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Case discussion and audit
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Deepak AgrawalDept of Neurosurgery, JPN Apex Trauma
Centre
MANAGEMENT OF SEVERE HEAD INJURY WITH ‘NORMAL’
CT HEAD
Case history7 year male childFall from height (4th floor ) 2 hours backH/o LOC following fallPresented to emergency with laboured
respiration Post resuscitation GCS E2Vet M5
Secondary survey - no other significant systemic injuries.
FAST negative.
NCCT head at admission
ICU MANAGEMENTPatient was admitted in neurotrauma ICUManaged as per standard protocol for severe
head injury Head elevation 300
Neutral neck positionSedation (Fentanyl & Midazolam)ventilation with normocapneaOsmotic agents (mannitol) and diuretics
(furosemide)
ICU MANAGEMENTContinous ICP Monitoring using Codman®
intraparenchymal catheter
Initial ICP was 15 mmHg
Gradual increase in ICP noticed
2 hrs after admission ICP rose to 40 mmHg
In view of refractory raised ICT, decompressive craniectomy was planned.
Patient taken up for emergency surgery
Surgery
Large fronto-temporo-parietal craniectomy performed
Brain tense intra-op.
Augmentation duraplasty using pericranial graft.
Calvarial flap cryo-preserved for later replacement.
Postoperative Course
Patient became conscious & GCS improved to E4VetM6 within a span of 2hrs following surgery
Successfully extubated on POD 3, to be discharged.
Post-operative scans
Post-operative scans
Indications for Intracranial Pressure MonitoringEvidence Level A.Level I: None B.Level II: Intracranial pressure (ICP) should be monitored in
all salvageable patients with a severe traumatic brain injury (TBI) (GCS 3 – 8 after resuscitation) and an abnormal CT scan. An abnormal CT scan of the head is one that reveals hematomas, contusions, swelling, herniation, or compressed basal cisterns.
C.Level III: ICP monitoring is indicated in patients with severe 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 blood pressure (BP) < 90 mm Hg.
American Association of Neurological Surgeons Guidelines
The gray zone No level I evidence yet for ICP monitoringCT may not detect all significant lesionsHead injury is evolving and dynamicCT at best permits periodic serial monitoringHence at JPNATC, a low threshold for ICP
monitoring.Aggressive surgical management for
refractory elevated ICP
Audit of Head injury at JPNATC
PERIOD: Nov 2007- Apr 2009 (18 months)
STUDY POPULATION : Head injured patients admitted in department of Neurosurgery, JPNATC
PATIENTS GROUPSMinor head injury (GCS 13-15)Moderate head injury (GCS 9-12)Severe head injury (GCS 8 or less)
Observations
Total patients: 2068
< 10 yr, 305, 15%
11-20 yr, 306, 15%
21-30 yr, 489, 23% 31-40 yr, 378,
18%
51-60yr, 158, 8%
61-70yr, 101, 5%
41-50 yr, 251, 12%
71-80yr, 80, 4%
OBSERVATIONS (AGE GROUP INCIDENCE)
PEDIATRIC (< 12 YR)= 328 ( 15 %)ELDERLY (>60 YRS)= 181 ( 8 %)
MINOR, 598
MOD, 380
SEVERE, 1090
0
200
400
600
800
1000
1200
OBSERVATIONS (INCIDENCE OF VARIOUS H.I. GROUPS)
MINOR HI -29%MOD. HI -18%SEVERE HI -53%
OBSERVATIONS SEVERE HEAD INJURY
809
281
0
200
400
600
800
1000
SURG(76%)
CON(24%)
OUTCOME(MORTALITY)
GROUP NO. OF IN-HOSPITAL
MORTALITY
TOTAL CASES
%
Overall 454 2068 22
Minor HI 14 598 2
Moderate HI 45 380 12
Severe HI 395 1090 36
OUTCOME
( MORTALITY AS PER AGE GROUP)
GROUP NO. OF MORTALITY
TOTAL CASES
%
Children (< 12 yrs)
118 305 38
Adult ( 20-50 yrs) 191 1118 17
Elderly ( 50-80 yrs)
126 339 37
Glasgow Outcome Score
(Following Severe Head Injury)
%age
1 Death 36%
2 Vegetative 18%
3 Severe disabled 12%
4 Mod. disabled 16%
5 Good recovery 18%
OUTCOME (GOS )
OVERALL DEATH - 454 / 2068 (22%)
OUTCOME (SURGERY vs CONSERVATIVE )
MODE OF TREATMENT ADMISSON GCS SCORE
SURVIVED DIED P VALUE
SEVERE HEAD INJURY
SURGERY 3-8 617 192 <0.05
CONSERVATIVE3-8 78 203
MODERATE HEAD INJURY
SURGERY9-12 109 18
CONSERVATIVE9-12 226 27
MINOR HEAD INJURY
SURGERY13-15 23 2
CONSERVATIVE13-15 561 12
Author MORTALITY
OVERALL
MINOR MODERATE
SEVERE
Kagan RJ 1994 26.7% - - 41.4%
Fakhry SM 2004 28.8% - - -
Udekwu P 2004 21% - - 31.5%
AIIMS 2009 22% 2% 12% 36%
COMPARISON WITH WORLD LITERATURE
CONCLUSIONSAggressive neurosurgical management may
improve outcome in head injured patients
Audit of our data shows that outcome in severe head injuries is comparable with the best centers in the world.