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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 -117 - 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 -118 - (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 -119 - 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 -120 - 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 |