Table 2 Indications for CT scanning of the resuscitated head-injured patient
A GCS sum score of 8 or less without eye opening is coma. In patients with a history of brain injury, an impaired conscious level should not be attributed to metabolic disturbance (hypoglycemia), intoxication (alcohol, drug overdose), or hypothermia. Repetitive assessment of the GCS allows the clinician to evaluate the efficacy of management and to chart deterioration. The GCS sum score and in particular the GCS motor score have prognostic value ( Iable3).
In sedated or paralyzed patients pupillary responses to light need to be assessed frequently. In the absence of a history of ocular or local trauma, a single fixed and dilated pupil indicates temporal lobe herniation. Bilateral fixed and dilated pupils are a poor prognostic sign when they are due to transtentorial brain herniation affecting the brainstem. These signs are urgent indications for an intravenous bolus of 1 g/kg of 20 per cent mannitol over 15 to 20 min.
Periodic unprovoked cardiovascular instability in the chemically paralyzed and ventilated head-injured patient may indicate seizure activity. Seizures need to be controlled early since an increased oxygen demand raises cerebral blood flow and blood volume and increases intracranial pressure (ICP) if compliance is reduced. Prolonged seizures (status epilepticus) can lead to ischemia. Phenytoin or benzodiazepines are recommended but can cause cardiovascular depression and alter conscious level. Early neurosurgical consultation is also necessary.
Full front and back exposure is indicated to reveal any further injury. Neck immobilization with log-rolling is necessary for posterior evaluation. Transfer to a tertiary care center
Patient transfer can be fraught with danger if it takes place before resuscitation and stabilization are maintained, adequate monitoring and emergency equipment are unavailable, or communication with the accepting facility is inadequate. Comprehensive guidelines for the resuscitation and transfer of these patients are available (GeOtleman.. efa/ 1993).
Indications for the admission of brain-injured patients to intensive care are given in Table.4. Patients who are admitted postoperatively following major neurosurgical procedures may be ventilated overnight and assessed within the next 24 h, but those with significant intracerebral trauma leading to unstable ICP or cerebral perfusion pressure or with multiple trauma require longer mechanical ventilation. Patients thought to have suffered severe brain trauma resulting in brainstem death are ventilated without sedation, analgesia, or paralysis until brainstem death testing can be performed and possible organ donation accomplished.
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l telopenir.t piieris vtc te* unterçow nftnwgsrç í Frowns irtti an ín^fTitíl «uiclcigjeaJ ata» r^Mrtïg
S P-^'s^'.iJMtirs^MKiitflÉOefe'e: Table 4 Indications for admission to intensive care
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