This document discusses the scalp block technique. It begins by describing scalp block as local anesthesia of the scalp nerves. It then discusses the history and development of scalp block, including the original description in 1986 and studies in the 1980s that demonstrated its effectiveness in reducing hemodynamic changes during craniotomy. The document outlines the specific nerves blocked in scalp block and techniques for each, and notes bupivacaine is often used. Advantages include decreased blood pressure and intracranial pressure changes during surgery. Potential complications are also reviewed. Finally, it briefly discusses recent updates to the Glasgow Coma Scale including the addition of a pupil reactivity score in 2018.

1. SCALP BLOCK
GCS - P
Tenzin Yoezer
1/6/2019

2. SCALP BLOCK

3. Scalp block
• Local anesthesia of the nerves of the scalp
• Sensory innervation of the scalp and forehead is
provided by both the trigeminal and spinal nerves
• Girvin originally described the ‘‘scalp block’’ technique
in 1986 for use during awake craniotomy, the
technique did not gain its due popularity for several
more years

4. Scalp block
• It was not until the middle of 1980s that Hillman et al
performed the first double-blind randomized study to
compare the effects of 0.5% bupivacaine with normal
saline injection in patients undergoing craniotomies.
• Increased cardiovascular hemodynamic stability was
found in the bupivacaine group.

5. Scalp block
• Four years later, Hartley et al demonstrated similar
results in children undergoing supratentorial
craniotomy.
• In this study, responses of mean arterial pressure and
heart rate to scalp incision and reflection were
attenuated by infiltrating the scalp subcutaneously
along the proposed incision line with bupivacaine
coupled with epinephrine

6. Scalp block
• Bupivacaine became the local anesthetic of choice for
scalp infiltration due to its long duration of action and
was reported to be safe when used in the vascular
tissues of the scalp

7. Advantages
• local anesthetic infiltration of the scalp before
craniotomy is effective in reducing tachycardia and
hypertension – decrease CBF and intracranial
pressure
• prevent the need for increased analgesic requirements
early in the surgical procedure

8. Technical description
• 6 nerves are blocked:
• Supraorbital
• Supratrochlear nerve
• Auriculotemporal nerve
• Zygomaticotemporal nerve
• Greater occipital nerve
• Lessor occipital nerve

9. Techniques
• Supraorbital Nerve
• Palpation of Supraorbital notch
• Needle – 1 cm medial to supraorbital foramen
perpendicular to skin
• Supratrochlear nerve
• Medial extension of supraorbital block above eyebrow line
• Auriculotemporal Nerve
• over zygomatic process, with 1 to 1.5 cm anterior to the ear
at the level of the tragus
• Palpate superficial temporal artery

10. • Zygomaticotemporal Nerve
• infiltration from the supraorbital margin to the posterior part
of the zygomatic arch.
• Need deep and superficial block
• Greater Occipital Nerve
• approximately halfway between the occipital protuberance
and the mastoid process, 2.5cm lateral to the nuchal
median line
• Best landmark – palpate the occipital artery, and inject
medially after careful aspiration
• Lessor occipital nerve
• Infiltration along the superior nucheal line, 2.5 cm lateral to
the greater occipital nerve

11. Scalp block
• Indication:
• Surgery In the scalp area
• Awake craniotomy
• Before putting pins
• Post craniotomy analgesia
• Drugs: 0.25%, 0.5% bupivacaine,
2% lidocaine
• With 1:200,000epinephrine
• (2ml, 5ml, 2ml, 5ml)

12. Complications
• Hypertension due to intravascular injection or systemic
absorption of bupivacaine mixed with vasoconstrictor
• Rapid rise in anesthetic concentration within first 15
minutes
• Hypotensive episodes
• Subarachnoid injection during occipital block
• Facial nerve paralysis
• infection

13. NEW GCS= GCS-P

14. New Gcs
GCS developed by prof. grham teasdale in 1974
Designed to quantify the level of consciousness in TBI
patients
Initial point is only 14

15. • In 2014 ( 40 yrs, on its aniniversary)- terminology was
updated to simplify the language used
• Glasgow Coma Scale 2014

16. • Another changes in 2014 is no points for non-testable
component.
• Eg:
• 42 year old man, intubated after traumatic brain injury
(TBI) for decreasing GCS. Currently, he opens his
eyes to pressure, is intubated, and withdraws his left
arm and leg to pain.
• 1979 – GCS: E 2, V 1t, M 4. Combined GCS: 7t
• 2014 – GCS: E 2, V NT, M 4. = 6NT
• Any element that cannot be tested should be marked
as NT, for “not testable”4.

17. 2018
• Adoption of pupil reactivity score (GCS-P)
• Improves to prognosticate based on initial presentation
• Helps to downstream the management
• Helps to guide goals of care discussion.

18. • Subtracted from the GCS
• GCS-P is adopted from the pooled CRASH and
IMPACT trail
• GCS 6 – 6 month mortality 28.82%
• GCS-P (6-2=4) – 6 month mortality of 42.94%
• Therefore, addition of a pupil examination appears to
allow clinicians to prognosticate outcomes better than
GCS alone and can be done quickly and easily at the
bedside.

20. References
• calp Block’’ During Craniotomy: A Classic Technique
Revisited, Irene Osborn, MD and Joseph Sebeo, PhD
• https://emottawablog.com/2018/07/gcs-remastered-
recent-updates-to-the-glasgow-coma-scale-gcs-p/
• https://www.eurekalert.org/pub_releases/2018-
04/jonp-ngc040418.php

21. Thank you