63. Head
From Primary Surgery
63.1 The General Method for Head Injuries
'No head injury is so severe as to be despaired of, nor so trivial as to be lightly ignored=so wrote Hippocrates. This is still true. Unfortunately, seemingly trivial injuries are often ignored, and every patient who dies from one is an indictment of the hospital which failed to treat him. Although a patient's scalp can be wounded and his skull broken, it is the concussion, contusion, or compression of his brain that affects his consciousness.
Concussion prevents a patient reacting to stimuli for a few minutes after a head injury, but has no after effects. Contusion resembles concussion except that: (1) A patient is unconscious for more than a few minutes. (2) He may have petechial bleeding in his brain. (3) Serious consequences may follow. These range from minor character changes to spastic hemiparesis.
Compression is the result of spreading oedema or an expanding blood clot which gradually damages the surrounding brain. It is the relief of compression that makes the care of head injuries so rewarding. A timely burr hole to remove the blood clot which is compressing a patient's brain may save his life. This clot can take two forms: (1) The small veins under his dura may bleed and cause a subdural haematoma. (2) Less often, a fracture of the vault of his skull tears a branch of his middle meningeal artery and causes an extradural haematoma. Evacuating this will usually restore him to perfect health, because his brain is usually normal underneath it. Unfortunately, his brain
is more likely to be injured under a subdural haematoma, so evacuating this is not so dramatically successful.
Making a burr hole is so comparatively simple that any doc- tor should be able to do it. If a patient dies, he will probably do so because his brain is hopelessly injured-or because you operated too late. So operate on the suspicion that a patient might have an expanding blood clot. If you fail to find one, you will have done him no harm. You will certainly not have time to refer him - the commonest mistake is to do nothing!
A patient with a head injury often has other injuries also, so make sure he has a clear airway, look for and treat any chest injuries, assess the state of his circulation, and look for injuries to his abdomen, spine, and limbs.
In practice, compression of the brain by a clot is uncommon,
and a patient is more likely to be in coma because his brain is
contused. So try to keep him alive until his natural healing processes
have done what they can. This means good nursing care
while he is unconscious, and especially the care of his airway
to prevent him inhaling blood, vomit, or secretions. A patient is more likely to die from these complications, than from any other cause, except irreversible injury to his brain. Even a short period of
respiratory obstruction can raise the carbon dioxide tension in
his blood and cause irreversible cerebral oedema and death. So
don't let a patient die from unnoticed airway obstruction in the
ward. Although craniotomy is the dramatic part of the care of a head injury, only a few patients need it. The careful nursing o coma is even more important than prompt surgery - it saves more lives than even the most expert surgeon-so make sure your nurses know this!
| JAQUES (10 years) was discharged following a minor head injury. He was brought back in again the following day deeply unconscious, with one fixed dilated pupil. He was rushed to the theatre, still in his out-door clothes. Within 20 minutes burr holes were being made. A large extradural clot was found and washed out. Next day he was up and walking. This is what we mean by a real emergency-rush these patients to the theatre, every minute matters! |
- BRACE, Hudson's, standard, 254 mm, one only. This is the neurosurgical equivalent of a carpenter's brace. If you don't have one, you can use gouges and short taps from a heavy hammer.
- PERFORATOR, Hudson's, with standard Hudson fittings, 12 mm, one only. Use this to start making a hole in his skull that you will later continue with burrs.
- BURRS, spherical, Hudson pattern, 11 mm, 13 mm, 16 mm, 19 mm, one only of each size. Use these to enlarge the hole made by the perforator. Trephines were traditionally used for opening the skull, and some hospitals still have them, but burrs are easier to use and have now replaced them. Spherical burrs are less likely to suddenly plunge through the dura and enter the brain than are conical ones.
- RONGEUR, (bone nibbler), Cairns, with fine angled on flat jaws and curved handles, 152 mm, one only. When you have made a hole in the skull with a perforator and burrs, enlarge it with these bone nibblers.
- e RONGEUR, Sargent, or van Havre, double action, curved on flat, 229 mm, one only. These are more powerful but more clumsy rongeurs than those of Cairns, listed above.
- ELEVATOR, skull, Penfield, double ended, one only. Use this to elevate depressed skull fragments.
- TUBE, suction, fine, 4 mm diameter, one only. This is used for sucking away injured brain. If it blocks, clear it with a stilette.
- e HOOK, dural, Cairns, sharp, 130 mm, one only. Use this for lifting up the dura. If you don't have one, use a skin hook.
CAREFUL NURSING MAKES ALL THE DIFFERENCE A TRACHEAL TUBE MAY SAVE THE PATIENT'S LIFE
THE GENERAL METHOD FOR AN UNCONSCIOUS
This extends Section 51.3 on the care of a severely injured patient. It applies to all patients who have lost consciousness after an injury, ever if their most obvious injury is a fractured femur.
CAUTION ! Admit all patients, especially children, who have been unconscious with a head injury even for a moment. Observe them carefully for 24 to 48 hours.
THE IMMEDIATE CARE OF A HEAD INJURY
AIRWAY This is critically important. (1) Place the patient in the recovery position (51-2). (2) Clear his mouth and pharynx. (3) Insert an oral airway.
If his consciousness is much impaired, so that he has no cough reflex, intubate him before you pass a stomach or a nasogastric tube. If his consciousness is not so deeply impaired, a tracheal tube is less essential. As soon as his consciousness improves he will reject a tracheal tube.
If he is deeply unconscious and intubation is impossible, or he fails to maintain an adequate airway, do a tracheostomy. He may need one if he is in coma for a long time.
EMPTY THE PATIENT'S STOMACH Many patients vomit and
aspirate their stomach contents after admission to hospital.
If a patient's stomach was full when he was injured, it will
still be full now. If it is obviously distended, pass an oral
stomach tube, and when it is empty, pass a nasogastric tube.
Otherwise, pass a nasogastric tube to begin with.
CAUTION ! If you decide to pass a stomach tube do so: (1) After you have intubated a patient, or you may drown him in his own gastric contents. (2) Pass it while he is in the recovery position.
THE HISTORY OF A PATIENT WITH A HEAD INJURY
What exactly happened? As far as possible, try to assess the patient's level of consciousness, from the moment of his accident. Now, or later, enquire how much loss of memory he has for the events following the injury. The duration of pre- and post-traumatic amnesia are good indications of the severity of a head injury.
Question witnesses. Did the patient have a lucid interval (a period of consciousness before becoming comatose) following the injury?
THE EXAMINATION OF A HEAD INJURY
GENERAL EXAMINATION Look at the patient in a good light, examine his body and limbs first, and then his head and neck. Smell his breath for alcohol and acetone, and don't forget the other causes of coma, including epilepsy, diabetes, liver failure, meningitis, drugs, malaria, and trypanosomiasis. CAUTION ! (1) However strongly he smells of alcohol, don't assume that this is the cause of his impaired consciousness. (2) Always admit an alcoholic who has sustained a head injury.
NEUROLOGICAL EXAMINATION
If the patient is sufficiently
conscious, test the motor power of all his four limbs. Look
especially for signs of weakness on one side of his body.
Recognizing this requires practice in a patient who is not fully
cooperative.
If he is restless, observe how he moves each side of his body. Rub his chest over his sternum with your closed fist and see how he responds. Press firmly with your nail above his orbits. His grimace may be weaker on one side than the other. Lift his arms and legs, release them and see how they fall away.
See how his limbs respond when you pinch them firmly. The signs may only be minimal. For example, a child may not be able to move his limbs quite so well on one side as on the other.
Examine his knee and ankle jerks, and his abdominal and plantar reflexes. Test for neck stiffness, and examine for Kernig's sign.
CAUTION ! Don't do a diagnostic lumbar puncture early on, because it will give you no information that you cannot get more safely in other ways. If a patient's CSF pressure is raised, l owering it suddenly may kill him. However, if you suspect meningitis (63.13) or subarachnoid haemorrhage, proceed to do one.
EXAMINE THE PATIENT'S EYES Record the size and equality of his pupils, and whether they react to light. You may have to use a very bright light. Examine his eyes now before they are closed by swelling, and frequently later, even if they become severely swollen. Don't give him atropine, because this will destroy the great diagnostic value of a unilateral dilating pupil.
Examine his nervous system often, because unequal pupils and unequal reflexes are important signs as to which side of his brain is being compressed. The inequality may disappear later. If you don't examine a patient often this important information will be lost.
Look for papilloedema. It is a rare but certain sign of raised intracranial pressure.
