الفهرس 
Anatomy and PhysiologyOnly 14 pages are availabe for public view
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Abstract
Acute head injury is the most common cranial condition that
the neurosurgeon deal with in the emergency room(ER).
Starting with the time of initial patient contact, the first priority
must be rapid physiologic resuscitation of the patient. This
includes management of airway, breathing, and circulation.
Specifically, it includes full-volume resuscitation without fluid
restriction and then primary neurological evaluation of the
patients with assessment of Glasgow Coma Scale (GCS) , pupil
size and reaction, eye movement , and motor function. It is
recommended that patients with a (GCS) score of less than 9,
should be transported to a trauma centre with immediately
available CT scanning capacity, prompt neurosurgical care and
a Neuro-Intensive Care Unit (Neuro-ICU) with the ability to
monitor and treat intracranial hypertension. Computed
tomography scanning has become the primary imaging
procedure in the evaluation of acute head head-injured patients,
which is indicated if there is loss of consciousness, definite
posttraumatic amnesia, posttraumatic seizure, confusion, focal
neurological deficit, sever headache, vomiting, skull fracture,
coagulopathy or history of taking anticoagulants, age more than
60 years. Patients with abnormal CT scans were hospitalized for
treatment (surgical or non-surgical). Elevated ICP in acute head
Summary and Conclusion
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injured patients is a potentially devastating complication of
neurologic injury and has been recognized as one of the most
important factors affecting morbidity and mortality rates
.Empiric therapy for presumed elevated ICP is unsatisfactory,
because CPP cannot be monitored reliably without accurate ICP
measurement; therefore, ICP monitoring has become important
in the management of acute severe head injuries. ICP
monitoring should be initiated in the majority of patients with a
postresuscitation GCS score of 8 or less. Specifically, ICP
monitoring is indicated in all such patients with an abnormal
CT scan. But those patients with a normal CT scan, ICP
monitoring is also indicated if they have two or three of the
following factors:
1. Age over 40 years
2. Unilateral or bilateral motor posturing
3. Systolic blood pressure, 90 mm Hg.
There are 3 main advantages of ICP monitoring with regard
to diagnosis and treatment in acute head injury:
(a) It helps in detecting the changes of ICP early and making
therapeutic decisions easier
(b) ICP monitoring is primarily a means for guiding therapy, as
it is not possible to treat ICP accurately without knowing
what it is
Summary and Conclusion
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(c) It helps to predict the patients’ outcome.
Although ICP monitoring has played an important role in
improving outcomes in patients with acute head injury, the
procedure is not without risk, producing a low incidence of
hemorrhagic or infectious complications.
There are 2 methods for ICP monitoring either invasive or
noninvasive methods;
A- Invasive methods:
(1) External ventricular drain(EVD)
(2) Intraparenchymal monitors
(3) subdural monitors
(4) Other methods; subarachnoid and epidural probes
B- Non invasive methods
Tissue resonance analysis (TRA)
Transcranial Doppler (TCD)
Tympanic membrane displacement
Jugular venous oxygen saturation monitoring
Palpation of the open fontanelle in infants
The goal of ICP monitoring and treatment should be to
maintain ICP <20 mmHg and CPP>70 mmHg. Interventions
should be undertaken only when ICP is elevated above 20
Summary and Conclusion
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mmHg for more than 5 to 10 minutes (20 to25 mmHg in adult,
20 mmHg in children).
There are 3 ways to manage an elevated ICP, either;
Pharmacologic therapy, Non-pharmacologic therapy, Surgical
management.
The pharmacological therapy includes:
(A) Hyperosmolar therapy (Osmotherapy)
(1) Mannitol
(2) Hypertonic saline
(3) Loop diuretics
(4) Glycerol and urea
(B) Intravenous anaesthetic and sedative agents
(1) Barbiturates
(2) Propofol
(3) Benzodiazepines
(4) Neuromuscular blockade
The non-pharmacological therapy includes:
(A) Positioning
(B) Hypothermia
(C) Hyperventilation
The surgical management includes:
(A) Decompressive craniectomy
(B) Removal of any mass effect
Summary and Conclusion
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When ventricular access is available, CSF drainage
should be the first treatment directly focused on lowering ICP.
If additional agents are needed, mannitol seems to have the next
most favorable risk:benefit ratio when a serial approach is being
used for ICP control. When intracranial hypertension proves
refractory to mannitol treatment, hyperventilation may be added
using a PaCO2 range of 30–35 mm Hg. When ICP control
proves refractory to the previous therapies, barbiturate may be
considered in patients who are believed to be potentially
salvageable as it is effective in lowering ICP. Decompressive
craniectomy is one of the modalities used in the management of
uncontrolled intracranial hypertension. It may be considered
when conventional medical therapy has failed.
This study came with the conclusion that management of
increased intracranial pressure in sever acute head injured
patients should start on arrival of them to the emergency
room(ER) to prevent secondary brain insults and prognosis and
outcome of those patients become better with:
1- Rapid and successful management of shock and
hypoxia
2- Rapid diagnosis of increased intracranial pressure
3- Rapid control and treatment of increased intracranial
pressure