NEUROSURGICAL

EMERGENCIES
 NEUROSURGICAL
EMERGENCIES

OHead injury
O Hydrocephalus
O BrainTumours
O Intracranial Bleeds/CVA‟s
O Shunt complications
O Spinal cord Injury
O Spinal cord compression and tumours.
 HEAD INJURY
O Major cause of mortality and morbidity in children.
O Leading cause of death in children > 1year is
trauma.
O Head injury is responsible for most trauma deaths
approximately 80%. (50% in adults)
 PATHOPHYSIOLOGY
O Children are more vulnerable to injury
from head trauma
O Relatively large (10% of body weight)
means increased momentum and tend to
land on head with falls.
O Elastic, underdeveloped cervical
ligaments and muscles are less
protective.
O Soft calvarium.
O Large subarachnoid space
(veins at increased risk of tearing)
 ETIOLOGY
O Road traffic accidents
Severe head injuries
O Falls
Usually in children <4years and usually mild
O Recreational activities
Bicycle accidents
O Assaults/NAI
Most head injuries in kids <1yr
are from falls and NAI
 ANATOMY
O BRAIN
Inelastic and non compressible
Has no internal support
O CRANIUM
Rigid and unyielding
Bony buttresses at anterior
and temporal poles
O MEMBRANOUS “SLINGS”
Rhoads & Pflanzer (1996) Human Physiology p. 211
Layers of the Cranial Vault

Anatomy of the Brain

www.neurosurgery.org/pubpgages/patres/anatofbrain.
 BRAIN INJURY

Primary Secondary

Ischaemia
hypoxia,
Intracranial Delayed cell
Mass Lesion hypotension
HTN death
and
hypercarbia
PRIMARY BRAIN INJURY

Coup
Focal
Contra
Primary coup

Diffuse DAI
 TRAUMATIC HEAD INJURY

ALL-NET Pediatric Critical Care Textbook Source: LifeART EM Pro (1998) Lippincott
Williams & Wilkins.
www.med.ub.es/All-Net/english/neuropage/trauma/head-8htm
 TYPES OF PRIMARY INJURY
O Focal injuries
Skull fracture
Parenchymal contusion
Parenchymal laceration
Vascular injury resulting in epidural,
subdural or parenchymal haematoma.
O Diffuse injuries
Diffuse axonal injury
Diffuse vascular injury
Scalp haematomas/lacerations
O Very vascular, but generally can‟t lose
enough blood to cause shock or
hypovolemia
O Cephalohematoma – beneath periosteum
(does not cross suture lines)
O Subgaleal bleed - beneath galea (crosses
suture lines, often boggy)
O Critical in neonate (e.g. from birth trauma)
O Can lead to shock/hypovolemia
O Clean and examine scalp wounds well to
r/o underlying skull fracture; often staple
 SKULL FRACTURES
O ANY skull fracture can
cause underlying
ICH, but 50% of bleeds
have no fracture
QuickTime™ and a

O Skull films are of little

decompressor
are neede d to see this picture.

use - if suspect skull

fracture or bleed, get
non contrast CT
 SKULL FRACTURES
O Linear(3/4)- outpatient observation OK, but
get neurosurgical evaluation and f/u if under
age 2
O Can develop leptomeningeal cyst if dural tear
O Depressed - require neurosurgical evaluation
possible repair if depression>skull thickness
O More often develop seizures
O Often get prophylactic AEDs
O Basilar (Battle‟s sign, haemotympanum,
raccoon eyes) - head CT with inpatient
observation, neurosurgical evaluation.
 Case 1
O A 2 year-old comes in after falling
approximately 3 feet from her parent‟s bed.
The CT scan shows the following:
 What is your diagnosis?
1. Epidural hematoma
2. Subdural hematoma
3. Diffuse axonal injury
4. Contusion
Subdural
 Subdural Hematoma
O More common than
epidural in children
O Tears in parasagittal
bridging veins
O Concave shape
O Often associated with
more diffuse shear injury
O Immediate surgical tx if pt
is unconscious and has
subdural bleed
O Suspect NAI
 Case 2
O A 5 year old girl falls from a second story
window. You find the following on CT scan:
 What is your diagnosis?
1. Epidural hematoma
2. Subdural hematoma
3. Diffuse axonal injury
4. Contusion
Epidural Hematoma
 Epidural Hematoma
O Caused by tears of
meningeal vessels
O Convex shape
O Often associated bone
fracture (up to 75%)
O Typically few hours of
lucidity followed by rapid
deterioration
O Need close observation
and often surgical
evacuation
O Good prognosis if
recognized and treated
 SUBDURAL VS. EPIDURAL