A 'black eye' is the result of bleeding into the eyelids and i s of little significance'by itself. Conjunctival haemorrhages only indicate a fracture (usually of the orbital plate of the frontal bone) if: (1) They make the patient's conjunctiva oedematous. (2) They are so large that you cannot see their posterior limit in any position of his eye. (3) They displace or restrict the movement of his eye. Otherwise, they are merely signs of local bruising.
EXAMINE HIS SCALP AND SKULL (1) Look for cuts and bruises. This is especially important if the patient is drunk, and you are not sure if he also has a head injury. Observe the site of the trauma accurately, before it becomes enlarged and oedematous. It is also a useful indication of the site of an intracranial haematoma. (2) Feel for: (a) The edges of a depressed fracture; this is not an easy sign and swelling of the scalp with blood in the tissues can give a similar feeling and be very deceptive. (b) Extensive boggy swelling of the patient's scalp. (c) Thickening of his temporalis muscle. These are all signs of a fractured skull. A pad and bandage will usually control bleeding from his scalp, but if it does not, sew it up temporarily. Don't attempt to explore it until you have taken him to the theatre!
ASSOCIATED SKULL FRACTURES
Surprisingly, a patient
seldom has a depressed skull fracture and a compressing
intracranial lesion at the same time. A plain or simple
depressed fracture is usually an urgency rather than an
emergency. If he does have a depressed skull fracture, this
can, if necessary, wait 12 hours or longer. A compressing
intracranial lesion will probably reveal itself before this, and
if it does, you can deal with both lesions together.
The only emergencies are compound depressed fractures
with open brain. Explore these early and close the patient's
skin before you refer him.
CAUTION ! Remember that the only time that a fracture alters the management of an unconscious patient with a head injury, is when it is depressed. Otherwise, you can proceed as if it was not there.
EARS AND NOSE
A bleeding nose may indicate a fractured
base, and a bleeding ear almost always does. If a patient's
ear is bleeding, don't examine it for fear of introducing infec.
tion. If it is not bleeding, examine the drum because blood
behind it confirms a fractured base. If you see blood leave it.
Postmastoid bruising a few days after the injury also confirms
a fractured base, but its absence does not exclude one.
Look also for leaking CSF
INJURIES ELSEWHERE
Look especially for injuries of a
patient's neck and back that may indicate fractures of his cervical
spine (64.3). Carefully roll him onto his side while maintaining
gentle head traction (64-4). Palpate every spinous
process. Look for even a small kyphus or an abrupt
misalignment.
If you suspect a fracture of his cervical spine, fit him with a cervical collar. He may also be paraplegic (64.13). If he is, make sure that he does not develop bed sores.
CAUTION ! (1) If the patient is shocked, look for severe injuries in other places, especially in his thorax and abdomen. By themselves head injuries seldom cause shock, unless bleeding is very severe. There are several special tests for abdominal injuries which may help you (66.1). (2) If a patient has any serious abdominal or thoracic injuries, these take precedence over his head injury.
RECORDS FOR HEAD INJURIES
Assess the patient's state of consciousness and start to fill in a coma chart (63-4). Careful notes are most important, especially if several people have to care for him. Note the exact times at which all observations are made.
X-RAYS FOR HEAD INJURIES
PLAIN X-RAYS are less important than regular assessment of the patient's clinical state. Poor films are useless. Even good ones are difficult to interpret and may fail to show serious fractures. If possible, take an AP and a lateral of the patient's cranial vault, especially if you suspect an extradural haematoma (impaired consciousness after a lucid interval). The position of the fracture line may tell you where to make your first burr hole. Most patients with an extradural haematoma have a fracture (but not vice versa). Fractures of the base are difficult or impossible to see on X-ray films. If litigation is no problem and films are scarce, keep them for more useful purposes.
If you X-ray the patient's skull, take a lateral view of his cervical spine at the same time and an AP view of his chest.
CAUTION ! While he is in the X-ray department his airway may obstruct, or he may vomit, or have a convulson, so send a responsible nurse to watch him.
If you have difficulty deciding what is a fracture and what is not, remember that:-
Fracture lines have clean cut edges, run in all directions, may cross arterial and suture lines, change direction abruptly, and branch irregularly.
Suture lines are fine or dentate- are in constant positions, and may be widened by trauma.
Grooves for the meningeal vessels run in known directions, branch dichotomously, and get smaller from below upwards.
Channels for the diploic veins run irregularly, and change course abruptly. They often start in lacunae near the superior sagittal sinus, and they vary in width.
Look carefully for a fracture line crossing a meningeal groove, and note which side it is, because it may indicate the site of an extradural haemorrhage. If you do see a fracture, make sure it does not date from a previous injury.
ARTERIOGRAMS Any X-ray machine that can take a skull Xray can take an arteriogram. The only equipment you need i s a 1.2 mm spinal needle. Arteriograms are usually not too difficult to interpret, and are very useful: (1) In an acute deteriorating head injury. (2) In the patient who is not improving after a week, and who may have a chronic clot.
NURSING A HEAD INJURY
POSITION Provided a patient has no other injuries which might prevent it, nurse him in the recovery position (51-2) and turn him 2 hourly. Raise the foot of his bed until his cough and swallowi ng reflexes have returned. This will raise his intracranial pressure, but his airway is more important. If he is disturbed or violent and you have no proper cot in which to nurse him, put him on a mattress on the floor. This better than tying him to his bed, which may cause a wrist drop and other injuries. You may occasionally have to do this to prevent him soiling the dressings over his head wounds.
BED SORES Care for his skin from the start, as for paraplegia
(64.13).
PAIN AND SEDATION If a patient is so violent on admission
that he is a danger to himself and other people, give him chlorpromazine
25 to 50 mg, or diazepam 10 mg intramuscularly,
or intravenously. Avoid stronger sedatives, especially morphine,
because they interfere with the assessment of consciousness
and depress his respiration.
Moderate restlessness is useful, because it is good physiotherapy for his lungs and prevents pressure sores. Make sure that his overactivity is not caused by a full bladder, or an uncomfortable position. If he is noisy, put him in a side ward.
TEMPERATURE If possible, take a patient's rectal
temperature every hour during the first 12 hours. Watch for
hyperthermia and start cooling him if it reaches 39°C.
CORNEA If his blinking or corneal reflexes are absent, take
care that his cornea does not rub against his pillow, or the
sheets, and ulcerate. If his eyes remain open, put adhesive
strapping across his closed eyelids-this is critically
important!
FOOD AND FLUIDS Start a fluid balance chart. While a
patient is unconscious, give him fluids intravenously. At 24
to 48 hours, or earlier if his cough and swallowing reflexes
return, give him food and fluids through a nasogastric tube.
Pass a tube and start feeding him, even if his cough reflex
has not returned at 24 to 48 hours, provided he has bowel
sounds. He needs energy; about 12 MJ (3 000 kcal) in 3 litres
of fluid (58.11). He may be unconscious for many days and
eventually recover, so don't let him starve meanwhile.
BLADDER Examine this to make sure it does not distend, and
catheterize a patient when necessary to prevent overflow.
Bed wetting may require an indwelling catheter in a female,
a Paul's tube strapped to the penis of a male, or a polythene
urinal in a child. If you pass a catheter, releasing it 4 hourly
i s better than letting it drain continuously.
OPEN HEAD INJURIES Give the patient benyzl penicillin and
sulphadimidine intramuscularly, both 6 hourly.
ANTICONVULSANT THERAPY Give all patients phenobarbitone
prophylactically while they are in hospital. 30 mg 8
hourly in an adult will not impair consciousness.
TETANUS PROPHYLAXIS Don't forget to give a patient
tetanus toxoid (54.11).
OTHER INJURIES If a patient with a head injury has fractures
elsewere, at least splint them temporarily in the reduced position,
even if you cannot treat them definitively.
THE FURTHER MANAGEMENT Of A PATIENT WITH A HEAD INJURY
Read on for: methods of monitoring a patient's consciousness, pulse and blood pressure (63.2), patterns of head i njury (63.3), the indications for burr holes (63.4), how to make a burr hole (63.5), open head wounds (63.6), fractures of the vault (63.7), ping-pong ball fractures in children (63.8), controlling bleeding (63.9), hyperthermia (63.10), convulsions (63.11), leaking CSF (63.12), meningitis (63.13), more difficulties with a head injury (63.14).
