41
Management of Acute Traumatic Head Injury Dr. Manoranjitha Kumari MCh
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Management of Acute Traumatic Head Injury
Dr Manoranjitha Kumari MCh
Introduction
Incidence of Head Injury Indian Scenario
bull 15 to 2 million persons are injured bull 1 million succumb to death every year in
India
Neurol Res 2002 Jan24(1)24-8Epidemiology of traumatic brain injuries Indian scenarioGururaj G1
Causes
Alcohol involvement-10-15
Mechanism of injury
Types of head injury
DAI
bull Management
Evaluation
bull ATLSmdashABCrsquosbull Historyndash loss of consciousness
bull Physical exam ndash Glasgow Coma Scale
bull Radiographic studiesndash CT Scan
GCS
Classifying based on GCS
Guidelines
Radiologic examinationbull CT scanndash required in ALL cases EXCEPT
bull LOC is brief AND
bull patient can be serially examinedndash lesions
bull focal--epidural subdural hematoma contusions
bull diffuse--diffuse axonal injury
bull Plain filmsndash useful only to detect skull fracture but in the trauma
setting wastes time
SDH EDH
Indication of surgery
bull EDH more than 30 cc clotbull SDH more than 1 cm thicknessbull ICH more than 30 CCbull Compound depressed fracturesbull Any deterioration of GCS by 2 from the time
of admission even with lesser volume of clotbull Increased intra cranial pressure
Hyper acute management in the ICU
bull Initialndash Intubation if unresponsive or combative to give
controlled ventilationndash pharmacologic paralysis bull after neurologic exam is completed
ndash Blood pressure and O2 saturation monitoringbull keep systolic gt 90 mm Hgbull 100 O2 saturation
ICP monitoring
bull Indicationsndash severe head injury (GCS lt 9)bull abnormal head CT
orbull Coma gt6 hrs
ndash Intracranial hematoma requiring evacuationndash Delayed neurologic deterioration from mild to
moderate (GCSgt9) to severe (GCS lt 8) ndash Requirement for prolonged ventilation
ndash Pulmonary injury surgery etc
Measures to reduce ICP
bull Hyper osmolar therapymannitol 3 NACL Glycerol
Decompressive craniectomyVentilation with paralysing agent
ICU management goals
bull O2 saturation 100bull Mean arterial pressure 90-110 mm Hgbull ICP lt 20 mm Hgbull Cerebral Perfusion Pressure (CPP=MAP-ICP)
gt70 mm Hg
CPP
Icu adjuncts
bull HCT~ 30-33bull PaCO2= 35plusmn2 mm Hgbull CVP= 8-14 mm Hgbull avoid dextrose IVbull maintain euthermia or mild hypothermia
Other issues
bull DVT prophylaxisbull Antibioticsbull Anti epilepticsbull Nutrition
Factors Influencing Prognosis
bull Agendash Younger pts have greatest potential for survival and
recovery ndash 61-75 mortality if over 65 ndash 90 mortality in elderly with ICP gt20 and coma for more
than 3 daysndash 100 mortality if GCS lt 5 uni- or bilateral dilated pupils
and age over 75
bull survival and recovery not predictable except in old pts
bull Treat presuming recovery
Factors Influencing Prognosis
bull Hypotension--50 increase in mortality with single episode of hypotension
bull Hypoxiabull Delay in treatmentndash prolonged transportndash surgical delay when lateralizing signs present
Potentially controllable
Introduction
Incidence of Head Injury Indian Scenario
bull 15 to 2 million persons are injured bull 1 million succumb to death every year in
India
Neurol Res 2002 Jan24(1)24-8Epidemiology of traumatic brain injuries Indian scenarioGururaj G1
Causes
Alcohol involvement-10-15
Mechanism of injury
Types of head injury
DAI
bull Management
Evaluation
bull ATLSmdashABCrsquosbull Historyndash loss of consciousness
bull Physical exam ndash Glasgow Coma Scale
bull Radiographic studiesndash CT Scan
GCS
Classifying based on GCS
Guidelines
Radiologic examinationbull CT scanndash required in ALL cases EXCEPT
bull LOC is brief AND
bull patient can be serially examinedndash lesions
bull focal--epidural subdural hematoma contusions
bull diffuse--diffuse axonal injury
bull Plain filmsndash useful only to detect skull fracture but in the trauma
setting wastes time
SDH EDH
Indication of surgery
bull EDH more than 30 cc clotbull SDH more than 1 cm thicknessbull ICH more than 30 CCbull Compound depressed fracturesbull Any deterioration of GCS by 2 from the time
of admission even with lesser volume of clotbull Increased intra cranial pressure
Hyper acute management in the ICU
bull Initialndash Intubation if unresponsive or combative to give
controlled ventilationndash pharmacologic paralysis bull after neurologic exam is completed
ndash Blood pressure and O2 saturation monitoringbull keep systolic gt 90 mm Hgbull 100 O2 saturation
ICP monitoring
bull Indicationsndash severe head injury (GCS lt 9)bull abnormal head CT
orbull Coma gt6 hrs
ndash Intracranial hematoma requiring evacuationndash Delayed neurologic deterioration from mild to
moderate (GCSgt9) to severe (GCS lt 8) ndash Requirement for prolonged ventilation
ndash Pulmonary injury surgery etc
Measures to reduce ICP
bull Hyper osmolar therapymannitol 3 NACL Glycerol
Decompressive craniectomyVentilation with paralysing agent
ICU management goals
bull O2 saturation 100bull Mean arterial pressure 90-110 mm Hgbull ICP lt 20 mm Hgbull Cerebral Perfusion Pressure (CPP=MAP-ICP)
gt70 mm Hg
CPP
Icu adjuncts
bull HCT~ 30-33bull PaCO2= 35plusmn2 mm Hgbull CVP= 8-14 mm Hgbull avoid dextrose IVbull maintain euthermia or mild hypothermia
Other issues
bull DVT prophylaxisbull Antibioticsbull Anti epilepticsbull Nutrition
Factors Influencing Prognosis
bull Agendash Younger pts have greatest potential for survival and
recovery ndash 61-75 mortality if over 65 ndash 90 mortality in elderly with ICP gt20 and coma for more
than 3 daysndash 100 mortality if GCS lt 5 uni- or bilateral dilated pupils
and age over 75
bull survival and recovery not predictable except in old pts
bull Treat presuming recovery
Factors Influencing Prognosis
bull Hypotension--50 increase in mortality with single episode of hypotension
