Management aims at preventing the development of secondary brain damage from intracranial haematoma, ischaemia, raised intracranial pressure with tentorial or tonsillar herniation and infection.
- Ensure the airway is patent and that blood oxygenation is adequate. Intubation is advisable in patients 'flexing to pain' or worse. Ventilation may be required if respiratory movements are depressed or lung function is impaired, e.g. 'flail' segment, aspiration pneumonia, pulmonary contusion or fat emboli. Hypoxia can cause direct cerebral damage, but in addition causes vasodilatation resulting in an increase in cerebral blood volume with subsequent rise in I CP.
- A space-occupying haematoma requires urgent evacuation (see over). If the patient's conscious level is deteriorating, give an initial or repeat i.v. bolus of mannitol (100 ml of 20%). Coagulation should be checked and any deficits corrected.
- Scalp lacerations require cleaning, inspection to exclude an underlying depressed fracture and suturing.
- Correct hypovolemia following blood loss - but avoid fluid overload as this may aggravate cerebral oedema. In adults, 2 litres/day of fluid is sufficient. Commence nasogastric fluids or oral fluids when feasible.
- Anticonvulsants (e.g. phenytoin) must be given intravenously if seizures occur; further seizures and in particular status epilepticus significantly increase the risk of cerebral anoxia.
- Monitor intracranial pressure (ICP), blood pressure and cerebral perfusion pressure (CPP) in selected patients with diffuse swelling or after evacuation of an intracranial haematoma. Maintain CPP either by raising blood pressure or by treating raised intracranial pressure (see below).
- Brain protective agents include free radical scavengers, calcium channel blockers and glutamate antagonists. Experimental evidence in animal studies has revealed encouraging results and the evolution of axonal damage after a diffuse shearing injury may provide a window of opportunity for treatment. Studies in head injured patients await completion. (Steroids; it is now well established that steroids, even in megadosage, are of no benefit in the management of the head injured patient).
- Operative repair of a dural defect is required if the CSF leaf persists for more than 7 days. (Many still use prophylactic antibiotics in patients with a CSF leak, but there is no conclusive evidence of their efficacy and they may do more harm than good by encouraging the growth of resistant organisms.) The development of meningitis requires prompt treatment with an empirical antibiotic.
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