LifeArt: Williams & Wilkins

http://www.lifeart.com
SUBDURAL HEMATOMA

WebPath: University of Utah

http://www-medlib.med.utah.edu
EPIDURAL HEMATOMA
 SUBDURAL vs EPIDURAL
HEMATOMA
O EPIDURAL O SUBDURAL
O Requires linear force O Requires significant
O Associated with skull rotational forces
fracture and torn O Associated with brain
artery. Brain often
uninjured injury and torn
O “Lucid” interval bridging veins
common O Neurologic
O Common in symptoms from the
accidental trauma start
O Common in infants
with NAI.
 Cerebral Contusion
O Occur at the site of blunt trauma
O Usually have loss of consciousness
O Can be very small/mild or large, resulting in
significant symptoms (cerebral edema,
increased ICP)
O Often associated with intracranial
hematomas or skull fractures
 Intracerebral Haemorrhage
O Rare in Paediatric population.
O Usually frontal or temporal lobe
O Can be bilateral(countracoup injury)
O Can act as mass lesions and cause
intracranial hypertension
O CT-Hyperdense/mixed
O MRI-Small petechia+DAI
O Rx: Small-non operative
Large-Sx drainage
 Penetrating Head Injury
O Infants and children: fall on sharp objects, NAI, GSW
O CT- Localizes bullet and bone fragments.
O MRI-Not advised till magnetic properties of bullet
known
O Treatment:
 Debridement of entry and exit wounds
 Remove accessible bullet and bony fragments
 Control haemorrhage
 Repair dural lacerations+closure of wounds
 No attempt to REMOVE BULLET OR BONE beyond
entry and exit wounds.
 Diffuse Axonal Injury
O Often from acceleration/deceleration
injuries (RTA, falls, shaking)

O Widespread shearing of white matter

O Suspect if patient has

subarachnoid bleeding and
cerebral edema

O Edema develops over 24-48 hours

 Diffuse Axonal Injury
• Shearing injury of axons
• Deep cerebral cortex, thalamus, basal
ganglia
• Punctate hemorrhage and diffuse cerebral
edema

Image from: Neuroscience for Kids

www.faculty.washington.edu/chudler/cells/html
 Secondary Injury
O Subsequent factors that secondarily cause brain
tissue damage
O Intracranial
O Hemorrhage/Ischemia
O Edema
O Increased ICP
O Systemic
O Hypoxia/hypercapnia
O Hypotension
O Hyperglycemia
Assessment of severity
 Defining Severity
O Mild Brain Injury
O GCS = 13-15
O Limited impaired consciousness (<30 min)
O Normal CT scan
O Shows signs of a concussion
O Vomiting
O Lethargy
O Dizziness
O Lacks recall about injury
 Defining Severity
O Moderate Brain Injury
O GCS = 9 - 12
O Impaired Consciousness (<24)
O CT scan Evidence

O Severe Brain Injury

O GCS = 3 - 8
O Impaired Consciousness
(> 24 hours)
 CAUTION!!

O GCS of 13 may not be so “mild”

O SC Stein, J Trauma. 2001;50:759-760

O Reviewed 14 studies
(1047 adult patients with GCS
of 13)
O 33.8% had intracranial lesions
O 10.8% required surgery
 Defining Severity

O GCS, hypoxemia and radiologic evidence of

SAH, cerebral edema and DAI are predictive
of morbidity.
O GCS alone does not predict morbidity.
Ong et al. (1996) Pediatric Neurosurgery, 24(6)

O Hypotension is predictive of morbidity.

O GCS and Pediatric Trauma Score are
not predictive of outcome.
Kokoska et al. (1998), Journal of Pediatric Surgery, 33(2)
 CT or no CT
O A 3months old baby presented with minor
head injury. Fell of the table about 2 feet
high.
NO LOC
GCS 15
O/E
well, pupils b/l equal and reacting
6 cm laceration occipital area
 CT or no CT
O 15 year old boy football injury.
Brief LOC
Vomited once at scene
O/E
Well, alert, GCS 15
No focal neurology
Admission or no Admission
Admission or no Admission
O 15 year old boy hit by car.
O GCS 14/15 E 4 M6 V4
O Rest all ok!