bull Hypoxiabull Delay in treatmentndash prolonged transportndash surgical delay when lateralizing signs present
Potentially controllable
Incidence of Head Injury Indian Scenario
bull 15 to 2 million persons are injured bull 1 million succumb to death every year in
India
Neurol Res 2002 Jan24(1)24-8Epidemiology of traumatic brain injuries Indian scenarioGururaj G1
Causes
Alcohol involvement-10-15
Mechanism of injury
Types of head injury
DAI
bull Management
Evaluation
bull ATLSmdashABCrsquosbull Historyndash loss of consciousness
bull Physical exam ndash Glasgow Coma Scale
bull Radiographic studiesndash CT Scan
GCS
Classifying based on GCS
Guidelines
Radiologic examinationbull CT scanndash required in ALL cases EXCEPT
bull LOC is brief AND
bull patient can be serially examinedndash lesions
bull focal--epidural subdural hematoma contusions
bull diffuse--diffuse axonal injury
bull Plain filmsndash useful only to detect skull fracture but in the trauma
setting wastes time
SDH EDH
Indication of surgery
bull EDH more than 30 cc clotbull SDH more than 1 cm thicknessbull ICH more than 30 CCbull Compound depressed fracturesbull Any deterioration of GCS by 2 from the time
of admission even with lesser volume of clotbull Increased intra cranial pressure
Hyper acute management in the ICU
bull Initialndash Intubation if unresponsive or combative to give
controlled ventilationndash pharmacologic paralysis bull after neurologic exam is completed
ndash Blood pressure and O2 saturation monitoringbull keep systolic gt 90 mm Hgbull 100 O2 saturation
ICP monitoring
bull Indicationsndash severe head injury (GCS lt 9)bull abnormal head CT
orbull Coma gt6 hrs
ndash Intracranial hematoma requiring evacuationndash Delayed neurologic deterioration from mild to
moderate (GCSgt9) to severe (GCS lt 8) ndash Requirement for prolonged ventilation
ndash Pulmonary injury surgery etc
Measures to reduce ICP
bull Hyper osmolar therapymannitol 3 NACL Glycerol
Decompressive craniectomyVentilation with paralysing agent
ICU management goals
bull O2 saturation 100bull Mean arterial pressure 90-110 mm Hgbull ICP lt 20 mm Hgbull Cerebral Perfusion Pressure (CPP=MAP-ICP)
gt70 mm Hg
CPP
Icu adjuncts
bull HCT~ 30-33bull PaCO2= 35plusmn2 mm Hgbull CVP= 8-14 mm Hgbull avoid dextrose IVbull maintain euthermia or mild hypothermia
Other issues
bull DVT prophylaxisbull Antibioticsbull Anti epilepticsbull Nutrition
Factors Influencing Prognosis
bull Agendash Younger pts have greatest potential for survival and
recovery ndash 61-75 mortality if over 65 ndash 90 mortality in elderly with ICP gt20 and coma for more
than 3 daysndash 100 mortality if GCS lt 5 uni- or bilateral dilated pupils
and age over 75
bull survival and recovery not predictable except in old pts
bull Treat presuming recovery
Factors Influencing Prognosis
bull Hypotension--50 increase in mortality with single episode of hypotension
bull Hypoxiabull Delay in treatmentndash prolonged transportndash surgical delay when lateralizing signs present
Potentially controllable
Causes
Alcohol involvement-10-15
Mechanism of injury
Types of head injury
DAI
bull Management
Evaluation
bull ATLSmdashABCrsquosbull Historyndash loss of consciousness
bull Physical exam ndash Glasgow Coma Scale
bull Radiographic studiesndash CT Scan
GCS
Classifying based on GCS
Guidelines
Radiologic examinationbull CT scanndash required in ALL cases EXCEPT
bull LOC is brief AND
bull patient can be serially examinedndash lesions
bull focal--epidural subdural hematoma contusions
bull diffuse--diffuse axonal injury
bull Plain filmsndash useful only to detect skull fracture but in the trauma
setting wastes time
SDH EDH
Indication of surgery
bull EDH more than 30 cc clotbull SDH more than 1 cm thicknessbull ICH more than 30 CCbull Compound depressed fracturesbull Any deterioration of GCS by 2 from the time
of admission even with lesser volume of clotbull Increased intra cranial pressure
Hyper acute management in the ICU
bull Initialndash Intubation if unresponsive or combative to give
controlled ventilationndash pharmacologic paralysis bull after neurologic exam is completed
ndash Blood pressure and O2 saturation monitoringbull keep systolic gt 90 mm Hgbull 100 O2 saturation
ICP monitoring
bull Indicationsndash severe head injury (GCS lt 9)bull abnormal head CT
orbull Coma gt6 hrs
ndash Intracranial hematoma requiring evacuationndash Delayed neurologic deterioration from mild to
moderate (GCSgt9) to severe (GCS lt 8) ndash Requirement for prolonged ventilation
ndash Pulmonary injury surgery etc
Measures to reduce ICP
bull Hyper osmolar therapymannitol 3 NACL Glycerol
Decompressive craniectomyVentilation with paralysing agent
ICU management goals
bull O2 saturation 100bull Mean arterial pressure 90-110 mm Hgbull ICP lt 20 mm Hgbull Cerebral Perfusion Pressure (CPP=MAP-ICP)
gt70 mm Hg
CPP
Icu adjuncts
bull HCT~ 30-33bull PaCO2= 35plusmn2 mm Hgbull CVP= 8-14 mm Hgbull avoid dextrose IVbull maintain euthermia or mild hypothermia
Other issues
bull DVT prophylaxisbull Antibioticsbull Anti epilepticsbull Nutrition
Factors Influencing Prognosis
bull Agendash Younger pts have greatest potential for survival and
recovery ndash 61-75 mortality if over 65 ndash 90 mortality in elderly with ICP gt20 and coma for more
than 3 daysndash 100 mortality if GCS lt 5 uni- or bilateral dilated pupils
and age over 75
bull survival and recovery not predictable except in old pts
bull Treat presuming recovery
Factors Influencing Prognosis
bull Hypotension--50 increase in mortality with single episode of hypotension
bull Hypoxiabull Delay in treatmentndash prolonged transportndash surgical delay when lateralizing signs present
Potentially controllable
Mechanism of injury
Types of head injury
DAI
bull Management
Evaluation
bull ATLSmdashABCrsquosbull Historyndash loss of consciousness
bull Physical exam ndash Glasgow Coma Scale
bull Radiographic studiesndash CT Scan
GCS
Classifying based on GCS
Guidelines