IF A PATIENT WITH A HEAD INJURY IS SHOCKED, LOOK FOR ANOTHER INJURY
63.2 Monitoring a patient with a head injury
Deterioration is a trend (for the worse), and is much more important than his status which is his state of consciousness at any one time. The idea that 'trend is more important than status' is the key to monitoring these patients. The only reliable way to monitor deterioration is to use a head injury chart, like that in Fig. 63-4. There is a blank full sized version of this on one of the end pages of the book. Have some photocopies made. All patients with a head injury need one, because even a mildly injured patient can deteriorate rapidly. When you assess consciousness, don't rely on subjective statements like 'fully conscious', or 'partly conscious'. Instead, record objectively what a patient can do. Use, and teach the nurses to use, expressions which do not need description, such as ' alert but confused', or , not speaking but obeys commands'. Show them how to fill in a head injury chart. If it is too complicated, teach them to fill in part of it. Encourage them to form their own base lines, so that they can say at any time if they think a patient is getting better, or worse.
Date the chart from the moment of a patient's injury, and enquire most carefully about his level of consciousness before admission. To begin with, make hourly, and later 2 hourly observations of his verbal responses, his motor activity, and his pupils. Record his systolic blood pressure and his pulse. Warn the nurses to expect rapid changes in the things you ask them to watch, and to report them urgently. For example, a blood pressure reading, which is obviously different from the previous one half an hour before, may be very important, but check it again before acting on it. Make sure they know how to examine a patient's pupils, and test their reactions to light. The easiest test for pain is to pinch him firmly with your finger nail. As with all charts, nobody is going to fill them in carefully, unless they understand them and see you look at them and act on them.
Assume that any deterioration of consciousness is caused by rising intracranial pressure, and needs burr holes, until you have proved otherwise. Here are some of the other causes.
Some major thoracic or abdominal injury causing severe blood loss, or impairing respiration and raising the carbon dioxide tension in the patient's blood. When this happens operate without delay, whatever his level of consciousness.
A major generalized or focal convulsion, especially in a child, can impair consciousness for several hours. Don't accept this as the cause, unless someone saw it happening. Prophylactic phenobarbitone should prevent it.
Fat embolism can cause rapid deterioration in consciousness, but usually only if the patient has long bone fractures of his legs, or severe soft tissue injuries (78.6). His consciousness can deteriorate before petechial haemorrhages appear. His pupils remain equal, and the characteristic pulse and blood pressure changes of cerebral compression are not seen.
ALL PATIENTS WITH A HEAD INJURY MUST HAVE A CHART
63.3 Patterns of head injury
Cerebral compression can be the result of bleeding in three places.
Extradural haemorrhage Bleeding outside the dura only occurs in about 2% of all head injuries. Some of these patients have a lucid interval (Patient D in Fig. 63-5) which is usually only a few hours, but it may be a week or more. Others have steadily deepening coma from time of the injury (Patient F). If they do have a lucid interval, their important first symptom is increasing headache, so take a complaint of headache very seriously in any patient with a recent head injury. If he also has giddiness, mental confusion, or drowsiness, he is may be bleeding extradurally. As this gets worse his unconsciousness deepens, and he develops pyramidal signs on the opposite side. Subdural haemorrhage Bleeding under the dura occurs in about 8% of head injuries, and can follow any of the patterns D, E, and F, in Fig. 63-5. Unfortunately, removing the clot is less dramatically beneficial than it is in extradural haemorrhage. In acute subdural haemorrhage the patient's unconsciousness deepens in a few hours, in the subacute form in a few days, but in the chronic form he may not become unconscious for months. The lucid interval before symptoms develop can thus be much longer than in extradural haemorrhage. In the chronic form the patient, who is usually elderly, suffers from repeated or increasingly severe headaches, drowsiness, apathy, or mental changes. The typical picture is that of a slowly developing cerebral crisis some time after a complete or partial recovery from a head injury, perhaps a very minor one, which the patient may not even remember. Unfortunately, you can seldom diagnose whether bleeding is subdural or extradural until you operate. The only clue is the short lucid interval and rapid progression of extradural haemorrhage.
Intracerebral haemorrhage Sometimes, when you open a patient's skull expecting to find a subdural haemorrhage, you find that his brain is swollen and discoloured, due to bleeding inside it or to cerebral oedema.
63.3a The prognosis in head injuries
During the first few hours following an injury you can seldom forecast what is going to happen to a patient with a head injury. If he has fixed dilated pupils and does not respond to any stimuli, his prognosis is not good. If he is alert, he is going to live. But between these two extremes anything can happen. Children, especially, can recover remarkably from seemingly severe trauma.
You will find yourself caring for the following kinds of patient. Some will be children. Some of the adults will also be drunk. A few will have open head injuries.
The patients who are conscious, or are rapidly becoming so, when you first see them (Patients A, and C, in Fig. 63-5) Although a patient may seem normal after a head injury, he may not be fully aware of what has happened, or be fit to drive a car. Subdural or extradural haemorrhage may occur later, so warn him and his relatives that he must return immediately, if he becomes drowsy or his headache gets worse.
The 2% of patients who are unconscious when you first see them, but who have had a lucid interval at some time since the accident. An example is Patient D in Fig. 63-5 who is particularly precious, and whose life you may be able to save. Patient F, who did not lose consciousness at the time of the accident, but who has lost it since, is especially precious. If you remove his clot, his brain will probably recover completely.
The patients who are unconscious when you first see them, and who have never been conscious since the accident These patients are of three kinds. Patient B is comatose; he shows no signs of improvement and dies. Patient C is drowsy, or even comatose, but his coma is lightening and his trend is towards improvement. Carefully nursed, he will recover. Patient E is important: he is unconscious, but his unconsciousness is deepening. His trend is to get worse-operate on him
| MANJI One Christmas Day a missionary doctor was called 40 kilometres to
see a patient who had been beaten over the head with an axe haft. By the time that the doctor arrived the patient had such a severe degree of cerebral compression that he appeared lifeless apart from his pulse. It seemed that each breath he took would be his last. Unfortunately, the primitive operating theatre had collapsed, so the operation was done in a little laboratory barely 4 metres square, with unglazed win doves and no runing water. Light was provided by an electric torch and some hurricane lamps. No anaesthesia was required, the patient was so limp, but after the removal of some bone and a large blod clot, he had to be held down to be sewn up. LESSON While there is life there is hope. |
63.4 Should you make burr holes, and if so where?
The patients who are worth great efforts to save are those whose consciousness is deteriorating, especially if they were fully conscious a short time ago. In order of importance, the factors to help you to decide are: (1) Deterioration in a patient's level of consciousness. (2) The development of localizing signs, such as weakness on one side of his body. (3) Change in his pupils, as in Fig. 63-3. (4) A rise in his blood pressure. (5) A slowing of his pulse.
As cerebral compression develops, a patient's blood pressure rises and his pulse becomes slow, full, and bounding. These signs are evidence of a physiological attempt to maintain the circulation to a patient's vital centres in the presence of cerebral compression. These signs are the reverse of those in internal haemorrhage, as from a ruptured spleen, for example, in which a patient's blood pressure falls and his pulse becomes rapid and weak. As with consciousness it is the trends in his pulse and blood pressure which are important, especially if he is a child, rather than any particular value. Restlessness, and particularly a very severe headache, are useful additional signs of intracranial bleeding in a conscious patient. Another suggestive sign is boggy oedema of his scalp over the site of a fracture. Don't depend on the presence of a fracture. The signs which do not in themselves indicate the need for urgent exploratory burr holes include: (1) Focal neurological signs in an alert patient. (2) A depressed skull fracture.
WHICH SIDE TO MAKE THE FIRST BURR HOLE?
Here are the localizing signs in decreasing order of reliability.
If, as occasionally happens, the X-ray shows the fracture side crossing a vessel, make the first burr hole there.
If you don't have this useful localizing sign, make it on the side which: (1) Is bruised or lacerated. (2) Is stronger if one side of the body is weaker than the other. (3) Has a dilated pupil, or was the first to have one, if they are now both dilated. (If his pupil was dilated from the moment of the injury, and fails to react to light, he has an orbital injury, and the sign i s not helpful.) (4) Shows less vigorous knee and ankle jerks, if these are unequal.
Rare localizing signs include focal epileptic fits, homonymous hemianopia which develops after the injury, and dysphasia.
WHERE TO MAKE THE FIRST BURR HOLE?
If the fracture crosses a vessel, make the hole there.
If a patient has an obvious scalp injury, make it in the centre of this.
If there is no fracture line or obvious scalp injury, make the first hole in the classical position in Fig. 63-9.
If the first hole is negative, make the next one in the parietal region, and then one in the frontal region.
If this too is negative, repeat the same three holes in the same order on the other side.
