Severe Head and Spinal Cord Injury	65
Deepak Agrawal

A 25-year-old adult traveling by a car suffered multiple injuries in a high-speed collision. On arrival to the emergency department, he was found unconscious, with bleeding from the right ear and obvious bleeding from the scalp. His pulse was 56/min and blood pressure (BP) was 180/96 mmHg. The right pupil was dilated and not reacting, and his breathing was labored. Smell of alcohol was also observed.

Head and spinal cord injuries are typically associated with major trauma from motor vehicle accidents, falls, sports injuries, and violence. These injuries are associated with high morbidity and mortality. Prompt and appropriate treatment can change the outcome of these patients.

Step 1: Initialasses sment

Airway, breathing, and circulation (ABC) approach takes precedence in spite of obvious head injury.

Airway and breathing

•Apply the cervical collar and check airway.

•Hypoxia (PaO2 <60 mmHg or O2 saturation <90%) should be avoided. Intubate and ventilate with 100% oxygen in case of threatened airway with manual in-line cervical immobilization.

•Mild hyperventilation (PaCO2 ³32 mmHg and £36 mmHg) is recommended as a temporizing measure for the reduction of raised intracranial pressure (ICP).

•Prophylactic hyperventilation (PaCO2 £25 mmHg) is not recommended.

D. Agrawal, M.S., M.Ch. (*)

Department of Neurosurgery, AIIMS, New Delhi, India e-mail: [e-mail]

R. Chawla and S. Todi (eds.), ICU Protocols: A stepwise approach,	521
DOI 10.1007/978-81-322-0535-7_65, © Springer India 2012

522	D. Agrawal

Circulation

•Maintain systolic BP >100 mmHg.

•Avoid antihypertensives in suspected head injuries as arterial hypertension is a part of protective Cushing’s reflex to maintain cerebral perfusion.

•Labetalol is the drug of choice for control of hypertensive emergency in the head injury patient (refer to Chap. 24 on hypertension).

Step 2: Secondary assessment

•Assess Glasgow coma score (GCS) and pupillary reaction, and check localizing signs (weakness in limbs).

•All patients with GCS of 8 or less should be intubated and electively ventilated (if not done at Step 1).

Step 3: Assess severity of head injury

On GCS grading

GCS of 14 or 15: mild head injury

GCS of 9–13: moderate head injury

GCS of 8 or less: severe head injury

Mild head injury

Step A	Shift to observational area.
Step B	Maintain ABC.
Step C	Send for a noncontrast CT (NCCT) of the head and cervical spine (if any neck
	pain/tenderness) in the following conditions:
	Loss of consciousness for more than 5 min
	Amnesia
	Severe headache
	GCS of less than 15
	Focal neurological deficit attributable to the brain
Step D	Inform the neurosurgeon.
Moderate head injury
Step A	Shift to observational area.
Step B	Maintain ABC.
Step C	Inform the neurosurgeon.
Step D	Send for the plain CT scan of the head cervical spine. (All patients to have the
	CT scan of cervical spine including C7 vertebrae.)
Severe head injury
Step A	Shift to the resuscitation room.
	Simultaneously inform the neurosurgeon.
Step B	Repeat ABC.
	Maintain temperature.
Step C	Send for baseline blood investigation (hemoglobin, hematocrit, platelets,
	coagulation profile, random blood sugar, serum sodium and potassium, urea,
	creatinine).
	Coagulation profile including prothrombin time, APTT, and platelet count
	should be done in all patients. Special tests like thromboelastography may be
	done, if available, to assess platelet function.

65 Severe Head and Spinal Cord Injury		523
	Arrange packed RBC or fresh frozen plasma.
	Arterial blood gas (to be repeated after 1 h).
	Foley’s catheterization.
	IV fluid maintenance—avoid dextrose-containing fluids as they may increase
	cerebral edema.
	Proton pump inhibitor.
	Phenytoin sodium IV loading dose of 20 mg/kg can be dissolved in normal
	saline and infused at a rate no faster than 50 mg/min. Fosphenytoin can also be
	used at a dose of 25 mg/kg and can be infused at a rate of up to 150 mg/min.
	Infuse 20% mannitol (1 g/kg IV stat) in 5 min (after BP correction).
	Give furosemide (0.3–0.5 mg/kg IV stat) (after BP correction).
Step D	A focused assessment by sonography in trauma (FAST) is required to assess
	any other site of free blood in case of persistent/recurrent hypotension.
Step E	Send for the non contrast CT scan of the head cervical spine on portable
	ventilator with the resident and the nurse, with prior information to the
	radiographer and radiology resident. All patients to have the CT scan of
	cervical spine up to C7.

The head injury patient should be monitored closely when he/she is kept for observation or waiting for admission.

In case neurosurgical facilities are not available in the hospital, the patient should not be denied initial assessment and management (Step 1) as these are critical to final outcome. The patient can be transferred to the nearest neurosurgical facility after initial management.

Step 4: Shift to the intensive care unit (ICU)

All patients with nonoperable lesions and requiring intubation should be shifted to the ICU for further management.

Step 5: Start analgesia and sedation

•Sedatives and analgesics can affect outcomes in head-injured patients.