Radiologic examinationbull CT scanndash required in ALL cases EXCEPT
bull LOC is brief AND
bull patient can be serially examinedndash lesions
bull focal--epidural subdural hematoma contusions
bull diffuse--diffuse axonal injury
bull Plain filmsndash useful only to detect skull fracture but in the trauma
setting wastes time
SDH EDH
Indication of surgery
bull EDH more than 30 cc clotbull SDH more than 1 cm thicknessbull ICH more than 30 CCbull Compound depressed fracturesbull Any deterioration of GCS by 2 from the time
of admission even with lesser volume of clotbull Increased intra cranial pressure
Hyper acute management in the ICU
bull Initialndash Intubation if unresponsive or combative to give
controlled ventilationndash pharmacologic paralysis bull after neurologic exam is completed
ndash Blood pressure and O2 saturation monitoringbull keep systolic gt 90 mm Hgbull 100 O2 saturation
ICP monitoring
bull Indicationsndash severe head injury (GCS lt 9)bull abnormal head CT
orbull Coma gt6 hrs
ndash Intracranial hematoma requiring evacuationndash Delayed neurologic deterioration from mild to
moderate (GCSgt9) to severe (GCS lt 8) ndash Requirement for prolonged ventilation
ndash Pulmonary injury surgery etc
Measures to reduce ICP
bull Hyper osmolar therapymannitol 3 NACL Glycerol
Decompressive craniectomyVentilation with paralysing agent
ICU management goals
bull O2 saturation 100bull Mean arterial pressure 90-110 mm Hgbull ICP lt 20 mm Hgbull Cerebral Perfusion Pressure (CPP=MAP-ICP)
gt70 mm Hg
CPP
Icu adjuncts
bull HCT~ 30-33bull PaCO2= 35plusmn2 mm Hgbull CVP= 8-14 mm Hgbull avoid dextrose IVbull maintain euthermia or mild hypothermia
Other issues
bull DVT prophylaxisbull Antibioticsbull Anti epilepticsbull Nutrition
Factors Influencing Prognosis
bull Agendash Younger pts have greatest potential for survival and
recovery ndash 61-75 mortality if over 65 ndash 90 mortality in elderly with ICP gt20 and coma for more
than 3 daysndash 100 mortality if GCS lt 5 uni- or bilateral dilated pupils
and age over 75
bull survival and recovery not predictable except in old pts
bull Treat presuming recovery
Factors Influencing Prognosis
bull Hypotension--50 increase in mortality with single episode of hypotension
bull Hypoxiabull Delay in treatmentndash prolonged transportndash surgical delay when lateralizing signs present
Potentially controllable
Types of head injury
DAI
bull Management
Evaluation
bull ATLSmdashABCrsquosbull Historyndash loss of consciousness
bull Physical exam ndash Glasgow Coma Scale
bull Radiographic studiesndash CT Scan
GCS
Classifying based on GCS
Guidelines
Radiologic examinationbull CT scanndash required in ALL cases EXCEPT
bull LOC is brief AND
bull patient can be serially examinedndash lesions
bull focal--epidural subdural hematoma contusions
bull diffuse--diffuse axonal injury
bull Plain filmsndash useful only to detect skull fracture but in the trauma
setting wastes time
SDH EDH
Indication of surgery
bull EDH more than 30 cc clotbull SDH more than 1 cm thicknessbull ICH more than 30 CCbull Compound depressed fracturesbull Any deterioration of GCS by 2 from the time
of admission even with lesser volume of clotbull Increased intra cranial pressure
Hyper acute management in the ICU
bull Initialndash Intubation if unresponsive or combative to give
controlled ventilationndash pharmacologic paralysis bull after neurologic exam is completed
ndash Blood pressure and O2 saturation monitoringbull keep systolic gt 90 mm Hgbull 100 O2 saturation
ICP monitoring
bull Indicationsndash severe head injury (GCS lt 9)bull abnormal head CT
orbull Coma gt6 hrs
ndash Intracranial hematoma requiring evacuationndash Delayed neurologic deterioration from mild to
moderate (GCSgt9) to severe (GCS lt 8) ndash Requirement for prolonged ventilation
ndash Pulmonary injury surgery etc
Measures to reduce ICP
bull Hyper osmolar therapymannitol 3 NACL Glycerol
Decompressive craniectomyVentilation with paralysing agent
ICU management goals
bull O2 saturation 100bull Mean arterial pressure 90-110 mm Hgbull ICP lt 20 mm Hgbull Cerebral Perfusion Pressure (CPP=MAP-ICP)
gt70 mm Hg
CPP
Icu adjuncts
bull HCT~ 30-33bull PaCO2= 35plusmn2 mm Hgbull CVP= 8-14 mm Hgbull avoid dextrose IVbull maintain euthermia or mild hypothermia
Other issues
bull DVT prophylaxisbull Antibioticsbull Anti epilepticsbull Nutrition
Factors Influencing Prognosis
bull Agendash Younger pts have greatest potential for survival and
recovery ndash 61-75 mortality if over 65 ndash 90 mortality in elderly with ICP gt20 and coma for more
than 3 daysndash 100 mortality if GCS lt 5 uni- or bilateral dilated pupils
and age over 75
bull survival and recovery not predictable except in old pts
bull Treat presuming recovery
Factors Influencing Prognosis
bull Hypotension--50 increase in mortality with single episode of hypotension
bull Hypoxiabull Delay in treatmentndash prolonged transportndash surgical delay when lateralizing signs present
Potentially controllable
DAI
bull Management
Evaluation
bull ATLSmdashABCrsquosbull Historyndash loss of consciousness
bull Physical exam ndash Glasgow Coma Scale
bull Radiographic studiesndash CT Scan
GCS
Classifying based on GCS
Guidelines
Radiologic examinationbull CT scanndash required in ALL cases EXCEPT
bull LOC is brief AND
bull patient can be serially examinedndash lesions
bull focal--epidural subdural hematoma contusions
bull diffuse--diffuse axonal injury
bull Plain filmsndash useful only to detect skull fracture but in the trauma
setting wastes time
SDH EDH
Indication of surgery
bull EDH more than 30 cc clotbull SDH more than 1 cm thicknessbull ICH more than 30 CCbull Compound depressed fracturesbull Any deterioration of GCS by 2 from the time
of admission even with lesser volume of clotbull Increased intra cranial pressure
Hyper acute management in the ICU
bull Initialndash Intubation if unresponsive or combative to give