CT or no CT?
Admission?
Neuro obs:
 Head injury
triage, assessment, investigation and early
management of head injury in infants,
children and adults (update)

Implementing NICE guidance

December 2007

NICE clinical guideline 56

 Updated guidance
O This guideline replaces „Head injury: triage,
assessment, investigation and early management of
head injury in infants, children and adults‟ (NICE
clinical guideline 4, 2003)

O There was sufficient new evidence to prompt an

update to be carried out which means changes in
clinical practice

O There are new and amended recommendations

 Key recommendations
O Initial assessment in the emergency department

O Urgency of imaging

O Admission
• Criteria for admission
• When to involve the neurosurgeon

O Organisation of transfer of patients between referring

hospital and neuroscience unit

O Advice about long-term problems and support

services
 Initial assessment in the
emergency department (ED)
O All patients presenting to an ED with a head injury
should be assessed by a trained member of staff
within 15 minutes of arrival at hospital

O This assessment should establish whether they are

high risk or low risk for clinically important brain
injury and/or cervical spine injury
Urgency of imaging: head CT
OCT of the head should be performed and analysed
within 1 hour of imaging request in patients who
have any of these risk factors:

O Glasgow Coma Scale (GCS) < 13 on initial assessment in

A&E or < 15 at 2 hours after injury
O Suspected open or depressed skull fracture or any sign of
basal skull fracture
O Two or more episodes of vomiting in adults; three or more
in children
O Post-traumatic seizure
O Coagulopathy, providing that some loss of
consciousness or amnesia has been experienced
O Focal neurological deficit
 Urgency of imaging: head CT
O Patients who have any of the risk factors below, and
none of the risk factors on the previous slide should
have CT imaging of the head performed within
8 hours of the injury:
O Amnesia for > 30 minutes of events before impact
(assessment unlikely to be possible in any child aged under
5 years)

O Age 65 years, providing that some loss of consciousness

or amnesia has been experienced

O Dangerous mechanism of injury (e.g. a fall from a height

of > 1 metre or 5 stairs), providing that some loss of
consciousness or amnesia has been experienced.
 Admission: Criteria
O Clinically significant abnormalities on imaging

O Patient has not returned to GCS 15 after imaging,

regardless of the imaging results

O Criteria for CT scanning fulfilled, but scan not done

within appropriate period, either because CT not
available or because patient not sufficiently cooperative
to allow scanning

O Continuing worrying signs (e.g. persistent vomiting)

O Other sources of concern (e.g. drug intoxication,

other injuries, non accidental injury)
 Secondary Brain Injury
Potentially Avoidable Or Treatable With Close
Monitoring / Treatment of ABC‟s

O Hypoxia
O Hypercarbia
O Hypotension/ischemia
O Intracranial hypertension
O Acidosis
O Seizures
O Hyperthermia
O Hypothermia
O Infections
 Evidence based management
of severe traumatic brain
injury in children
O Guidelines for the Acute Medical Management of
severe traumatic Brain Injury in infants, Children, and
Adolescents.
Journal of Pediatric Critical Care Medicine.
January 2012-Second edition
O Text book of Paediatric critical care
Bradley P.Fuhrman, Jerry J.Zimmerman
Third edition2006
O NICE Guidelines-
Updated December 2007
 Level of Evidence
O Level I
 Good quality RCT

O Level II
 Moderate or poor quality RCT
 Good quality cohort
 Good quality case control

O Level III
 Moderate or poor quality RCT or cohort
 Moderate or poor quality case control
 Case series, databases, registeries
 INITIAL MANAGEMENT
O AIRWAY with C-Spine control

O BREATHING

O C T SCAN CIRCULATION

OD
OE
OF&G
 EARLY RESUSCITATION OF CHILDREN WITH
MODERATE-TO-SEVERE TRAUMATIC BRAIN
INJURY
PEDIATRICS 2009;124;56-64 MICHELLE ZEBRACK, CHRISTOPHER DANDOY,
KRISTINE HANSEN, ERIC SCAIFE, N. CLAY MANN AND SUSAN L. BRATTON

O CONCLUSIONS: Hypotension and hypoxia are

common events in pediatric traumatic brain injury.
Approximately one third of children are not properly
monitored in the early phases of their management.
Attempts to treat hypotension and hypoxia
significantly improved out-comes.
Circulatory Support:
Maintain Cerebral Perfusion CPP = MAP -
Pressure ICP
6

5
Number of 4 Good
Hypotensiv Moderate
e Episodes 3
Severe
in the first
24 hours 2 Vegetative
after TBI Dead
1

0
Patient Outcome

Kokoska et al. (1998), Journal of Pediatric Surgery, 33(2)

 Airway and ventilation
Criteria for the intubation of Head injured child

O GCS<10
O Decrease in GCS of >3, independent of the
initial GCS.
O Anisocoria>1mm
O Cervical spine injury compromising ventilation.
O Apnoea
O Hypercarbia(PaCo2>45mmg/6.0Kpa)
O Loss of pharyngeal reflex
O Spontaneous hyperventilation causing
PaCo2<25mmHg/3.3Kpa
 Airway and ventilation
O Hypoxia to be avoided.
 Aim Pao2 of >13kpa
 Aim PaCo2 of 4.5-5.0kpa

O Avoidance of prophylactic severe hyperventilation to

a PaCO2 of <30mmHg(4.0kpa).