Occasionally, you will have to make six holes; only if they are all six negative can you be sure that there is no clot above a patient's tentorium. He may still have a clot in his posterior fossa, but you have no practical way of diagnosing it. To begin with, each burr hole will take you an hour. Looking for a clot by this 'woodpecker method' may be tedious, and is certainly less elegant than doing a CAT scan, but it is not difficult. Only when you have reached the dura will you see if the bleeding is outside or inside it. The one place not to make a burr hole is over a major sinus!
THE PUPIL ON THE SIDE OF THE LESION DILATES FIRST
63.5 Making burr holes
Treatment is urgent. As soon as you have made the diagnosis tell the theatre staff that the patient is coming. He should be on the operating table within a few minutes of the diagnosis being made. If his respiration is failing, operation is very urgent indeed. There have been times when burr holes have had to be made without asepsis, before even the theatre could be reached. Don't try to raise flaps-they are not necessary for emergency surgery.
| ALPHONSE (22 years) fell out of a truck. Six weeks later he went to a health
unit complaining of a severe headache. Fortunately, the health unit had a radio, and the pilot from the local mission hospital was in the area, so he was able to call and pick up the patient. By the time the pilot arrived the patient was in coma, but a medical student who was doing his elective, and who met the plane, obtained the history that he had previously fallen out of a truck. The signs of cerebral compression were classical. He was on the operating table within 2 hours, burr holes were made, and he was sitting u conscious the following day. LESSON A chronic extradural haematoma can follow a head injury incurred weeks, or even months, before. |
SUBDURAL AND EXTRADURAL BLEEDING
Be sure you are familiar with the methods of controlling bleeding in Section 63.9.
EQUIPMENT A general set (4.11), a self retaining mastoid or thyroid retractor such as Mallison's, a brace, a perforator, burrs, a curved dissector, a dural elevator, a dural hook or fine needle and holder, a wide bore cannula and stillette, a fine suction tube, and a large Volkmann's spoon or a small teaspoon. Horsley's bone wax to plug the bleeding diploe, and a sterile pointed match stick. A bottle of warm sterile saline and a drip set, or a bowl of warm saline and a bladder syringe.
ANAESTHESIA See Primary Anaesthesia Section A 16.8. General
anaesthesia is best because you can hyperventilate the
patient, which will make his brain contract. A method of local
anaesthesia is described below.
CAUTION ! Keep his airway clear. The slightest obstruction will make his brain swell.
PREPARATION Work quickly; shave the patient's whole scalp
so that you can operate on both sides if necessary. Take care
not break his skin. Include his ears in the area you prepare.
Close his eyes, pad them and seal them with strapping, so that the fluid used for skin preparation or blood cannot drip into them.
Prepare one of his thighs so that you can take a fascial graft, if necessary, as in Fig. 63-17.
POSITION Position him yourself. Support the patient's head carefully with sandbags or a kidney dish, so that it projects over the end of the table, and does not move about when you operate. If you are using local anaesthesia, strap him to the table. After preparing him, scratch the sites of the burr holes, and inject local anaesthetic. If you don't do this, you may not know where you are when his nose and eyes are hidden under the drapes.
DRAPES Wet a towel with antiseptic and wrap it round the
base of the patient's cranium. Stitch it to his head so that
you can move his head with the towel attached. Expose his
occiput, the tops of his ears, his zygomas, and the whole of
his forehead, so that you can get at the whole of his head.
If possible, lay the drapes from his face across to an overhead
table, so that the anaesthetist can get at his face. Ideally, use
the special frame made for the purpose.
Arrange to minimize venous bleeding by adjusting the slope of the table, so that the patient's head is above his heart. Make sure that nothing obstructs the veins of his neck.
SITING THE BURR HOLE
Site the burr hole according to the rules in Section 63.4. The classical position is as follows.
THE CLASSICAL POSITION Make the burr hole midway between the posterior margin of the patient's orbit and his external meatus 2 cm above his zygomatic arch, and 1 cm in front of his ear.
CAUTION ! The common mistake is to make the hole too high.
Make a hockey stick incision starting at the lower border of his zygoma 4 cm in front of his ear, and carry it upwards and backwards for 8 cm, as A, Fig. 63-19. Experts make a shorter incision.
If you are using local anaesthesia, infiltrate the line of the incision with anaesthetic solution. Also anaesthetize a line from the margin of the patient's orbit anteriorly to his mastoid posteriorly. Take care to anaesthetize the tissues above his ears.
Inject the anaesthetic solution at right angles to his skin in several places, so as to infiltrate the lower part of his temporalis muscle and block his deep temporal nerves as they turn upwards. Use a generous quantity of solution and make his whole temporalis fossa insensitive.
Control bleeding by asking your assistants to press the edges of the wound (B, Fig. 63-9). Pick up the edges of the patient's galea in haemostats and evert them. When you remove them at the end of the operation bleeding will have stopped. Make a T-shaped incision in his temporalis fascia (C), and turn it back as two short flaps (D). The small horizontal incision above his zygomatic arch makes access to the inferior surface of his brain easier.
Split the patient's temporalis muscle from top to bottom in the line of its fibres, and separate it from his skull with a curved dissector (E).
Insert a self-retaining retractor, to expose about 4 cms of his skull (F).
AN ALTERNATIVE PROCEDURE FOR A DESPERATE EMERGENCY
INCISION This is quicker, and many operators prefer it to the classical one in Fig. 63-9, especially if they are in a hurry in the middle of the night.
To minimize bleeding infiltrate the line of the incision with adrenaline in saline (or local anaesthetic solution). Make this i ncision over the temporal lines of the patient's skull (you can feel these) above the mid part of his zygomatic arch. Cut down through it right down to his pericranium in one quick deep i ncision. Quickly free the cut edges of his galea from his skull, pick them up with several haemostats, and turn them over to control bleeding.
USING A PERFORATOR AND BURRS
Place the knob at the top of the brace in the palm of your left hand; take its handle in your right hand. With the perforator i n position, make a funnel shaped hole in the bone as in A, Fig. 63-10, until you just see the pale blue of the normal dura, or the dark purple of an extradural clot, then stop!
CAUTION ! (1) Don't go on any further, because you may pierce the patient's dura and lacerate his cortex. This is very easily done. (2) The squamous temporal bone is often thin so don't press too hard.
Replace the perforator with a burr (B) and enlarge the hole. Avoid the smaller burrs and choose one which is large enough to rest on the edges of the hole. A small burr can easily go through into the brain. Use a certain amount of force, but lock your shoulder muscles, so that the brace is under control, if the bone gives way. The burr must not suddenly go thorugh the skull into the brain, as in F!
Stop turning when the bite on the burr increases suddenly, because this shows that it is now through to the inner table. Stop while there is still a rim of inner table round the edge of the burr hole, as in D, Fig. 63-10. Don't go on until you have made a parallel sided hole E, or the burr will certainly go through into the brain. You should be able to make a large enough hole with a single burr. If not, replace it with a larger one one, until the hole is just large enough to let you put in the nibblers.
Nibbling should not be necessary in the first instance because most subdural haematomas can be drained through an ordinary sized burr hole. Only nibble if you need more room. Push the dura gently away from the inner table with a dural elevator (G, and H), so that it is not torn when you insert the nibbler to enlarge the edge of the hole (I). The cut edges of the bone will bleed. Suck away the blood and don't apply wax until you are about to close the wound.
WHAT DO YOU SEE THROUGH THE BURR HOLE?
Make sure you have a good light. The normal brain and dura should pulsate; if they do not, suspect that there is something abnormal underneath. If you don't see anything, enlarge the burr hole a little. This is why it is best to make burr holes away from the line of the middle meningeal artery, not over it.
If a meningeal artery spurts at you as soon as you make the burr hole, you probably cut it with your instruments, and an extradural haematoma is not present. If there is clot immediately under the hole, the patient has an extradural haematoma, so see below. You will not see the dura or the middle meningeal artery because these will have been displaced inwards by the clot.
If the patient's dura looks abnormally purple, he has a subdural haemorrhage, or occasionally an intracerebral one, so deal with it as described below. This is more common than extradural bleeding.
If hIs dura is its normal pinkish white and swollen, the brain underneath is swollen. Open his dura, to make sure that the swelling is due to his brain and not to a subdural clot, then make another burr hole.
If his dura is normal in colour and not swollen, explore the hole for 5 cm in all directions with the dural elevator. There may be clot close to the hole which the elevator may reveal.
If you find blood, nibble towards it, or make a new hole.
If thorough exploration reveals no clot, make more burr
holes, in the order shown in Fig. 63-6.
EXTRADURAL HAEMORRHAGE
You made a burr hole and found clot immediately under it. Nibble the hole in the patient's skull to make it larger. If necessary, lengthen the skin incision upwards and backwards,and extend the split in his temporalis muscle. Retract the tissues widely, so that you get a good look into the hole. If you are able to turn back a small flap, do so. This is quicker than enlarging a burr hole by nibbling.