controlled ventilationndash pharmacologic paralysis bull after neurologic exam is completed
ndash Blood pressure and O2 saturation monitoringbull keep systolic gt 90 mm Hgbull 100 O2 saturation
ICP monitoring
bull Indicationsndash severe head injury (GCS lt 9)bull abnormal head CT
orbull Coma gt6 hrs
ndash Intracranial hematoma requiring evacuationndash Delayed neurologic deterioration from mild to
moderate (GCSgt9) to severe (GCS lt 8) ndash Requirement for prolonged ventilation
ndash Pulmonary injury surgery etc
Measures to reduce ICP
bull Hyper osmolar therapymannitol 3 NACL Glycerol
Decompressive craniectomyVentilation with paralysing agent
ICU management goals
bull O2 saturation 100bull Mean arterial pressure 90-110 mm Hgbull ICP lt 20 mm Hgbull Cerebral Perfusion Pressure (CPP=MAP-ICP)
gt70 mm Hg
CPP
Icu adjuncts
bull HCT~ 30-33bull PaCO2= 35plusmn2 mm Hgbull CVP= 8-14 mm Hgbull avoid dextrose IVbull maintain euthermia or mild hypothermia
Other issues
bull DVT prophylaxisbull Antibioticsbull Anti epilepticsbull Nutrition
Factors Influencing Prognosis
bull Agendash Younger pts have greatest potential for survival and
recovery ndash 61-75 mortality if over 65 ndash 90 mortality in elderly with ICP gt20 and coma for more
than 3 daysndash 100 mortality if GCS lt 5 uni- or bilateral dilated pupils
and age over 75
bull survival and recovery not predictable except in old pts
bull Treat presuming recovery
Factors Influencing Prognosis
bull Hypotension--50 increase in mortality with single episode of hypotension
bull Hypoxiabull Delay in treatmentndash prolonged transportndash surgical delay when lateralizing signs present
Potentially controllable
bull Management
Evaluation
bull ATLSmdashABCrsquosbull Historyndash loss of consciousness
bull Physical exam ndash Glasgow Coma Scale
bull Radiographic studiesndash CT Scan
GCS
Classifying based on GCS
Guidelines
Radiologic examinationbull CT scanndash required in ALL cases EXCEPT
bull LOC is brief AND
bull patient can be serially examinedndash lesions
bull focal--epidural subdural hematoma contusions
bull diffuse--diffuse axonal injury
bull Plain filmsndash useful only to detect skull fracture but in the trauma
setting wastes time
SDH EDH
Indication of surgery
bull EDH more than 30 cc clotbull SDH more than 1 cm thicknessbull ICH more than 30 CCbull Compound depressed fracturesbull Any deterioration of GCS by 2 from the time
of admission even with lesser volume of clotbull Increased intra cranial pressure
Hyper acute management in the ICU
bull Initialndash Intubation if unresponsive or combative to give
controlled ventilationndash pharmacologic paralysis bull after neurologic exam is completed
ndash Blood pressure and O2 saturation monitoringbull keep systolic gt 90 mm Hgbull 100 O2 saturation
ICP monitoring
bull Indicationsndash severe head injury (GCS lt 9)bull abnormal head CT
orbull Coma gt6 hrs
ndash Intracranial hematoma requiring evacuationndash Delayed neurologic deterioration from mild to
moderate (GCSgt9) to severe (GCS lt 8) ndash Requirement for prolonged ventilation
ndash Pulmonary injury surgery etc
Measures to reduce ICP
bull Hyper osmolar therapymannitol 3 NACL Glycerol
Decompressive craniectomyVentilation with paralysing agent
ICU management goals
bull O2 saturation 100bull Mean arterial pressure 90-110 mm Hgbull ICP lt 20 mm Hgbull Cerebral Perfusion Pressure (CPP=MAP-ICP)
gt70 mm Hg
CPP
Icu adjuncts
bull HCT~ 30-33bull PaCO2= 35plusmn2 mm Hgbull CVP= 8-14 mm Hgbull avoid dextrose IVbull maintain euthermia or mild hypothermia
Other issues
bull DVT prophylaxisbull Antibioticsbull Anti epilepticsbull Nutrition
Factors Influencing Prognosis
bull Agendash Younger pts have greatest potential for survival and
recovery ndash 61-75 mortality if over 65 ndash 90 mortality in elderly with ICP gt20 and coma for more
than 3 daysndash 100 mortality if GCS lt 5 uni- or bilateral dilated pupils
and age over 75
bull survival and recovery not predictable except in old pts
bull Treat presuming recovery
Factors Influencing Prognosis
bull Hypotension--50 increase in mortality with single episode of hypotension
bull Hypoxiabull Delay in treatmentndash prolonged transportndash surgical delay when lateralizing signs present
Potentially controllable
Evaluation
bull ATLSmdashABCrsquosbull Historyndash loss of consciousness
bull Physical exam ndash Glasgow Coma Scale
bull Radiographic studiesndash CT Scan
GCS
Classifying based on GCS
Guidelines
Radiologic examinationbull CT scanndash required in ALL cases EXCEPT
bull LOC is brief AND
bull patient can be serially examinedndash lesions
bull focal--epidural subdural hematoma contusions
bull diffuse--diffuse axonal injury
bull Plain filmsndash useful only to detect skull fracture but in the trauma
setting wastes time
SDH EDH
Indication of surgery
bull EDH more than 30 cc clotbull SDH more than 1 cm thicknessbull ICH more than 30 CCbull Compound depressed fracturesbull Any deterioration of GCS by 2 from the time
of admission even with lesser volume of clotbull Increased intra cranial pressure
Hyper acute management in the ICU
bull Initialndash Intubation if unresponsive or combative to give
controlled ventilationndash pharmacologic paralysis bull after neurologic exam is completed
ndash Blood pressure and O2 saturation monitoringbull keep systolic gt 90 mm Hgbull 100 O2 saturation
ICP monitoring
bull Indicationsndash severe head injury (GCS lt 9)bull abnormal head CT
orbull Coma gt6 hrs
ndash Intracranial hematoma requiring evacuationndash Delayed neurologic deterioration from mild to
moderate (GCSgt9) to severe (GCS lt 8) ndash Requirement for prolonged ventilation
ndash Pulmonary injury surgery etc
Measures to reduce ICP
bull Hyper osmolar therapymannitol 3 NACL Glycerol
Decompressive craniectomyVentilation with paralysing agent
ICU management goals
bull O2 saturation 100bull Mean arterial pressure 90-110 mm Hgbull ICP lt 20 mm Hgbull Cerebral Perfusion Pressure (CPP=MAP-ICP)
