During one of the editors first week in Iraq, a soldier with an obvious severe head injury from a roadside bomb was brought in. He was rapidly tagged as “needing urgent transfer” to the neurosurgery team in Balad. While waiting for the helicopter, his nurse fortunately noted that he was becoming more hypotensive and alerted one of the trauma surgeons. A more thorough evaluation was performed, a FAST exam demonstrated hemoperitoneum, and the patient underwent emergent splenectomy with subsequent rapid stabilization and then transfer. The most important point of this chapter is: the presence of a head injury should not change the initial treatment of the trauma patient. As a corollary, the premature transfer of a trauma patient to a neurosurgeon prior to appropriate initial treatment will adversely affect outcomes.

War-related trauma differs significantly from trauma seen in the civilian world . The prevalence of burn, penetrating and blast injuries sets the stage, and a multitude of other factors, including environmental conditions (e.g., mountains and deserts), physical settings (e.g., tents), and supply issues serve to make the wartime physician’s job worlds apart from anything else on the planet. Setting aside uniquely military aspects of being in a theater of operations (carrying a weapon and wearing body armor), this chapter will provide you with the basic information that you need to care for head-injured patients prior to their transfer to a higher echelon of care.

With medical operations in the various theaters fairly mature after years of combat operations, lack of ready access to a neurosurgeon in theater is becoming an infrequent problem. However, this access depends on the ability to transport the patient to the proper facility with a neurosurgical team. This means that as the initial receiving physician or surgeon, you are the neurosurgeon until that patient is put on a helicopter out of your facility. This results in a number of situations that will require a general or trauma surgeon to manage the patient with a head injury and occasionally even have to perform a neurosurgical operation . This chapter will provide a cookbook-type approach for this initial management and provide guidance to the general surgeon on when and how to proceed should the situation call for basic neurosurgical intervention when there is no neurosurgeon available.

As with other types of traumatic injuries, there are head injuries that are fatal, no matter what intervention is undertaken. The phrase “arrived dead, stayed dead” does apply occasionally, although you do not need to take it upon yourself to determine whether or not a head injury is survivable. Your job is avoiding secondary neurologic injury, most of which can be attributed to decreased oxygen delivery to the brain. If you have optimized the hemodynamics and blood oxygenation, then you have addressed the two most important factors which will save neurons. The third major factor is intracranial pressure (ICP) . There are a limited number of maneuvers that you can perform in order to manage ICP, which will be described in the pages to follow. The final steps in the management of refractory ICP are surgical. While this chapter will provide guidelines which will allow a general or trauma surgeon to perform a decompressive craniectomy with a reasonable degree of safety, the carrying out of that surgical procedure does require a certain degree of surgeon comfort and confidence. The decision to perform a decompressive craniectomy is not an easy one. Only the combination of a known or suspected ICP problem, deteriorating neurologic function, and the unavailability of neurosurgical care (timely transport via medevac assets) should trigger this decision.

Glasgow Coma Scale (GCS) is a very simple, yet useful assessment in the head-injured population. It gives a reproducible numerical scale from 3 to 15 which correlates very well with outcomes, especially when used to separate “severe” head injuries from all others (mild and moderate). Many times patients will arrive already intubated or under sedation. In these cases you should attempt to glean a GCS from the medevac crew or piece it together from a brief interview with the medics (what was the soldier/patient doing at the scene). Also remember that intubation does not preclude assessing mental status – if the patient is awake or moving, get a good basic neurologic exam before you re-sedate or paralyze. GCS pearl: don’t use the “squeeze my fingers” test to determine if the patient is following commands. Grasping can be a reflexive motor function. Tell the patient to do something and observe for the proper response, such as “give me a thumbs-up” or “move your left foot.”

When evaluating patients at a location that has ready access to CT, the following are general indications for obtaining a CT scan of the head:

Most, if not all, patients with a penetrating head injury will require treatment by a neurosurgeon; thus transfer to an appropriate facility should be planned in order to minimize delay after their assessment, stabilization, and resuscitation have been initiated. In patients that meet the above criteria for CT scan when there is no scanner, transfer to another medical asset needs to be considered after appropriate initial stabilization, assessment, and resuscitation.

Many people mistakenly think the neurologic exam doesn’t come until the secondary survey. After the ABCs have been done, the next step is D – disability. The goal of D is simple – identify significant head injury and any evidence of ICP elevation . This is done by calculating the GCS and examining the pupils . Remember that GCS is a measure of overall cerebral function, not localized neurologic function. A patient can have complete hemiparesis and still have a GCS of 15. You must understand the clinical signs of rising or elevated ICP. These include rapid neurologic deterioration or coma, unilateral or bilateral fixed/dilated pupils, and motor posturing (flexor or extensor). Cushing’s triad of hypertension, bradycardia, and altered respirations is a classic response to elevated ICP, and this pattern is rarely seen in non-head-injured trauma patients. If these signs are present, begin treatment immediately – you don’t need to wait for a CT scan.

After establishing your baseline neurologic exam and initiating any interventions, you then decide on whether the patient needs immediate operation, transfer, or admission. In any case, the patient should have frequent serial neurologic examinations done to immediately identify deterioration (rising ICP) and intervene. A decline in GCS of two points in the absence of confounding factors is generally significant and requires further diagnostic and therapeutic maneuvers. The worse the head injury, the more important a good and detailed neuro exam is! Anyone can pick up a GCS decline from 15 to 13, but identifying a drop from eight to six requires much more attention to detail.

CT scan should be obtained if available. Follow the “four N’s” from the BLUF box (above). If initial GCS is greater than 8, serial neurological examinations can be used to follow the patient’s status. Call the neurosurgeon on call to let him or her know what you are doing; they will likely provide good advice. If the initial GCS is 8 or less, consider placing an ICP monitor or external ventricular drain if available (technique to follow). Employ the ICP management strategy (see the excellent JTTS clinical practice guideline) to keep sustained ICP less than 20. If this cannot be accomplished, consider performing decompressive craniectomy (technique to follow). Decompression should be performed on the side with the most abnormality on CT, or in the absence of CT, laterality can be determined based in the following neurologic findings : (1) ipsilateral to a penetrating head injury or dilated pupil and (2) contralateral to a hemiparesis/hemiplegia/Babinski’s sign. In a patient who has not had neuromuscular blockade, the presence of bilaterally large and nonreactive pupils (without significant globe injuries), the absence of all cranial nerve reflexes (cough, gag, corneal reflexes), and the absence of any response to peripheral and central noxious stimulation are extremely poor prognostic factors, and consideration should be given to treating them as expectant.

With the increasing prevalence of explosive injury mechanisms in combat trauma, multi-system injury including severe brain trauma is much more common than seen in civilian practice. Blast injuries will often result in a devastating combination of skull fractures, blunt parenchymal injury, and multiple fragmentation injuries (Fig. 25.1). These patients will typically present intubated and having received sedation and neuromuscular blockade. It is very important to try and obtain a GCS from the scene of the trauma to assess for a head injury. A patient with a low GCS at the scene, even in the absence of physical findings or CT findings consistent with a head injury, may indeed have a severe brain injury. Even with CT at your disposal, patients may harbor unrecognized head injuries. Occasionally, there will be a great deal of effort expended by the trauma/general surgeons in order to stabilize a patient, after which it is determined that the patient has an extremely poor neurologic prognosis (see paragraph above). Again, consideration must be given to palliating the patient. Also remember that the classic hemodynamic response of hypertension and bradycardia may not be present in the hypovolemic trauma patient.