Nibble away the bone in the direction of the clot; this is usually towards the base of the skull. The common error is to remove too little bone. If necessary, nibble away ruthlessly to get the access you need. A cranioplasty can be done later if he survives to need it. It is seldom necessary. The hole should be at least 7 cm in its maximum diameter. With a low temporal haematoma, remove bone well down to and i ncluding the pterion, which is the outer end of the sphenoid ridge. This is the only way you can remove clot lying low under the temporal lobe. Use a curved dissector to separate the patient's dura from his skull each time you nibble more bone.
After you have removed bone, wait a few minutes to allow the circulation in the patient's brain to adjust itself to the new conditions.
CAUTION ! (1) Don't disturb the clot until you are in a position to control bleeding. (2) Don't put your finger into the wound to try to remove the clots, because the extra compression may kill him. Instead, remove the clot, a little at a time with a teaspoon or a curved dissector, or suck it out, or syringe it away forcibly with warm saline.
Watch for further bleeding, and if necessary, nibble towards it -this is very important; don't worry about how much bone you remove.
If there is no further bleeding, after you have removed the clot, don't hunt for the injured artery, instead close the wound. The patient's dura will probably be slack showing that there is no significant brain swelling. Pull up his dura to the bone with black silk stitches through the surrounding pericranium and temporalis muscle. You may have to make a small incision in the dura to do so. This is good practice anyway, because you may find some removable subdural clot. If you don't do this, clot will reaccumulate. Usually, the brain does not expand rapidly, unless air or saline gets underneath it.
If the bleedIng is arterial and floods up into the wound as you remove the clot, it is certainly coming from his middle meningeal artery, so try to find it. Syringing with warm saline may help. The best way may be to make a hole in the dura beside the bleeder, and catch it with a haemostat. Or, pick it up with a sharp hook and pass a needle round it, so that you do not mistakenly damage any cortical veins. When you have controlled bleeding you can coagulate the vessel with diathermy or tie it. Immediate coagulation with diathermy usually results in the vessel 'burning back' and continuing to bleed.
If the bleeding is venous, it is either coming from the veins which accompany his meningeal artery, or from the veins of his dura. If it is very severe it may be coming from a tear in his saggittal sinus, or its lacunae. Try to find the bleeding point and stop it as described in Section 63.9. In about 10% of cases the blood is coming from a sinus, so raise the patient's head and insert a pack as described below. If there is a venous ooze from everywhere, insert a suction drain.
If you have secured the main bleeding point, but there is much persistent bleeding, don't hurry. Leave a pack in place. Go away and wait for 10 minutes. It will probably settle spontaneously over the next hour, and allow you to close the wound. Provided you are able to replace the blood that is lost, you can afford to wait. Don't forget to remove the pack!
If the clot extends backwards under the patient's parietal bone, the posterior branch of his middle meningeal artery has probably been torn. You cannot tie this from your present incision. So try to tie its main trunk. If this is impossible make another burr hole 4 cm above and behind his ear. This is the burr hole marked 'X' in Fig. 63-6. Fortunately, it is rarely needed.
If the vessels in a bone groove or tunnel are bleeding, apply Horsley's bone wax, or plug them with a sterile pointed match stick. Do the same if his diploic veins are bleeding. Some surgeons say that match sticks don't work and that these vessels are better plugged with muscle.
If arterial bleeding comes from the under surface of the patient's brain, his middle meningeal artery may have ruptured at or close to his foramen spinosum. Retract his brain andthe dura so as to expose it, and plug it with bone wax, or a sterile pointed match stick. Fortunately this is rarely necessarily.
If you cannot find the bleeding vessel, pack pieces of haemostatic gauze, or temporalis muscle, between the patient's dura and the bone where the bleeding is coming from. Hold them in place by stitching the dura to the pericranium over the edges of the hole in his skull, as in Figure 63-19. Insert a suction drain and raise the patient's head.
If bleeding is uncontrollable, it is probably coming from a torn sagittal sinus. Raise the patient's head. Leave the wound open for a few hours, or even until the next day. Pack It lightly with gauze towards the bleeding point, keep it covered with sterile dressings, and transfuse him with several units of fresh blood. Give him calcium gluconate. Severe bleeding of this kind is also rare, which is lucky because it is often fatal.
SUBDURAL HAEMORRHAGE AFTER A HEAD INJURY
You have found purple clot under the patient's dura. Extend the skin incision, and enlarge the hole with nibblers, If necessary, which it usually is not. Hold up his dura on a hook. Use a No. 11 blade on a holder to make across-shaped incision in it. Interpreting what you find may be difficult. His brain may be contused and lacerated, with some clot and blood in the subdural space. This is not in itself a significant compressing lesion. He will only benefit if you can remove a subdural clot about 1.5 cm thick or more. Remove it in the same way as for an extradural haemorrhage.
If moderate bleeding is still taking place, enlarge the burr hole in the direction of the bleeding, and then try to seal it with diathermy, or by one of the methods in Section 63.9.
If there is a venous ooze from everywhere, which is impossible to control, leave it and insert a drain, preferably a mild suction drain.
If torrential bleeding occurs from a tear in a large venous sinus or from deep in the patient's brain, i ts source may be Impossible to find, or repair. Try to control it as in Section 63.9. This type of bleeding is seen in acute subdural haemorrhage; his outlook is bad.
If you have controlled all bleeding, close the dura without a drain. Otherwise, leave a rubber drain in when you close the wound. Stitch it to the skin, take great care with asepsis and remove it after 24 hours. Some surgeons consider that a Paul's tube rubber drain is useless.
BLEEDING INTO THE BRAIN AFTER A HEAD INJURY
You have made a burr hole; the dura under it is purple and bulges into the incision. Insert a wide bore cannula, or a Tuohy needle, into the swollen area and remove the stilette. Purple fluid may exude. If it does not, gently aspirate 2 or 3 times I n various directions. If this fails, widen the hole in the skull, i ncise the cerebral cortex and suck out the clot, or syringe it away.
FURTHER BURR HOLES WHEN THESE ARE NECESSARY
EXTRADURAL HAEMORRHAGE is rarely bilateral. So if you find extradural bleeding, and the patient is recovering, and the X-ray shows no fracture on the other side, there is no need to make any more holes.
SUBDURAL BLEEDING. In 20% of cases bleeding is
bilateral, so never make less than 4 holes.
When you make more holes, do so in the order shown in Fig. 63-6. Make the parietal holes through a separate longitudinal incision over the point of maximum convexity of the patient's skull, above and behind his ear. If this is unsuccessful, make a frontal burr hole in the line of his pupil 2 cm behind his hair line. If you find nothing here, make the same three burr holes on the other side.
Unless you find extradural bleeding, always make at least one bole on the other side, and don't stop operating, even if the patient is dying. The relief of his cerebral compression is his only chance of living. You can cut more burr holes very quickly. Incise the skin and periosteum with a single cut, quickly elevate the periosteum, insert a retractor, and then apply the perforator.
In subdural bleeding you will usually find clots through temporal burr holes when the patient's history is less than 2 weeks, and through frontal or parietal ones in more chronic cases. Sometimes, there is no clot, only pale yellow fluid under tension, but treatment is the same.
CLOSING THE WOUND AFTER MAKiNG BURR HOLES
SUBDURAL HAEMORRHAGE There is no need to suture the patient's dura, or to insert a drain routinely. Most wounds will drain quite satisfactorily into his temporalis muscle. Only i nsert a drain if you have been unable to control bleeding. If you do insert one, be sure to remove it in 24 hours. Occasionally, you may need to close a gap in his dura with fascia lata (63-17).
EXTRADURAL HAEMORRHAGE If you can, insert an
extradural suction drain. Some surgeons don't insert one if
they have been able to draw the patient's dura up well.
ALL PATIENTS Stop bleeding from the cut edges of the
patient's skull by pressing Horsley's bone wax into it all round.
Use fine monofilament sutures on curved needles to bring
the edges of his temporalis muscle together.
If the patient's brain bulges Into the wound, and makes it difficult to close his dura, close it with a fascia lata graft, while hyperventilating him. Give him mannitol and frusemide as described below.
Suture his temporalis fascia. It contracts during the operation, so you will probably only be able to sew up its lower half. Careful closure will diminish the evidence of a bony defect in his skull.
Close his galea with buried sutures of monofilament or chromic catgut, cut the sutures close to the knot, or their ends may project from the wound, prevent healing, and encourage infection. If closing the wound is difficult, close it with monofilament, as in Fig. 63-14.