gt70 mm Hg
CPP
Icu adjuncts
bull HCT~ 30-33bull PaCO2= 35plusmn2 mm Hgbull CVP= 8-14 mm Hgbull avoid dextrose IVbull maintain euthermia or mild hypothermia
Other issues
bull DVT prophylaxisbull Antibioticsbull Anti epilepticsbull Nutrition
Factors Influencing Prognosis
bull Agendash Younger pts have greatest potential for survival and
recovery ndash 61-75 mortality if over 65 ndash 90 mortality in elderly with ICP gt20 and coma for more
than 3 daysndash 100 mortality if GCS lt 5 uni- or bilateral dilated pupils
and age over 75
bull survival and recovery not predictable except in old pts
bull Treat presuming recovery
Factors Influencing Prognosis
bull Hypotension--50 increase in mortality with single episode of hypotension
bull Hypoxiabull Delay in treatmentndash prolonged transportndash surgical delay when lateralizing signs present
Potentially controllable
GCS
Classifying based on GCS
Guidelines
Radiologic examinationbull CT scanndash required in ALL cases EXCEPT
bull LOC is brief AND
bull patient can be serially examinedndash lesions
bull focal--epidural subdural hematoma contusions
bull diffuse--diffuse axonal injury
bull Plain filmsndash useful only to detect skull fracture but in the trauma
setting wastes time
SDH EDH
Indication of surgery
bull EDH more than 30 cc clotbull SDH more than 1 cm thicknessbull ICH more than 30 CCbull Compound depressed fracturesbull Any deterioration of GCS by 2 from the time
of admission even with lesser volume of clotbull Increased intra cranial pressure
Hyper acute management in the ICU
bull Initialndash Intubation if unresponsive or combative to give
controlled ventilationndash pharmacologic paralysis bull after neurologic exam is completed
ndash Blood pressure and O2 saturation monitoringbull keep systolic gt 90 mm Hgbull 100 O2 saturation
ICP monitoring
bull Indicationsndash severe head injury (GCS lt 9)bull abnormal head CT
orbull Coma gt6 hrs
ndash Intracranial hematoma requiring evacuationndash Delayed neurologic deterioration from mild to
moderate (GCSgt9) to severe (GCS lt 8) ndash Requirement for prolonged ventilation
ndash Pulmonary injury surgery etc
Measures to reduce ICP
bull Hyper osmolar therapymannitol 3 NACL Glycerol
Decompressive craniectomyVentilation with paralysing agent
ICU management goals
bull O2 saturation 100bull Mean arterial pressure 90-110 mm Hgbull ICP lt 20 mm Hgbull Cerebral Perfusion Pressure (CPP=MAP-ICP)
gt70 mm Hg
CPP
Icu adjuncts
bull HCT~ 30-33bull PaCO2= 35plusmn2 mm Hgbull CVP= 8-14 mm Hgbull avoid dextrose IVbull maintain euthermia or mild hypothermia
Other issues
bull DVT prophylaxisbull Antibioticsbull Anti epilepticsbull Nutrition
Factors Influencing Prognosis
bull Agendash Younger pts have greatest potential for survival and
recovery ndash 61-75 mortality if over 65 ndash 90 mortality in elderly with ICP gt20 and coma for more
than 3 daysndash 100 mortality if GCS lt 5 uni- or bilateral dilated pupils
and age over 75
bull survival and recovery not predictable except in old pts
bull Treat presuming recovery
Factors Influencing Prognosis
bull Hypotension--50 increase in mortality with single episode of hypotension
bull Hypoxiabull Delay in treatmentndash prolonged transportndash surgical delay when lateralizing signs present
Potentially controllable
Classifying based on GCS
Guidelines
Radiologic examinationbull CT scanndash required in ALL cases EXCEPT
bull LOC is brief AND
bull patient can be serially examinedndash lesions
bull focal--epidural subdural hematoma contusions
bull diffuse--diffuse axonal injury
bull Plain filmsndash useful only to detect skull fracture but in the trauma
setting wastes time
SDH EDH
Indication of surgery
bull EDH more than 30 cc clotbull SDH more than 1 cm thicknessbull ICH more than 30 CCbull Compound depressed fracturesbull Any deterioration of GCS by 2 from the time
of admission even with lesser volume of clotbull Increased intra cranial pressure
Hyper acute management in the ICU
bull Initialndash Intubation if unresponsive or combative to give
controlled ventilationndash pharmacologic paralysis bull after neurologic exam is completed
ndash Blood pressure and O2 saturation monitoringbull keep systolic gt 90 mm Hgbull 100 O2 saturation
ICP monitoring
bull Indicationsndash severe head injury (GCS lt 9)bull abnormal head CT
orbull Coma gt6 hrs
ndash Intracranial hematoma requiring evacuationndash Delayed neurologic deterioration from mild to
moderate (GCSgt9) to severe (GCS lt 8) ndash Requirement for prolonged ventilation
ndash Pulmonary injury surgery etc
Measures to reduce ICP
bull Hyper osmolar therapymannitol 3 NACL Glycerol
Decompressive craniectomyVentilation with paralysing agent
ICU management goals
bull O2 saturation 100bull Mean arterial pressure 90-110 mm Hgbull ICP lt 20 mm Hgbull Cerebral Perfusion Pressure (CPP=MAP-ICP)
gt70 mm Hg
CPP
Icu adjuncts
bull HCT~ 30-33bull PaCO2= 35plusmn2 mm Hgbull CVP= 8-14 mm Hgbull avoid dextrose IVbull maintain euthermia or mild hypothermia
Other issues
bull DVT prophylaxisbull Antibioticsbull Anti epilepticsbull Nutrition
Factors Influencing Prognosis
bull Agendash Younger pts have greatest potential for survival and
recovery ndash 61-75 mortality if over 65 ndash 90 mortality in elderly with ICP gt20 and coma for more
than 3 daysndash 100 mortality if GCS lt 5 uni- or bilateral dilated pupils
and age over 75
bull survival and recovery not predictable except in old pts
bull Treat presuming recovery
Factors Influencing Prognosis
bull Hypotension--50 increase in mortality with single episode of hypotension
bull Hypoxiabull Delay in treatmentndash prolonged transportndash surgical delay when lateralizing signs present
Potentially controllable
Guidelines
Radiologic examinationbull CT scanndash required in ALL cases EXCEPT
bull LOC is brief AND
bull patient can be serially examinedndash lesions
