (anesthesia for head trauma) page 601

14. Clinical Scenario:
A 25-year-old male is brought to the emergency department following a severe head
injury sustained in a motor vehicle accident. He is unconscious and has a Glasgow Coma
Scale (GCS) score of 6. Initial imaging reveals a large subdural hematoma with midline
shift. What is the most appropriate next step in the management of this patient?
A) Immediate surgical evacuation of the hematoma
B) Administering a high dose of glucocorticoids
C) Initiating moderate hyperventilation
D) Applying in-line stabilization during intubation

15. Clinical Scenario:
A 40-year-old female with a history of head trauma presents to the operating room for
craniotomy and evacuation of an epidural hematoma. The patient's preoperative
computed tomography (CT) scan shows a 10-mm midline shift. Which of the following
findings is associated with increased morbidity in this patient?
A) Presence of a skull fracture
B) Subdural hematoma
C) Brain contusion
D) Ventricular compression on imaging

16. Clinical Scenario:
A 55-year-old male with severe head trauma undergoes surgery for decompressive craniectomy due to
increased intracranial pressure. Postoperatively, his intracranial pressure (ICP) needs to be closely
monitored. Which of the following interventions is indicated to manage elevated ICP in this patient?
A) Administration of mannitol
B) Sustained hyperventilation
C) Early use of large doses of glucocorticoids
D) Initiation of propanol infusion

17. Answer choices:
A) Immediate surgical evacuation of the hematoma
D) Ventricular compression on imaging
A) Administration of mannitol