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cervical spine lms and cervical CT scanning detected all cervical injuries After severe head or neck injury, it is therefore advisable also to obtain standard anteroposterior, lateral, and oblique neck lms, with additional gentle exion (20 ) and extension (30 ) views of the neck and a neck CT scan If these are normal and there is little or no neck pain, the cervical collar is no longer required If these studies cannot be obtained or if there is signi cant persistent pain or other neurologic ndings induced by head movement, a cervical MRI is advisable In the hospital, the rst step is to clear the airway and ensure adequate ventilation by endotracheal intubation if necessary A careful search for other injuries must be made, particularly of the abdomen, chest, spine, and long bones Chestnut et al, in analyzing the data from the Traumatic Coma Data Bank, found that sustained early hypotension (systolic blood pressure 90 mmHg) was associated with a doubling of mortality If shock was present on admission to the emergency ward, the mortality was 65 percent Although the hypotension that follows some injuries is a vasodepressor response and usually comes under control without pressor drugs, a large, unimpeded intravenous line should be inserted Persistent hypotension due to head injury alone is an uncommon occurrence and should always raise the suspicion of a ruptured viscus or thoracic or abdominal internal bleeding, extensive fractures, or trauma to the cervical cord Initially, the infused uid should be normal saline, avoiding the administration of excessive free water because of its adverse effect on brain edema Oxygen should continue to be administered until it can be shown that the arterial oxygen saturation is normal without it A rapid survey can now be made, with attention to the depth of coma, size of the pupils and their reaction to light, ocular movements, corneal re exes, facial movements during grimace, swallowing, vocalization, gag re exes, muscle tone and movements of the limbs, predominant postures, reactions to pinch, and re exes Bogginess of the temporal or postauricular area (Battle sign), bleeding from the nose or ear, and extensive conjunctival edema and hemorrhage are useful signs of an underlying basal skull fracture However, it should be remembered that rupture of an eardrum or a blow to the nose may also cause bleeding from these parts Fracture of the orbital bones may displace the eye, with resulting strabismus; fracture of the jaw results in malocclusion and discomfort on attempting to open the mouth If urine is retained and the bladder is distended, a catheter should be inserted and kept there Temperature, pulse, respiration, blood pressure, arterial oxygen saturation, and state of consciousness should be checked and charted every hour The Glasgow Coma Scale, mentioned above, has provided a practical means by which the state of impaired consciousness can be evaluated at frequent intervals (Table 35-1), but it should not be considered a substitute for a more complete neurologic examination A deteriorating scale dictates a change in management CT scanning is of central importance at this juncture A sizable epidural, subdural, or intracerebral blood clot is an indication for immediate surgery The presence of contusions, brain edema, and displacement of central structures calls for measures to monitor progression of these lesions and to control intracranial pressure These measures are best carried out in a critical care unit Management of Raised Intracranial Pressure It is the practice on some services to insert one of several available devices that permits continuous recording of intracranial pressure (ICP) in cases of moderate and severe head injury (Narayan et al) Pressure measurements through a lumbar puncture needle do not accurately re-.

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ect the ICP and increase the risk of a cerebellar or temporal lobe herniation Nor do the neurologic signs that constitute the Glasgow Coma Scale re ect the pressure in the cranium The arguments for and against monitoring the ICP have been addressed earlier (page 532) Our impression is that in comatose patients, monitoring of the ICP, at a minimum, prevents errors in uid administration and re nes all the other details of management, including the appropriate use of osmotic diuretics and the correct level of hyperventilation In these respects, monitoring can be helpful However, there are few critical data to support the routine use of ICP monitoring; certainly the patient who is only drowsy or shows only minimal mass effect on CT scanning is not likely to be of bene t In the absence of data to help in making the decision regarding the insertion of these devices, as a practical guide we favor their use to warn of impending deterioration from brain edema or hemorrhage if the patient shows sustained drowsiness with inability to follow commands, has a Glasgow Coma Scale score of 8, and has evidence of mass effect on a CT scan The current generation of ICP monitors employs beroptic strain gauges that can be inserted directly into the cerebral cortex without apparent damage While the risk of infection is low, prolonged use may be complicated by bacterial meningitis The monitor is left in place for 3 to 5 days or less if the clinical state and ICP are stable for 24 to 48 h The rst step in lowering high ICP is to control the incidental factors that are known to raise the pressure, such as hypoxia, hypercarbia, hyperthermia, awkward head positions that compress the jugular veins, and high mean airway pressures (see the monograph by Ropper and colleagues) If the intracranial pressure exceeds 15 to 20 mmHg, several measures can be instituted, such as inducing hypocarbia by controlled ventilation (maintaining PCO2 at 28 to 33 mmHg) and hyperosmolar dehydration (025 to 10 g of 20% mannitol every 3 to 6 h or 075 to 1 mg/kg of furosemide, see below) to maintain serum sodium above 138 meq/L and an osmolality of 290 to 300 mosmol/L Even if ICP monitoring is not utilized, an attempt should be made to maintain this level of osmolality for the rst days if contusion and brain swelling are detected on the CT scan Elevations in osmolality due to excessive concentrations of diffusible solutes such as glucose are not useful in reducing intracranial volume because they do not provide a water gradient across the cerebral vasculature For this reason, the measurement of serum sodium is in some ways a more accurate re ection of free water depletion An initial sodium level of 136 to 141 meq/L is adequate Intravenous uids with free water should be avoided so as not to intensify cerebral edema This poses a particular danger in children who, because of inappropriate secretion of antidiuretic hormone, easily develop water intoxication With this exception, however, restriction of the overall volume of uid is less of a concern than effecting a reduction in free water Fluids such as 5% dextrose in water, 05% saline, and 5% dextrose in 05% saline are therefore avoided; lactated Ringer s solution is permissible; normal saline, with or without added dextrose, is ideal The effects of mannitol have been of great interest to neurosurgeons who treat head trauma, but the best plan for its use has never been established Among the randomized studies that provide clinical data, only the one by Cruz and colleagues has demonstrated a clear bene t and particularly in relation to acute subdural hematoma These authors administered mannitol in a bolus, 06 g/kg, to all patients immediately, and then, once a subdural hematoma was identi ed by CT scan, gave an additional similar second dose to those with reactive pupils and twice the original dose to those with unreactive pupils or anisocoria Bene ts were obtained.

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