bull focal--epidural subdural hematoma contusions
bull diffuse--diffuse axonal injury
bull Plain filmsndash useful only to detect skull fracture but in the trauma
setting wastes time
SDH EDH
Indication of surgery
bull EDH more than 30 cc clotbull SDH more than 1 cm thicknessbull ICH more than 30 CCbull Compound depressed fracturesbull Any deterioration of GCS by 2 from the time
of admission even with lesser volume of clotbull Increased intra cranial pressure
Hyper acute management in the ICU
bull Initialndash Intubation if unresponsive or combative to give
controlled ventilationndash pharmacologic paralysis bull after neurologic exam is completed
ndash Blood pressure and O2 saturation monitoringbull keep systolic gt 90 mm Hgbull 100 O2 saturation
ICP monitoring
bull Indicationsndash severe head injury (GCS lt 9)bull abnormal head CT
orbull Coma gt6 hrs
ndash Intracranial hematoma requiring evacuationndash Delayed neurologic deterioration from mild to
moderate (GCSgt9) to severe (GCS lt 8) ndash Requirement for prolonged ventilation
ndash Pulmonary injury surgery etc
Measures to reduce ICP
bull Hyper osmolar therapymannitol 3 NACL Glycerol
Decompressive craniectomyVentilation with paralysing agent
ICU management goals
bull O2 saturation 100bull Mean arterial pressure 90-110 mm Hgbull ICP lt 20 mm Hgbull Cerebral Perfusion Pressure (CPP=MAP-ICP)
gt70 mm Hg
CPP
Icu adjuncts
bull HCT~ 30-33bull PaCO2= 35plusmn2 mm Hgbull CVP= 8-14 mm Hgbull avoid dextrose IVbull maintain euthermia or mild hypothermia
Other issues
bull DVT prophylaxisbull Antibioticsbull Anti epilepticsbull Nutrition
Factors Influencing Prognosis
bull Agendash Younger pts have greatest potential for survival and
recovery ndash 61-75 mortality if over 65 ndash 90 mortality in elderly with ICP gt20 and coma for more
than 3 daysndash 100 mortality if GCS lt 5 uni- or bilateral dilated pupils
and age over 75
bull survival and recovery not predictable except in old pts
bull Treat presuming recovery
Factors Influencing Prognosis
bull Hypotension--50 increase in mortality with single episode of hypotension
bull Hypoxiabull Delay in treatmentndash prolonged transportndash surgical delay when lateralizing signs present
Potentially controllable
Radiologic examinationbull CT scanndash required in ALL cases EXCEPT
bull LOC is brief AND
bull patient can be serially examinedndash lesions
bull focal--epidural subdural hematoma contusions
bull diffuse--diffuse axonal injury
bull Plain filmsndash useful only to detect skull fracture but in the trauma
setting wastes time
SDH EDH
Indication of surgery
bull EDH more than 30 cc clotbull SDH more than 1 cm thicknessbull ICH more than 30 CCbull Compound depressed fracturesbull Any deterioration of GCS by 2 from the time
of admission even with lesser volume of clotbull Increased intra cranial pressure
Hyper acute management in the ICU
bull Initialndash Intubation if unresponsive or combative to give
controlled ventilationndash pharmacologic paralysis bull after neurologic exam is completed
ndash Blood pressure and O2 saturation monitoringbull keep systolic gt 90 mm Hgbull 100 O2 saturation
ICP monitoring
bull Indicationsndash severe head injury (GCS lt 9)bull abnormal head CT
orbull Coma gt6 hrs
ndash Intracranial hematoma requiring evacuationndash Delayed neurologic deterioration from mild to
moderate (GCSgt9) to severe (GCS lt 8) ndash Requirement for prolonged ventilation
ndash Pulmonary injury surgery etc
Measures to reduce ICP
bull Hyper osmolar therapymannitol 3 NACL Glycerol
Decompressive craniectomyVentilation with paralysing agent
ICU management goals
bull O2 saturation 100bull Mean arterial pressure 90-110 mm Hgbull ICP lt 20 mm Hgbull Cerebral Perfusion Pressure (CPP=MAP-ICP)
gt70 mm Hg
CPP
Icu adjuncts
bull HCT~ 30-33bull PaCO2= 35plusmn2 mm Hgbull CVP= 8-14 mm Hgbull avoid dextrose IVbull maintain euthermia or mild hypothermia
Other issues
bull DVT prophylaxisbull Antibioticsbull Anti epilepticsbull Nutrition
Factors Influencing Prognosis
bull Agendash Younger pts have greatest potential for survival and
recovery ndash 61-75 mortality if over 65 ndash 90 mortality in elderly with ICP gt20 and coma for more
than 3 daysndash 100 mortality if GCS lt 5 uni- or bilateral dilated pupils
and age over 75
bull survival and recovery not predictable except in old pts
bull Treat presuming recovery
Factors Influencing Prognosis
bull Hypotension--50 increase in mortality with single episode of hypotension
bull Hypoxiabull Delay in treatmentndash prolonged transportndash surgical delay when lateralizing signs present
Potentially controllable
SDH EDH
Indication of surgery
bull EDH more than 30 cc clotbull SDH more than 1 cm thicknessbull ICH more than 30 CCbull Compound depressed fracturesbull Any deterioration of GCS by 2 from the time
of admission even with lesser volume of clotbull Increased intra cranial pressure
Hyper acute management in the ICU
bull Initialndash Intubation if unresponsive or combative to give
controlled ventilationndash pharmacologic paralysis bull after neurologic exam is completed
ndash Blood pressure and O2 saturation monitoringbull keep systolic gt 90 mm Hgbull 100 O2 saturation
ICP monitoring
bull Indicationsndash severe head injury (GCS lt 9)bull abnormal head CT
orbull Coma gt6 hrs
ndash Intracranial hematoma requiring evacuationndash Delayed neurologic deterioration from mild to
moderate (GCSgt9) to severe (GCS lt 8) ndash Requirement for prolonged ventilation
ndash Pulmonary injury surgery etc
Measures to reduce ICP
bull Hyper osmolar therapymannitol 3 NACL Glycerol
Decompressive craniectomyVentilation with paralysing agent
ICU management goals
bull O2 saturation 100bull Mean arterial pressure 90-110 mm Hgbull ICP lt 20 mm Hgbull Cerebral Perfusion Pressure (CPP=MAP-ICP)
gt70 mm Hg
CPP
Icu adjuncts
bull HCT~ 30-33bull PaCO2= 35plusmn2 mm Hgbull CVP= 8-14 mm Hgbull avoid dextrose IVbull maintain euthermia or mild hypothermia
