Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXII: Craniocerebral Injury

Nonoperative, Intensive Care Unit Management of Closed Injuries and Postoperative Patients

United States Department of Defense
Peer Review Status: Internally Peer Reviewed

The goal of management is the prevention of secondary brain injury due to systemic and intracranial causes. Good pulmonary care is essential. How long intubated patients can be maintained before performing tracheostomy will depend on the respiratory care facilities available In some cases, intubation can be maintained for one or two weeks without tracheal damage.

Feeding should be started via nasogastric tube as soon as bowel sounds are present. As high a caloric intake as can be accomplished without producing fluid overload is desirable. Arterial hypertension should be controlled with hydralazine and betablocking antihypertensive drugs if blood pressure becomes greater than 160 mm Hg systolic. Arterial blood gases, serum osmolality, electrolytes, and hemoglobin should be monitored daily, or more frequently as needed.

Prevention of secondary damage due to intracranial swelling and herniation can be accomplished most easily when the intracranial pressure is monitored. This may not be practical in the combat environment. A rising intracranial pressure indicates either (1) the expansion of a hematoma, (2) the late development of a hematoma, typically intracerebral, or (3) the presence of brain swelling. Expanding hematomas should be localized and evacuated. Brain swelling should be treated with a series of steps listed here in order of increasing complexity:

1. Repositioning the patient to avoid neck vein compression. In general, a flat position or slight head elevation will minimize the intracranial pressure.
2. Correction of hypoxia and hypercarbia; hyperventilation to achieve a PaCO₂ of about 25 mm Hg.
3. CSF drainage via ventriculostomy.
4. Administration of mannitol 1 gm/kg, IV.
5. Other pharmacological measures to reduce intracranial pressure, such as lidocaine infusions or the induction of barbiturate coma, may be of benefit but should only be considered if optimal neurosurgical ICU support is available.  

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