O If hyperventilation is used in the management of

refractory intracranial hypertension, advanced
neuromonitoring like
 jugular venous oxygen saturations,
 brain tissue oxygen tension measurements
for evaluation of cerebral ischemia may be
considered.
(LEVEL III)
Head elevation of 30 degrees
O This improves venous drainage with minimal
effect on arterial pressure.

O Head in midline to ensure no pressure or

kinking of neck veins.

O If head raised more then 30 degrees possible

adverse effect on cerebral arterial pressure.

Carter BG, Butt W, Taylor A: ICP and CPP: Excellent predictors of long term
outcome in severely brain injured children. Childs Nerv Syst 2008; 24:245–
251
Keep neck mid-line and elevate head of bed …. To what degree?
Feldman et al. (1992)
Journal of Neurosurgery,
76
March et al. (1990)
Journal of Neuroscience
Nursing, 22(6)
Parsons & Wilson (1984)
Nursing Research, 33(2)
 Normal Cerebral Metabolism
O Brain tissue relies on aerobic metabolism.

O Normal cerebral metabolism requires a

blood flow of approximately 50 mL/100g/min.

O Serious neurological deficits begin to occur

at 20 mL/100g/min.

O Prolonged Cerebral Blood Flow < 12

mL/100g/min. results in cerebral infarction.
 CBF Autoregulation
O CBF maintained within CPP
range of 50 – 150 mmHg.
O CPP =MAP – ICP
O <50 CPP= Maximal dilation
CBF falls
O >150 CPP=Maximal constric
CBF raises
Autoregulation
1)Completely lost-linear relation
CBF & CPP
2)Incompletely lost-Plateau after
CPP of 80 mmHg
Copied from: Rogers (1996) Textbook of Pediatric Intensive Care p. 646
 ICP Monitoring-Level III
O A frequently reported high incidence of
intracranial hypertension in children with severe
TBI.

O A widely reported association of intracranial

hypertension and poor neurologic outcome

O The concordance of protocol-based intracranial

hypertension therapy and best-reported clinical
outcomes

O Improved outcomes associated with successful

ICP-lowering therapies
 Monitoring of Intracranial
pressure
O Indications:
 GCS <8
 Abnormal head CT
 Rapid neurological deterioration
 Normal CT head in adults
O Age>40
O Unilateral or bilateral motor posturing
O Systolic BP <90
 Treatment of raised ICP
O Treatment of intracranial pressure (ICP) may
be considered at a threshold of 20 mm Hg
(LEVELIII).

Grinkeviciute DE, Kevalas R, Matukevicius A, et al.: Significance of

intracranial pressure and cerebral perfusion pressure in severe
pediatric traumatic brain injury. Medicina (Kaunas, Lithuania) 2008;
44:119–125
 Cerebral perfusion pressure

O A minimum CPP OF 40mmHg (Level III) may

be considered in children with TBI.

O A CPP threshold of 40-50mmHg may be

considered; infants at lower end and
adolescents at the upper end of this range.
(Level III).
 ICP Measurement-Invasive
O Intraventricular catheter coupled to ICP transducer
is Gold standard.
Adv: CSF can be drained
Dis adv: Infection, Ventricular compression
leads to inaccuracy
O Fiberoptic cath:
Adv: Improved Longevity, can be placed
intraparenchymal/intraventricular/subdural
Dis adv: Not able to drain CSF
O Subdural/subarachnoid Bolts:
Occulusion of ports can lead to inaccuracy
 Advanced Neuromonitoring
O If brain oxygenation monitoring is
used, maintenance of partial pressure of
brain tissue oxygen (PbtO2) >10 mm Hg
may be considered.(LEVEL III)