•Adequate pain control and sedation can be used as initial measures to control raised ICP. Short-acting agents such as fentanyl, midazolam, or propofol are preferred for frequent neurological assessments.

•Propofol infusion and high-dose barbiturate administration are recommended to control elevated ICP refractory to maximum standard medical and/or surgical treatment.

•Hemodynamic stability is essential before and during barbiturate therapy.

Commonly used sedatives

Fentanyl	2 mcg/kg test dose, 2–5 mcg/kg/h continuous infusion
Midazolam	2 mg test dose, 2–4 mg/h continuous infusion
Sufentanil	10–30 mcg test bolus, 0.05–2 mcg/kg continuous infusion
Propofol	0.5 mg/kg test bolus, 20–75 mcg/kg/min continuous infusion (not to exceed
	5 mg/kg/h)

524	D. Agrawal

•Continuous use may increase the risk of ventilator-associated pneumonia; hence, daily interruption of sedation along with other VAP prevention measures should be used.

Step 6: ICP monitoring

Indications of ICP monitoring

ICP should be monitored in patients with GCS of 8 or less and an abnormal computed tomography (CT) scan.

An abnormal CT scan of the head is one that reveals hematomas, contusions, swelling, herniation, or compressed basal cisterns.

ICP should be monitored in patients with severe traumatic brain injury (TBI) with a normal CT scan if two or more of the following features are noted at admission: age over 40 years, unilateral or bilateral motor posturing, or systolic BP less than 90 mmHg.

All children (<12 years) should have ICP monitoring irrespective of CT findings if GCS is 8 or less.

Monitoring method

The ventricular catheter connected to an external strain gauge is the most accurate, low-cost, and reliable method of monitoring ICP with the additional benefit of having a therapeutic role by cerebrospinal fluid drainage. However, they carry a higher risk of infection and may be difficult to insert in brain swelling with effaced ventricles.

ICP transduction via fiber-optic or microstrain gauge devices placed in parenchyma is easy to insert, equally accurate, but much more expensive.

Treatment target

Treatment should be initiated with ICP thresholds above 20 mmHg.

A combination of ICP values, and clinical and brain CT findings, should be used to determine the need for treatment. Decompressive craniectomy may be considered for persistently high ICP (>20 mmHg) despite maximal medical therapy but its role is debatable.

Step 7: Start mannitol (refer to Chap. 31)

•In absence of hypotension, mannitol is effective for the control of raised ICP at doses of 0.25–1 g/kg body weight.

•Mannitol is contraindicated in extradural hematoma and should be given only after reviewing the CT scan of the head and under neurosurgical supervision.

Step 8: Tracheostomy

•Plan an early tracheostomy (within 72 h) for all patients whose motor response is 4 or less.

Step 9: Deep venous thrombosis (DVT) prophylaxis

•Intermittent pneumatic compression stockings or graduated compression stockings should be used (except in lower limb injuries) and continued till the patient is ambulatory.

•Low-molecular-weight heparin or low-dose unfractionated heparin should be used in combination with mechanical prophylaxis when it is safe, preferably after 72 h of intracranial hemorrhage/craniotomy with close monitoring and repeat NCCT head to detect expansion of hematoma.

65 Severe Head and Spinal Cord Injury	525

Step 10: Seizure prophylaxis

•Phenytoin (5 mg/kg/day) or valproate (15 mg/kg/day) should be given for at least a week in all patients.

•Prophylactic use of phenytoin or valproate is not recommended for preventing late posttraumatic seizures. However, their use in the first week following injury decreases the incidence of early posttraumatic seizures.

Step 11: Maintain nutrition

•Good caloric intake (30–50 kcal/kg/day) and protein intake of 2 g/kg/day should be maintained. To achieve full caloric replacement in 7 days, nutritional replacement should begin no later than 72 h after injury.

Step 12: Other drugs/interventions

•Avoid steroids. Use of steroids is not recommended for improving outcome or reducing ICP.

•Use of high-dose methylprednisolone increases mortality, and therefore, it is contraindicated.

•Prophylactic mild hypothermia (33–35°C) remains experimental and is not recommended for routine clinical use presently.

Step 13: Surgical intervention

•Head injuries: Decompressive craniectomy

•If the patient continues to have persistently raised ICP (>20 mmHg) in spite of maximal medical management, decompressive craniectomy is the only available option to decrease ICP.

•Recent evidence has shown poor neurological outcome in patient undergoing decompressive craniectomy.

Management of High Cervical Spinal Cord Injuries

A 50-year-old male fell from a 20-ft height. On arrival to the emergency department, he was found to be conscious, with labored breathing and no limb movement. His pulse was 52/min and his BP was 70/40 mmHg.

Steps 1 and 2 Remain the same as for severe head injuries
Step 3	ICU care
	Management of patients with acute spinal cord injury (SCI), particularly
	patients with severe cervical level injuries, is recommended in an ICU or
	similar monitored setting.
Step 4	BP management
	Maintain mean arterial BP at 85–90 mmHg for the first 7 days following acute
	SCI as it improves spinal cord perfusion.
	If central venous pressure exceeds 10 cm of water, dopamine and/or noradrena-
	line infusion may be given to maintain BP at this level.