DIFFICULTIES WITH BURR HOLES
If you DON'T HAVE A BRACE AND BURRS, use a hammer and gouges and control them carefully. Small taps with a large hammer are better than large taps with a small one. Or, borrow a drill from a garage.
Some hospitals have trephines instead of burrs. If you use a trephine, start with a small one and hold it in a handle, or a brace. Put the locating pin in the trephine and start to make the hole with this. It will be hard work! As soon as the trephine has started to bite, remove the pin. It must not go through the dura.
If a CHILD needs burr holes, fit the perforator into the handle for it, and open his skull with this. Then go straight to the nibbler, without using burrs. A child's skull is thin with no distinct inner and outer table, so a brace and burrs, and especially a drill, can be dangerous. You may be able to remove the blood from a haematoma in a baby with a large needle without using a perforator.
If a BURR GOES STRAIGHT THROUGH the patient's dura into his brain, this is not as dangerous as you might suppose, and he will probably recover. It should never happen, but when it does happen, as in F, Figure 63-10, it usually does so in a child.
If BRAIN OOZES LIKE TOOTHPASTE from an open hole in a patient's skull, pass a tracheal tube, and hyperventilate him. His brain will suck itself in, and he may recover. If his i ntracranial pressure is high enough, his brain can ooze from a burr hole, or from an open wound in his skull.
If, after hyperventilation and a thorough search for bleeding, the patient's BRAIN BULGES THROUGH THE WOUND, there is either deep intracerebral bleeding or oedema. There is nothing you can do for deep intracerebral
bleeding, but you can reduce oedema with mannitol. Give him 500 ml of 10% mannitol (50 g) over 30 to 60 minutes. Repeat this every 6 to 8 hours if his consciousness improves, but don't
exceed 200 g in 24 hours. Drain his bladder with a catheter
because he should have a marked diuresis. From the second
day onwards for 3 or 4 days give him frusemide 40 to 80 mg
intravenously daily. Steroids are useless.
63.6 Open head wounds
The first principle in an open head wound is that what may look like a simple scalp wound may have a tear in the dura underneath it. The dura forms an excellent barrier to infection, so that wounds which go through it are much more serious than those which do not. Even the most seemingly trivial head wound is potentially dangerous. If you neglect a wound of the dura, meningitis, a brain abscess or osteomyelitis may follow. X-rays are useful-much more so than in fractures of the base. So X-ray all but the most trivial open head injuries in search of: (1) An open fracture under a penetrating wound. (2) A depressed fracture needing elevation. (3) A spicule of bone going through the dura which needs to be removed. (4) A foreign body. If you suspect that any of these four things might be present, explore the patient's scalp right down to the bone.
ARE YOU SURE THERE IS NO PENETRATING SKULL WOUND?
OPEN HEAD WOUNDS
If the patient has more serious wounds elsewhere, his head wound can usually wait 12 or 18 hours. Before you operate, study the control of bleeding in Section 63.9.
X-RAYS If a patient has anything more than the most trivial
wound, X-ray the vault of his skull.
THEATRE Unless a patient's wound is very superficial, take
him to the theatre, because it may be deeper than it looks.
Torrential bleeding can occur, so you may need the full
facilities of the theatre in a hurry. Examine his wound on a
tipping table, not in a chair. He may bleed severely, or become
shocked.
ANAESTHESIA Do a ring block of the scalp as described in
A 6.6.
WOUND TOILET Shave the patient's whole scalp, and clean
it with detergent. Be prepared to use several razor blades, because any grit in his scalp will blunt them. Protect his
wound meanwhile with a sterile swab or towel.
If his wound is clean-cut, and its edges are healthy and bleeding, don't excise them.
If it is dirty and ragged, as in C, Fig. 63-19 excise the skin edges all round it in one clean sweep right down to his pericranium. Take care not to cut away more scalp than is necessary, or there will be so much bare skull that his wound will be difficult to close.
Put in a self retaining retractor, and explore his wound cautiously with your gloved finger. This is safer and provides more information than a metal probe. Remove all debris and dead tissue, and syringe it out with saline.
If you feel any sharp bony edges, expose the surface of his skull widely, and goto Section 63.7. STITCHING A wound which only cuts a patient's skin does not gape, but one which cuts his galea gapes widely. Close i t with big square vertical mattress sutures of stout monofilament, as in Fig. 63-14. Put them through his skin and his galea. Unless you catch the skin edges in the suture, they will dive i nwards, and you will not know if you have closed his wound properly or not. Put most of the sutures in place before you start to tie them.
LOSS OF SCALP Try to bring the skin edges together without
too much tension, or his scalp may necrose. Follow the
methods for flaps in Section 57.11. Don't leave bare bone
exposed, or it will slough.
(1) If there is comparatively little loss of scalp, you may be able to free it from his pericranium round the wound, so as to mobilize it over the subgaleal space. Mobilize his scalp in the layer between his galea and his pericranium, as in Fig. 63-12.
(2) You may be able to elongate the ends of the wound in a long curved 'S'. Move the skin at the edges of these flaps, so that it closes the incisions, as in Fig. 63-13.
(3) You may be able to cut the flaps shown in Fig. 63-13, or Fig. 63-15. Cut them big. If possible, design them round one of the arteries supplying his scalp. If there is a dog ear at the end of the flap, disregard it, or close it with a small incision at right angles to the main one, as in Fig. 57-16.
DIFFICULTIES WITH OPEN HEAD WOUNDS
If BLOOD COLLECTS UNDER A PATIENT'S GALEA, don't drain the swelling, or you may infect it. The haematoma will subside spontaneously, just as a cephalhaematoma does in a newborn child.
If he has a head wound, you have NO X-RAYS and you don't know if he has a penetrating wound involving his dura or not, explore and toilet his wound. If you are in doubt, do a burr hole close beside it, insert the nibblers, and work towards the fracture.
If you CANNOT CLOSE A SCALP WOUND even with flaps, don't leave the bare bone of the outer table of his skull at the bottom of the wound, for it will take months to granulate over. (1) See again if you can cover the bone with any of the flaps i n Fig. 63-15. If necessary, graft the area from which you mobilized the flap. (2) If his exposed skull is covered by epicranium, graft it immediately (57.2). (3) If his epicranium has been stripped off, so that bare bone is exposed, gouge away the outer cortex of his skull. The exposed area of bone will granulate rapidly, and you will soon be able to graft it.
If a patient's SCALP HAS BEEN PARTLY TORN OFF and hangs loose from his head, transfuse him, trim his scalp, wash it with an antiseptic, such as hydrogen peroxide, and suture it back. Its excellent blood supply, which caused it to bleed so much, will probably keep it alive, provided it is attached to his head by a reasonably broad base. If any exposed skull
is still covered by pericranium, graft it immediately. If his pericranium has been removed, gouge the surface of his skull, let it granulate and graft it, as above.
63.7 Fractures of the vault of the skull
When you suspect that a patient has fractured the vault of his skull, ask yourself these questions: (1) Are the fragments depressed? Provided that his dura is not torn, you can leave most depressed fractures, which will be safer than trying to raise them. (2) Does he have an overlying skin wound? If he has, toilet it. (3) Has his dura been torn? If it has, repair it. (4) Are there any foreign bodies in the wound and particularly in his brain? If so, remove all foreign bodies from the wound. You may sometimes have to leave a bullet, or a large bony fragment deep in his brain. (5) Has his underlying brain been damaged? If it has, there is unfortunately little you can do.
Try to repair a patient's torn dura. Sometimes his X-ray shows a fracture which has obviously torn it, or it may. show air in his subdural space. Often, the diagnosis is far from obvious, so don't hesitate to explore a wound if: (1) There might be a dural tear. (2) There might be a bony fragment piercing the patient's dura. If necessary, enlarge his scalp wound, and feel and look at his skull. You may find any of these things :-
A fissured fracture should be left alone, unless it is filled with dirt or leaking CSF. CSF seldom leaks from fractures of the vault, and more often does so from basal fractures which involve a patient's nose or ears.
If a wound in the skull is leaking CSF from a fissured fracture, make a burr hole and then nibble away the patient's skull towards the tear, so as to expose enough of his dura to allow you to repair the tear.
A depressed fracture with fairly small skull fragments can be fatal if you try to elevate them. So, base your decision to operate on the indications given below. If you need to elevate a depressed fracture, make a burr hole in the nearby normal skull, enlarge the hole with nibblers, insert a bone elevator, and lever up the depressed fragment(s). Often, you cannot do this because they are jammed up against one another, so you have to remove them. Then, if necessary, repair the dura.