Other issues
bull DVT prophylaxisbull Antibioticsbull Anti epilepticsbull Nutrition
Factors Influencing Prognosis
bull Agendash Younger pts have greatest potential for survival and
recovery ndash 61-75 mortality if over 65 ndash 90 mortality in elderly with ICP gt20 and coma for more
than 3 daysndash 100 mortality if GCS lt 5 uni- or bilateral dilated pupils
and age over 75
bull survival and recovery not predictable except in old pts
bull Treat presuming recovery
Factors Influencing Prognosis
bull Hypotension--50 increase in mortality with single episode of hypotension
bull Hypoxiabull Delay in treatmentndash prolonged transportndash surgical delay when lateralizing signs present
Potentially controllable
Indication of surgery
bull EDH more than 30 cc clotbull SDH more than 1 cm thicknessbull ICH more than 30 CCbull Compound depressed fracturesbull Any deterioration of GCS by 2 from the time
of admission even with lesser volume of clotbull Increased intra cranial pressure
Hyper acute management in the ICU
bull Initialndash Intubation if unresponsive or combative to give
controlled ventilationndash pharmacologic paralysis bull after neurologic exam is completed
ndash Blood pressure and O2 saturation monitoringbull keep systolic gt 90 mm Hgbull 100 O2 saturation
ICP monitoring
bull Indicationsndash severe head injury (GCS lt 9)bull abnormal head CT
orbull Coma gt6 hrs
ndash Intracranial hematoma requiring evacuationndash Delayed neurologic deterioration from mild to
moderate (GCSgt9) to severe (GCS lt 8) ndash Requirement for prolonged ventilation
ndash Pulmonary injury surgery etc
Measures to reduce ICP
bull Hyper osmolar therapymannitol 3 NACL Glycerol
Decompressive craniectomyVentilation with paralysing agent
ICU management goals
bull O2 saturation 100bull Mean arterial pressure 90-110 mm Hgbull ICP lt 20 mm Hgbull Cerebral Perfusion Pressure (CPP=MAP-ICP)
gt70 mm Hg
CPP
Icu adjuncts
bull HCT~ 30-33bull PaCO2= 35plusmn2 mm Hgbull CVP= 8-14 mm Hgbull avoid dextrose IVbull maintain euthermia or mild hypothermia
Other issues
bull DVT prophylaxisbull Antibioticsbull Anti epilepticsbull Nutrition
Factors Influencing Prognosis
bull Agendash Younger pts have greatest potential for survival and
recovery ndash 61-75 mortality if over 65 ndash 90 mortality in elderly with ICP gt20 and coma for more
than 3 daysndash 100 mortality if GCS lt 5 uni- or bilateral dilated pupils
and age over 75
bull survival and recovery not predictable except in old pts
bull Treat presuming recovery
Factors Influencing Prognosis
bull Hypotension--50 increase in mortality with single episode of hypotension
bull Hypoxiabull Delay in treatmentndash prolonged transportndash surgical delay when lateralizing signs present
Potentially controllable
Hyper acute management in the ICU
bull Initialndash Intubation if unresponsive or combative to give
controlled ventilationndash pharmacologic paralysis bull after neurologic exam is completed
ndash Blood pressure and O2 saturation monitoringbull keep systolic gt 90 mm Hgbull 100 O2 saturation
ICP monitoring
bull Indicationsndash severe head injury (GCS lt 9)bull abnormal head CT
orbull Coma gt6 hrs
ndash Intracranial hematoma requiring evacuationndash Delayed neurologic deterioration from mild to
moderate (GCSgt9) to severe (GCS lt 8) ndash Requirement for prolonged ventilation
ndash Pulmonary injury surgery etc
Measures to reduce ICP
bull Hyper osmolar therapymannitol 3 NACL Glycerol
Decompressive craniectomyVentilation with paralysing agent
ICU management goals
bull O2 saturation 100bull Mean arterial pressure 90-110 mm Hgbull ICP lt 20 mm Hgbull Cerebral Perfusion Pressure (CPP=MAP-ICP)
gt70 mm Hg
CPP
Icu adjuncts
bull HCT~ 30-33bull PaCO2= 35plusmn2 mm Hgbull CVP= 8-14 mm Hgbull avoid dextrose IVbull maintain euthermia or mild hypothermia
Other issues
bull DVT prophylaxisbull Antibioticsbull Anti epilepticsbull Nutrition
Factors Influencing Prognosis
bull Agendash Younger pts have greatest potential for survival and
recovery ndash 61-75 mortality if over 65 ndash 90 mortality in elderly with ICP gt20 and coma for more
than 3 daysndash 100 mortality if GCS lt 5 uni- or bilateral dilated pupils
and age over 75
bull survival and recovery not predictable except in old pts
bull Treat presuming recovery
Factors Influencing Prognosis
bull Hypotension--50 increase in mortality with single episode of hypotension
bull Hypoxiabull Delay in treatmentndash prolonged transportndash surgical delay when lateralizing signs present
Potentially controllable
ICP monitoring
bull Indicationsndash severe head injury (GCS lt 9)bull abnormal head CT
orbull Coma gt6 hrs
ndash Intracranial hematoma requiring evacuationndash Delayed neurologic deterioration from mild to
moderate (GCSgt9) to severe (GCS lt 8) ndash Requirement for prolonged ventilation
ndash Pulmonary injury surgery etc
Measures to reduce ICP
bull Hyper osmolar therapymannitol 3 NACL Glycerol
Decompressive craniectomyVentilation with paralysing agent
ICU management goals
bull O2 saturation 100bull Mean arterial pressure 90-110 mm Hgbull ICP lt 20 mm Hgbull Cerebral Perfusion Pressure (CPP=MAP-ICP)
gt70 mm Hg
CPP
Icu adjuncts
bull HCT~ 30-33bull PaCO2= 35plusmn2 mm Hgbull CVP= 8-14 mm Hgbull avoid dextrose IVbull maintain euthermia or mild hypothermia
Other issues
bull DVT prophylaxisbull Antibioticsbull Anti epilepticsbull Nutrition
Factors Influencing Prognosis
bull Agendash Younger pts have greatest potential for survival and
recovery ndash 61-75 mortality if over 65 ndash 90 mortality in elderly with ICP gt20 and coma for more
than 3 daysndash 100 mortality if GCS lt 5 uni- or bilateral dilated pupils
and age over 75
bull survival and recovery not predictable except in old pts
bull Treat presuming recovery
Factors Influencing Prognosis
bull Hypotension--50 increase in mortality with single episode of hypotension
