Advanced Trauma Life Support ATLS Student Course Manual 2018

SURGICAL MANAGEMENT 123
individuals who anticipate the need for this procedure
receive proper training from a neurosurgeon.
Penetrating Brain Injuries
n FIGURE 6-12 Blood loss from scalp wounds can be extensive,
especially in children.
Depressed Skull Fractures
For patients with depressed skull fractures, a CT scan
is valuable in identifying the degree of depression and,
importantly, excluding the presence of an intracranial
hematoma or contusion. Generally, depressed skull
fractures require operative elevation when the degree
of depression is greater than the thickness of the
adjacent skull, or when they are open and grossly
contaminated. Less severe depressed fractures can
often be managed with closure of the overlying scalp
laceration, if present.
Intracranial Mass Lesions
Intracranial mass lesions should be managed by a
neurosurgeon. If a neurosurgeon is not available in
the facility that initially receives a patient with an
intracranial mass lesion, early transfer to a hospital
with neurosurgical capabilities is essential. In
exceptional circumstances, a rapidly expanding
intracranial hematoma can be imminently lifethreatening
and may not allow time for transfer if
neurosurgical care is a considerable distance away,
such as in austere or remote areas. Emergency
craniotomy in a rapidly deteriorating patient by a nonneurosurgeon
should be considered only in extreme
circumstances. Surgeons properly trained in the
procedure should perform this surgery, but only after
discussing the lesion with and obtaining the advice of
a neurosurgeon.
There are few indications for a craniotomy performed
by a non-neurosurgeon. This procedure is justified only
when definitive neurosurgical care is unavailable.
The Committee on Trauma strongly recommends that
CT scanning of the head is strongly recommended to
evaluate patients with penetrating brain injury. Plain
radiographs of the head can be helpful in assessing
bullet trajectory and fragmentation, as well as the
presence of large foreign bodies and intracranial air.
However, when CT is available, plain radiographs are
not essential. CT and/or conventional angiography are
recommended with any penetrating brain injury and
when a trajectory passes through or near the skull base
or a major dural venous sinus. Substantial subarachnoid
hemorrhage or delayed hematoma should also prompt
consideration of vascular imaging. Patients with a
penetrating injury involving the orbitofacial or pterional
regions should undergo angiography to identify a
traumatic intracranial aneurysm or arteriovenous
(AV) fistula; when an injury of this kind is identified,
surgical or endovascular management is recommended.
Magnetic resonance imaging (MRI) can play a role
in evaluating injuries from penetrating wooden and
other nonmagnetic objects. The presence on CT of
large contusions, hematomas, and intraventricular
hemorrhage is associated with increased mortality,
especially when both hemispheres are involved.
Prophylactic broad-spectrum antibiotics are appropriate
for patients with penetrating brain injury,
open skull fracture, and CSF leak. (Management of Penetrating
Brain Injury guidelines, L3 recommendation). Early
ICP monitoring is recommended when the clinician
is unable to assess the neurological examination
accurately, the need to evacuate a mass lesion is
unclear, or imaging studies suggest elevated ICP.
It is appropriate to treat small bullet entrance wounds
to the head with local wound care and closure in
patients whose scalp is not devitalized and who have
no major intracranial pathology.
Objects that penetrate the intracranial compartment
or infratemporal fossa and remain partially
exteriorized (e.g., arrows, knives, screwdrivers) must
be left in place until possible vascular injury has been
evaluated and definitive neurosurgical management
established. Disturbing or removing penetrating
objects prematurely can lead to fatal vascular injury or
intracranial hemorrhage.
Burr hole craniostomy/craniotomy, which involves
placing a 10- to 15-mm drill hole in the skull, has been
advocated as a method of emergently diagnosing
accessible hematomas in patients with rapid neurologic
deterioration who are located in austere or remote
regions where neurosurgeons and imaging are
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