A large, closed, depressed fracture is caused by a blow from a large blunt object, and involves wide areas of the skull. A child's skull merely bends, and the result is the `ping - pong ball fracture' in Section 63.8. In an adult the fragments may be comminuted, and those at the apex of the fracture may tear the dura and enter the brain. Fragments of the inner table displace more than those of the outer table, so an injury may be worse than it looks. Even with a large depressed fracture, a patient may be conscious and have no neurological signs.
Raising large pieces of bone is difficult, and you may not be able to do it through a trephine hole. So, if possible, leave them. Don't operate merely because a fracture is depressed. If a patient has neurological signs, or a marked depression, or an obviously torn dura, refer him.
A serious consequence of an infected wound of the vault is ' brain fungus'. The patient's brain becomes infected, swells through the gap in his skull and dura, and forms a stinking, fungating swelling on the surface of his head. Once this has happened, there is nothing anyone can do. It is the result of- (1) infection, (2) foreign bodies including bone fragments in his brain, and (3) a raised intracranial pressure. It used to be thought that the important step in preventing brain fungus was to close the dura. This is now thought to be much less important than a careful wound toilet and the removal of all foreign bodies.
If you have to leave a gap in the dura, close it with an absorbable sponge ('Sterispon') or fascia lata from the patient's thigh. This will lie between his brain and his scalp, both of which are highly vascular, so it will readily take and fuse with the surrounding dura. You may be able to replace the pieces of his skull, as described below, but if you cannot, this is not important.
| JULIUS was walking about quite fit, smiling and gesticulating, but quite unable
to speak since the previous week when he had been hit on the head in a fight. Palpation showed him to have a depressed fracture of his skull. As this was being elevated under local anaesthesia a sepulchral voice from under the drapes called out "Shikamoo" (I am holding your feet", a local term of subservience and indebtedness). The patient went home talking volubly and everyone was happy. LESSON Aphasia is one of the indications for raising a depressed fracture. |
| FILIMON'S scalp was split and torn, his brains were pouring out of his head
and dripping slowly to the ground. This is the literal truth. A tree had fallen on it, smashing it like an egg. On the operating table it became clear that his skull was in five pieces. As these were manoeuvred into position more brain kept oozing out. At last the jigsaw was complete and his scalp was sewn up. To everyone's suprise he made a quick recovery and walked home. He did seem to have a rather simple and euphoric personality, but his family said that he had always been like that. LESSON Few patients are so severely injured that they must be given up as hopeless. Both these accounts are from Leader Stirling's `Tanzanian Doctor', William Heinemann, London. |
DON'T HESITATE TO EXPLORE A HEAD WOUND ALWAYS CLOSE THE DURA IF NECESSARY, GRAFT IT
FRACTURES OF THE VAULT
Be sure you are familiar with the methods of controlling bleeding in Section 63.9.
INDICATIONS FOR RAISING DEPRESSED FRACTURES IN ADULTS (1) Coma, or other signs of cerebral compression. (2) Local neurological signs such as hemiplegia or aphasia. (3) A depressed fracture over the patient's motor cortex. (4) Fragments of bone or foreign bodies in his brain. (5) Penetration of his dura. (6) Leaking CSF. (7) If a fragment is depressed by more than the thickness of his skull, say 5 mm, most expert surgeons would raise it, even if there are no other indications for doing so. If it is causing the patient no symptoms, you, who are less expert, would be wise to leave it. (8) If a fracture i s open, this is a strong indication for raising it, and, if necessary, removing the fragments which may promote Infection.
CONTRAINDICATIONS (1) Depressed fractures over a sinus
(63.9) without neurological signs. (2) Very large closed
depressed fractures. Most experts would operate on these.
WHEN TO OPERATE? if a patient has more serious injuries
elsewhere, you can, if absolutely necessary, leave his
depressed fracture for up to 24 hours or longer. This is provided
you toilet and close his scalp wound and provided his
dura is not damaged.
X-RAYS Look carefully at these to see if the patient's sagittal
or lateral sinuses are in danger. If they are, expect severe
bleeding.
PREPARATION Shave all the hair from his scalp.
ANTIBIOTICS In the hope of preventing infection, give the
patient an antibiotic which will enter his CSF, such as
suphadiazine 2 g followed by 1 g 4 hourly, or chloramphenicol.
Also, give him penicillin; start immediately, and don't continue
antibiotics beyond 5 days.
EQUIPMENT A general set, preferably two general sets, so
that you can use the second one when you are inside his skull.
Hudson's brace, a perforator, and burrs. A fine suction tube.
A malleable copper retractor. A bottle of warm sterile saline
and a drip set arranged so that you can irrigate the wound
to wash away blood and damaged brain.
ANAESTHESIA If possible, give the patient a general
anaesthetic (A 16.8).
Local anaesthesia is also possible. The skull, the dura, and the brain are insensitive to pain, so you need only anaesthetize the patient's skin. Before you inject the anaesthetic, test the mobility of his scalp, and plan carefully how you can best cover his wound subsequently. You may need to swing flaps to close the incision. Add adrenaline to the anaesthetic solution to control the bleeding. Inject it well beyond the edges of his wound, wherever you expect to incise. Arrange to minimize venous bleeding by adjusting the slope of the table, and carefully positioning the patient's head and neck as in Section 63.9.
PREPARING THE PATIENT'S OUTER THIGH Always prepare and towel the lateral aspect of his thigh, so that you can quickly take a piece of his fascia lata to repair a torn sinus or a gap in his dura. Take it as in Fig. 63-17. Be sure to take i t from the lateral aspect-there is little fascia anteriorly.
THE SCALP INJURY Toilet and explore this to remove all visible
dirt as described in Section 63.7.
If the patient's scalp wound is small, excise any very ragged edges, sew it up, and turn down a separate U-shaped flap with its base facing downwards. Make this flap carefully and use the methods in Section 63.9 to prevent excessive bleeding.
If there Is a gap in his scalp, you may be able to close it by using one of the sliding flap methods (Fig. 63-15). Explore the surface of his skull thoroughly. If you find a fissured fracture, leave it, unless it is leaking CSF, or is filled with dirt. Remove all dirt and contaminated periosteum.
RAISING A DEPRESSED SKULL FRACTURE
Discard the instruments you have used for the skin, and take a fresh set.
Insert a self retaining retractor, to improve the exposure. Strip the patient's pericranium away from the depressed bone, starting at the edge of the depression. Then strip it off the surrounding bone, as far as the edges of the wound. Make a burr hole in sound bone of his intact skull, close to the edge of the depressed area. If there is a choice, make it over a silent area in his brain. Start with a perforator, and use the brace and burrs as in Fig. 63-10.
CAUTION I Don't make the burr hole in the depressed fragment. It may be loose and go straight into his brain with the burr.
Enlarge the hole with bone nibblers. Before you insert them, push his dura away from the inner table with a dural separator.
Occasionally, you will be able to insert a bone elevator and l ever up the depressed fragments, as in Fig. 63-16. More often, you will have to remove them piece by piece as in Fig. 63-18. Remove all loose or grossly contaminated fragments. If they are clean, lay them back on the surface of the dura. They will act as a graft, and help to close the bony defect.
If the fragments are locked, you may have to make a second burr hole to unlock them.
If the fragments are very large, expose the fracture widely with large skin flaps which must have an adequate base. Lift up the fragments, and suture them in position with stitches through the pericranium.
If a clean fragment remains attached to the patient's pericranium, leave it.
If the surrounding edges of the patient's skull are dirty, nibble them away.
CAUTION 1 If there are any fragments in or near a venous sinus, leave them. It may bleed torrentially if you try to remove them.
THE DURA IN A FRACTURE OF THE VAULT OF THE SKULL
If the patient's dura is intact, leave it, remove any extradural haematoma present, and close the wound.
If his dura is blood stained or CSF oozes from the burr hole, his dura has been torn. Expose the whole tear by nibbli ng away more bone to expose 2 cm of intact dura all round it. This will allow you to see any laceration in his cortex.
If the tear in his dura has ragged edges, cut them away. If necessary, enlarge the tear. The bony fragments responsible for the tear are usually near the surface of the brain. Remove them.
If his brain Is uninjured, close his dura with interrupted stitches of fine monofilament and close the wound.
If part of the patient's dura has been lost, you cannot close it by simple suture, so sew a piece of pericranium or fascia lata in place with fine monofilament. For small gaps use pericranium, for large ones use fascia lata. Trim the edges of the dura, then trim the patch to fit the gap exactly, and sew it in place edge to edge.
