The document discusses the role of anaesthesiologists in managing head injury patients. It covers assessing patients based on Glasgow Coma Scale, classifying injuries, monitoring intracranial pressure, and providing conservative care like oxygen therapy, diuretics, or surgical intervention. The anaesthesiologist's responsibilities include smooth induction, positioning, fluid management, monitoring, and ensuring safe extubation to prevent pressure increases and optimize outcomes. Overall, the anaesthesiologist aims to maintain normal intracranial pressure, oxygenation, and cerebral perfusion pressure through various medical and surgical techniques.
70% of RTA patients have head injury(HI).
One of the most important public health problems of today.
70% of deaths in RTA are due to HI.
At Risk population
Males 15-24
Infants
Young Children
Elderly
70% of RTA patients have head injury(HI).
One of the most important public health problems of today.
70% of deaths in RTA are due to HI.
At Risk population
Males 15-24
Infants
Young Children
Elderly
There are numerous types of brain surgery. The type used is based on the area of the brain and the condition being treated.
Brain surgery is a critical and complicated process. The type of brain surgery done depends highly on the condition being treated.
Intracranial surgery refers to various medical procedures that involve repairing structural problems in the brain.
Craniotomy
A craniotomy involves making an incision in the scalp and creating a hole known as a bone flap in the skull. The hole and incision are made near the area of the brain being treated.
During open brain surgery, it is done to remove tumors, clip off an aneurysm, drain blood or fluid from an infection & remove abnormal brain tissue
Decompressive craniectomy
It is a neurosurgical procedure in which part of the skull is removed to allow a swelling brain room to expand without being squeezed. It is performed on victims of traumatic brain injury, stroke and other conditions associated with raised intracranial pressure.
Head injury types, clinical manifestations, diagnosis and managementVibha Amblihalli
I prepared this presentation for CME at 108 Emergency Services GVK-EMRI, Bangalore in January 2013. I kept it simple and concise as the CME was attended by EMTs too. Hope its of help to any medical professional out there.
Undergraduate level presentation on head injury
Includes:
Physiology & Pathophysiology
Epidemiology
Initial evaluation and management
History
Examination
Classification
Management
Outcomes
regarding head injury.
A head injury is any trauma to the scalp, skull, or brain. The injury may be only a minor bump on the skull or a serious brain injury. Head injury can be either closed or open (penetrating). A closed head injury means you received a hard blow to the head from striking an object, but the object did not break the skull.
There are numerous types of brain surgery. The type used is based on the area of the brain and the condition being treated.
Brain surgery is a critical and complicated process. The type of brain surgery done depends highly on the condition being treated.
Intracranial surgery refers to various medical procedures that involve repairing structural problems in the brain.
Craniotomy
A craniotomy involves making an incision in the scalp and creating a hole known as a bone flap in the skull. The hole and incision are made near the area of the brain being treated.
During open brain surgery, it is done to remove tumors, clip off an aneurysm, drain blood or fluid from an infection & remove abnormal brain tissue
Decompressive craniectomy
It is a neurosurgical procedure in which part of the skull is removed to allow a swelling brain room to expand without being squeezed. It is performed on victims of traumatic brain injury, stroke and other conditions associated with raised intracranial pressure.
Head injury types, clinical manifestations, diagnosis and managementVibha Amblihalli
I prepared this presentation for CME at 108 Emergency Services GVK-EMRI, Bangalore in January 2013. I kept it simple and concise as the CME was attended by EMTs too. Hope its of help to any medical professional out there.
Undergraduate level presentation on head injury
Includes:
Physiology & Pathophysiology
Epidemiology
Initial evaluation and management
History
Examination
Classification
Management
Outcomes
regarding head injury.
A head injury is any trauma to the scalp, skull, or brain. The injury may be only a minor bump on the skull or a serious brain injury. Head injury can be either closed or open (penetrating). A closed head injury means you received a hard blow to the head from striking an object, but the object did not break the skull.
HEAD INJURY- AN OVERVIEW
Dear viewers,
Greetings from “Surgical Educator”
Today I have uploaded a video on Head injury- an important topic in trauma because 50% of trauma deaths are due to head injuries. I haven’t talked elaborately but have included the essential minimum an undergraduate medical student should know. I have talked about pathophysiology, clinical approach, symptoms, signs, investigations, different individual types of head injuries and management of all the varieties of head injuries. My aim is after watching this video all of you should be able to arrive at a correct working diagnosis of the type of head injury and should also be able to institute immediate lifesaving treatment to the patients if there is a need. You can watch the video in the following links:
Surgicaleducator.blogspot.com
Youtube.com/c/surgicaleducator
Thank you for watching the video.
The Anesthetized Brain is less Vulnerable to ischemic injury than the awake brain.
EEG changes suggestive of severe ischemia are present.
Basic Methode Brain Protection are “ Corner Stone “
CPP, CBF, CBV maintained in “Normal Range”, MAP may increased up to 10 – 20 %.
Anesthetics Drugs may have Brain Protectection effect.
Volatile anesthetics do provide some Transient Protection (< 1,5 MAC)
Barbiturates, although long considered to be the gold standard.
Hypothermic methode are controversial, Hyperthermia should be avoided.
Insulin is Administered if glucose values exceed 180 mg/dl.
Close monitoring of BSL to ensure that Hypoglycemia does not develop
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journey
Management of 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.
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.
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.
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.
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.