Advanced Trauma Life Support ATLS Student Course Manual 2018

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CHAPTER 6 n Head Trauma
not readily available. Unfortunately, even in very
experienced hands, these drill holes are easily placed
incorrectly, and they seldom result in draining enough of
the hematoma to make a clinical difference. In patients
who need an evacuation, bone flap craniotomy (versus
a simple burr hole) is the definitive lifesaving procedure
to decompress the brain. Trauma team members should
make every attempt to have a practitioner trained and
experienced in doing the procedure perform it in a
timely fashion.
Prognosis
All patients should be treated aggressively pending
consultation with a neurosurgeon. This is particularly
true of children, who have a remarkable ability to
recover from seemingly devastating injuries.
Brain Death
A diagnosis of brain death implies that there is no
possibility for recovery of brain function. Most experts
agree that the diagnosis of brain death requires
meeting these criteria:
••
Glasgow Coma Scale score = 3
••
Nonreactive pupils
••
Absent brainstem reflexes (e.g., oculocephalic,
corneal, and doll’s eyes, and no gag reflex)
••
No spontaneous ventilatory effort on formal
apnea testing
••
Absence of confounding factors such as alcohol
or drug intoxication or hypothermia
Ancillary studies that may be used to confirm the
diagnosis of brain death include:
••
Electroencephalography: No activity at
high gain
••
CBF studies: No CBF (e.g., isotope studies,
Doppler studies, xenon CBF studies)
••
Cerebral angiography
Certain reversible conditions, such as hypothermia
or barbiturate coma, can mimic brain death; therefore,
consider making this diagnosis only after all
physiological parameters are normalized and central
nervous system function is not potentially affected
by medications. Because children are often able to
recover from extremely severe brain injuries, carefully
consider diagnosing brain death in these patients.
If any doubt exists, especially in children, multiple
serial exams spaced several hours apart are useful in
confirming the initial clinical impression. Notify local
organ procurement agencies about all patients with
the diagnosis or impending diagnosis of brain death
before discontinuing artificial life support measures.
The team leader must:
TeamWORK
••
Ensure that the team is capable of managing a
primary brain injury to the best possible outcome
by preventing secondary brain injury.
••
Recognize the importance of managing the
airway to ensure patients with head injuries do
not experience unnecessary hypoxia.
••
Recognize the need to involve neurosurgical
expertise at an appropriate stage and in a
timely fashion, particularly when a patient
requires surgical intervention.
••
Ensure the timely transfer of patients with TBI
to a trauma center when it is required.
••
However, the team leader must ensure that
patients with significant head injuries are
transferred to facilities where they can be
appropriately monitored and observed closely
for signs of deterioration.
••
Because some patients require neurosurgical
intervention early, be able to prioritize the
treatment of brain injury with other lifethreatening
injuries such as hemorrhage.
Manage the discussion between representatives
of different surgical specialties to ensure the
patient’s injuries are treated in the correct
sequence. For example, a patient who is
exsanguinating from a pelvic fracture requires
control of the bleeding before being transferred
for a neurosurgical procedure.
Chapter Summary
1. Understanding basic intracranial anatomy and
physiology is vital to managing head injury.
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