bull Hypoxiabull Delay in treatmentndash prolonged transportndash surgical delay when lateralizing signs present
Potentially controllable
Measures to reduce ICP
bull Hyper osmolar therapymannitol 3 NACL Glycerol
Decompressive craniectomyVentilation with paralysing agent
ICU management goals
bull O2 saturation 100bull Mean arterial pressure 90-110 mm Hgbull ICP lt 20 mm Hgbull Cerebral Perfusion Pressure (CPP=MAP-ICP)
gt70 mm Hg
CPP
Icu adjuncts
bull HCT~ 30-33bull PaCO2= 35plusmn2 mm Hgbull CVP= 8-14 mm Hgbull avoid dextrose IVbull maintain euthermia or mild hypothermia
Other issues
bull DVT prophylaxisbull Antibioticsbull Anti epilepticsbull Nutrition
Factors Influencing Prognosis
bull Agendash Younger pts have greatest potential for survival and
recovery ndash 61-75 mortality if over 65 ndash 90 mortality in elderly with ICP gt20 and coma for more
than 3 daysndash 100 mortality if GCS lt 5 uni- or bilateral dilated pupils
and age over 75
bull survival and recovery not predictable except in old pts
bull Treat presuming recovery
Factors Influencing Prognosis
bull Hypotension--50 increase in mortality with single episode of hypotension
bull Hypoxiabull Delay in treatmentndash prolonged transportndash surgical delay when lateralizing signs present
Potentially controllable
ICU management goals
bull O2 saturation 100bull Mean arterial pressure 90-110 mm Hgbull ICP lt 20 mm Hgbull Cerebral Perfusion Pressure (CPP=MAP-ICP)
gt70 mm Hg
CPP
Icu adjuncts
bull HCT~ 30-33bull PaCO2= 35plusmn2 mm Hgbull CVP= 8-14 mm Hgbull avoid dextrose IVbull maintain euthermia or mild hypothermia
Other issues
bull DVT prophylaxisbull Antibioticsbull Anti epilepticsbull Nutrition
Factors Influencing Prognosis
bull Agendash Younger pts have greatest potential for survival and
recovery ndash 61-75 mortality if over 65 ndash 90 mortality in elderly with ICP gt20 and coma for more
than 3 daysndash 100 mortality if GCS lt 5 uni- or bilateral dilated pupils
and age over 75
bull survival and recovery not predictable except in old pts
bull Treat presuming recovery
Factors Influencing Prognosis
bull Hypotension--50 increase in mortality with single episode of hypotension
bull Hypoxiabull Delay in treatmentndash prolonged transportndash surgical delay when lateralizing signs present
Potentially controllable
CPP
Icu adjuncts
bull HCT~ 30-33bull PaCO2= 35plusmn2 mm Hgbull CVP= 8-14 mm Hgbull avoid dextrose IVbull maintain euthermia or mild hypothermia
Other issues
bull DVT prophylaxisbull Antibioticsbull Anti epilepticsbull Nutrition
Factors Influencing Prognosis
bull Agendash Younger pts have greatest potential for survival and
recovery ndash 61-75 mortality if over 65 ndash 90 mortality in elderly with ICP gt20 and coma for more
than 3 daysndash 100 mortality if GCS lt 5 uni- or bilateral dilated pupils
and age over 75
bull survival and recovery not predictable except in old pts
bull Treat presuming recovery
Factors Influencing Prognosis
bull Hypotension--50 increase in mortality with single episode of hypotension
bull Hypoxiabull Delay in treatmentndash prolonged transportndash surgical delay when lateralizing signs present
Potentially controllable
Icu adjuncts
bull HCT~ 30-33bull PaCO2= 35plusmn2 mm Hgbull CVP= 8-14 mm Hgbull avoid dextrose IVbull maintain euthermia or mild hypothermia
Other issues
bull DVT prophylaxisbull Antibioticsbull Anti epilepticsbull Nutrition
Factors Influencing Prognosis
bull Agendash Younger pts have greatest potential for survival and
recovery ndash 61-75 mortality if over 65 ndash 90 mortality in elderly with ICP gt20 and coma for more
than 3 daysndash 100 mortality if GCS lt 5 uni- or bilateral dilated pupils
and age over 75
bull survival and recovery not predictable except in old pts
bull Treat presuming recovery
Factors Influencing Prognosis
bull Hypotension--50 increase in mortality with single episode of hypotension
bull Hypoxiabull Delay in treatmentndash prolonged transportndash surgical delay when lateralizing signs present
Potentially controllable
Other issues
bull DVT prophylaxisbull Antibioticsbull Anti epilepticsbull Nutrition
Factors Influencing Prognosis
bull Agendash Younger pts have greatest potential for survival and
recovery ndash 61-75 mortality if over 65 ndash 90 mortality in elderly with ICP gt20 and coma for more
than 3 daysndash 100 mortality if GCS lt 5 uni- or bilateral dilated pupils
and age over 75
bull survival and recovery not predictable except in old pts
bull Treat presuming recovery
Factors Influencing Prognosis
bull Hypotension--50 increase in mortality with single episode of hypotension
bull Hypoxiabull Delay in treatmentndash prolonged transportndash surgical delay when lateralizing signs present
Potentially controllable
Factors Influencing Prognosis
bull Agendash Younger pts have greatest potential for survival and
recovery ndash 61-75 mortality if over 65 ndash 90 mortality in elderly with ICP gt20 and coma for more
than 3 daysndash 100 mortality if GCS lt 5 uni- or bilateral dilated pupils
and age over 75
bull survival and recovery not predictable except in old pts
bull Treat presuming recovery
Factors Influencing Prognosis
bull Hypotension--50 increase in mortality with single episode of hypotension
bull Hypoxiabull Delay in treatmentndash prolonged transportndash surgical delay when lateralizing signs present
Potentially controllable
bull survival and recovery not predictable except in old pts
bull Treat presuming recovery
Factors Influencing Prognosis
bull Hypotension--50 increase in mortality with single episode of hypotension
bull Hypoxiabull Delay in treatmentndash prolonged transportndash surgical delay when lateralizing signs present
Potentially controllable
Factors Influencing Prognosis
bull Hypotension--50 increase in mortality with single episode of hypotension
bull Hypoxiabull Delay in treatmentndash prolonged transportndash surgical delay when lateralizing signs present
Potentially controllable