O Figaji AA, Zwane E, Thompson C, et al.: Brain tissue oxygen tension

monitoring in pediatric severe traumatic brain injury. Part 1:
Relationship with outcome. Childs Nerv Syst 2009; 25:1325–1333
O Narotam PK, Burjonrappa SC, Raynor SC, et al.: Cerebral oxygenation
in major pediatric trauma: its relevance to trauma severity and
outcome. J Pediatr Surg 2006; 41:505–513
 Neuroimaging
O In the absence of neurologic deterioration or
increasing intracranial pressure (ICP),
obtaining a routine repeat computed
tomography (CT) scan >24hrs after the
admission and initial follow-up study may not
be indicated for decisions about
neurosurgical intervention. (LEVEL III)
 Hyperosmolar therapy
O Hypertonic saline should be considered for the
treatment of severe paediatric traumatic brain injury
associated with intracranial hypertension. Effective
doses for acute use range between 6.5 and 10
mL/kg (of 3%) (LEVEL II).
 Temperature control
O Moderate hypothermia (32–33°C) beginning early
after severe traumatic brain injury (TBI) for only
24hr‟s duration should be avoided
O Moderate hypothermia (32–33°C) beginning within 8
hrs after severe TBI for up to 48 hrs‟ duration should
be considered to reduce intracranial hypertension.
O If hypothermia is induced for any
indication, rewarming at a rate of >0.5°C/hr should
be avoided (LEVEL II).
O Moderate hypothermia (32–33°C) beginning early
after severe TBI for 48 hrs, duration may be
considered (LEVEL III).
 Cerebrospinal fluid drainage
O Cerebrospinal fluid (CSF) drainage through an
external ventricular drain may be considered in the
management of increased intracranial pressure (ICP)
in children with severe traumatic brain injury (TBI).
O The addition of a lumbar drain may be considered in
the case of refractory intracranial hypertension with a
functioning external ventricular drain, open basal
cisterns, and no evidence of a mass lesion or shift on
imaging studies (LEVEL III).
 Barbiturates
O High-dose barbiturate therapy may be considered in
haemodynamically stable patients with refractory
intracranial hypertension despite maximal medical
and surgical management.

O When high-dose barbiturate therapy is used to treat

refractory intracranial hypertension, continuous
arterial blood pressure monitoring and
cardiovascular support to maintain adequate
cerebral perfusion pressure are required (LEVEL III).
Decompressive craniectomy

O Decompressive craniectomy (DC) with

duraplasty, leaving the bone flap out, may
be considered for paediatric patients with
TBI who are showing early signs of
neurologic deterioration or herniation or
are developing intracranial hypertension
refractory to medical management during
the early stages of their treatment.
(LEVEL III).
 Corticosteroids
O The use of corticosteroids is not recommended to
improve outcome or reduce intracranial pressure
(ICP) for children with severe traumatic brain
injury.(LEVEL III)
Analgesics, sedatives, and
neuromuscular blockade
O Thiopental may be considered to
control intracranial hypertension.
O Propofol Not recommended.(LEVEL
III)
O Etomidate can be used as a
one off bolus but look for
adrenal suppression.
 Nursing Activities and
ICP
20
18
16
14
ICP 12
Turning
10
8
Suctioning
6 Bathing
4
2
0
Before During After
Rising (1993) Journal of Neuroscience Nursing, 25(5)
Glucose and nutrition
O The evidence does not support the use of
an immune-modulating diet for the
treatment of severe traumatic brain injury
(TBI) to improve outcome (LEVEL II).

O In the absence of outcome data, the

specific approach to glycemic control in
the management of infants and children
with severe TBI should be left to the
treating physician (LEVEL III)
 Antiseizure prophylaxis
O Prophylactic treatment with phenytoin may be
considered to reduce the incidence of early
posttraumatic seizures (PTS) in paediatric
patients with severe TBI (LEVEL III).

O The incidence of early PTS in paediatric

patients with TBI is approximately 10% given
the limitations of the available data. Based on a
single class III study, prophylactic
anticonvulsant therapy with phenytoin may be
considered to reduce the incidence of early
posttraumatic seizures.
Questions?
 Summary
O Serial neurologic assessments and
physical examination
O Continuous cardio-respiratory, ICP, and
CPP monitoring, +/- cerebral metabolism
monitoring adjuncts
O Maximize Oxygenation and Ventilation
 Maximize oxygenation
 Normo-ventilate
 Support circulation / maximize cerebral perfusion pressure
 Maintain mean arterial blood pressure and maintain CPP.
 Summary
O Decrease intracranial pressure
O Evacuate mass occupying
hemorrhages/lesions.
O Consider draining CSF when possible
O Hyperosmolar therapy, cautious use to avoid
hypovolemia and decreased BP
O Mid-line neck, elevated head to 30 degree.
O Treat pain and agitation - consider pre-
medication for nursing activities, +/-
neuromuscular blockade.
O Careful monitoring of ICP during nursing
care, cluster nursing activities and limit
handling when possible
 Summary
O Decrease Cerebral Metabolic Rate
O Prevent seizures
O Reserve thiopentone for refractory conditions
O Avoid hyperthermia, +/- hypothermia
O Avoid hyperglycemia (early)