If his dura Is purple and bulging, stroke its surface with the point of a No. 11 scalpel blade. As soon as it is opened, enlarge the opening with fine scissors, to expose the blood clot.
THE BRAIN IN A FRACTURE OF THE VAULT OF THE SKULL
If necessary, get a better view of a patient's brain by nibbling away more of his skull and opening his dura wider. Handle his brain gently. Remove all the dead tissue, clot, bone fragments, and foreign bodies that you can reach.
Remove any damaged brain tissue with a jet of warm saline from a syringe or by suction. Fix a rubber catheter on the end of the sucker and gently suck out any blood clots or purple damaged brain. Provided the nozzle of the sucker is not too wide, it will suck away soft injured brain safely, without injuri ng normal brain. Foot suction is usually safe. Stroke the surface of his brain with a fine suction tube until you get to healthy tissue. If you are not sure how much brain to remove, take away too much rather than too little.
When the toilet is complete, there should be a clean hole in his brain. It will close up and become smaller.
If there might be a foreign body in the patient's brain, insert brain retractors, suck and look. If you know where it is because you can see it on an X-ray, explore very gently with fine dissecting forceps. You can usually find and remove it quite easily. Or, you may be able to remove it on the end of a sucker. Don't try to feel it with your finger, you may push it further in. If you cannot remove it easily, leave it. You may have to leave a deeply embedded bullet, but try to remove a large deep bony fragment.
CAUTION 1 Keep the patient's exposed brain wet with saline. Control bleeding by the methods in Section 63.9.
CLOSING THE DURA IN A FRACTURE OF THE VAULT OF THE SKULL
When you have controlled all bleeding inside the patient's dura, close it, if closure is easy. Otherwise graft it. If necessary, hitch the dura to the pericranium as in Fig. 63-19.
The wound should be perfectly dry before you close a patient's skull, especially after an extradural haemorrhage, and when his brain has not completely expanded. If it is not dry, a clot will form postoperatively, and bleeding will not stop until the tension in it raises sufficiently to cause undesirable pressure on his brain.
CLOSING THE WOUND IN A FRACTURE of THE VAULT of THE SKULL
Ask an assistant to close the patient's thigh wound, while you close his head. Most scalp wounds heal by first intention, and delayed primary suture is seldom necessary. Close them with the stitiches in Fig. 63-14.
CAUTION ! Accurate closure of the skin wound without tension is most important. If necessary cut flaps (Fig. 63-15).
Continue penicillin, sulphadiazine, and chloramphenicol for 5 days.
DIFFICULTIES WITH A FRACTURE OF THE VAULT OF THE SKULL
If a WOUND HAS LEFT A GAP IN A PATIENT'S SKULL suggest that he wears a helmet if his occupation is such that his head might be injured. If his skull defect is over a prominent convexity, repair may be necessary.
If you DON'T HAVE A BONE NIBBLER and the patient has a fissured fracture which is leaking CSF, do a careful wound toilet and close his skin. Or, you can plug a fissured fracture with a piece of his temporalis muscle to prevent his CSF leaki ng out. If there is enough space for CSF to leak out, there will be enough space for you to push some muscle in. So explore and toilet his scalp wound. Take a piece of his temporal! s muscle, crush it and force it into the fissure. Then close his skin wound, and give him antibiotics.
If he has a BULLET WOUND toilet the entry and the exit wounds, and suck out the clot together with any pulped brain. If the wound is deep, pass a rubber catheter along its path. Control bleeding with hydrogen peroxide packs.
If the bullet comes out easily, extract it together with any foreign bodies or pieces of bone that you can remove without too much difficulty with fine dissecting forceps. But, if the bullet is difficult to remove, toilet the superficial parts of the wound carefully, and leave it where it is. Close the wound (Fig. 63-14), and give the patient antibiotics. A bullet makes a smaller wound on entering the skull than on leaving it, and fractures the inner table more severely than the outer one. Remove any bony fragments in the brain; these must come out, the bullet need not.
CAUTION ! 20 vols hydrogen peroxide produces 20 times its volume of oxygen, so make sure that there is a space for the oxygen to come out, or it may compresss the brain. Inexpert surgeons would be wiser not to use it.
If a FRACTURE HAS ENTERED HIS FRONTAL OR ETHMOID SINUSES, do nothing if the posterior wall of the sinus is intact. But if it is fragmented and torn, so that he has rhinorrhoea, he is in danger of meningitis, a brain abscess, or a pneumatocoele. Treat him conservatively with antibiotics, and he will probably recover. If a pneumatocoele develops, or CSF continues to leak for more than two weeks, refer him.
If a patient has a penetrating injury and PRESENTS LATE WITH MOTOR WEAKNESS ON THE OPPOSITE SIDE, he has escaped the immediate danger of meningitis, and he probably now has a cerebral abscess. Refer him if you possibly can. If you cannot refer him, all you can do is to explore the wound, and open his dura and his brain. Syringe out the abscess cavity with a jet of saline, and close his wound as above.
63.8 Ping-pong ball skull fractures in children
A blunt object, which causes a large depressed fracture in an adult, causes a ping-pong ball fracture in a child, whose skull is soft and dents instead of fracturing. The indications for not operating on a child are even stronger than in an adult, because these fractures rarely cause trouble. If a child has a single fit, disregard it. The dent will disappear as he grows.
ELEVATING A PING PONG BALL FRACTURE If you decide to raise the fracture, try first with a vacuum extractor. Apply one of the vacuum cups, as you would during delivery. Pull, and hold the surrounding skull with your other hand. If this fails, make a hole with a perforator at the edge of the depression and elevate the fracture with a skull elevator, as in Fig. 63-16. Make the hole for it with a perforator and nibblers and don't use burrs.
63.9 Controlling bleeding in head injuries
The scalp has an excellent blood supply from: (1) The temporal arteries ascending in front of the ears. (2) The supraorbital arteries which ascend over a patient's forehead from the medial ends of his eyebrows. (3) The occipital arteries behind his mastoid processes. This excellent blood supply helps wounds to heal quickly, and maintains the circulation in skin flaps with a small base, but it does mean that a patient can quickly lose much blood from a scalp wound. Minimize this bleeding by making incisions from above downwards parallel to the main vessels, rather than across them, or round his head.
Controlling bleeding in head injuries can be difficult, and there are some useful special methods. You must have a sucker, and you will find diathermy useful. If you don't have it, you will have to use a muscle patch to control venous bleeding. Don't use diathermy superficial to the galea, and especially not on skin edges, or the small areas of necrosis it causes will prevent the skin healing by first intention. For the same reason, when you are operating deep to the galea, don't let the diathermy electrode accidentally touch the haemostats on the skin edges.
CONTROLLING BLEEDING IN HEAD INJURIES
From without inwards, control a bleeding head injury like this:
BLEEDING FROM THE SCALP
Bleeding scalp vessels are difficult to pick up in haemostats, because they are held by the fibro-fatty tissue. Instead, use stitches, and control bleeding like this:
(1) Ask one, or even two assistants, to press on the patient's scalp close to the edges of the wound.
(2) Pick up the cut edge of his galea with haemostats 1 cm apart along the incision. Then evert them so that they compress the bleeding vessels in the edge of his scalp. Keep them together in bundles with rubber bands round their handles, out the way of the operation.
(3) Add adrenaline to the local anaesthetic solution. If the patient is having a general anaesthetic, infiltrate his scalp and temporalis muscle with adrenaline and saline. Try to control all bleeding before you stitch up his scalp. If you don't, a large haematoma may form under it, become infected, and need opening later.
BLEEDING VEINS AND VENOUS SINUSES
When you operate, prevent venous bleeding by taking the following precautions before you start:
(1) Use methods of anaesthesia which minimize bleeding. It will be worse if the patient strains. Ideally, give him a general anaesthetic, intubate him under relaxants, and hyperventilate him. This will reduce his intracranial pressure and minimize bleeding. If general anaesthesia is unlikely to be perfect, local anaesthesia may be better.
(2) Make sure that nothing obstructs the veins of the patient's neck. If necessary, raise his shoulders on sandbags.
(3) Reduce the venous pressure in his wound. Arrange the position of his head so that his wound lies uppermost. Give the table just enough head up tilt, about 10°, to raise his head above his heart and minimize venous bleeding. Don't raise it too much because air may be sucked in and cause an air embolus. The first sign of this will be sudden weakening of his pulse and an increase in its rate. Embolism will be less likely if there is fluid over the surface of his wound, so keep syringing it with saline.
Elevating the head of the table will also help to control bleeding from his dura or his brain, but is less useful on the more superficial tissues.
If a sinus bleeds during an intracranial operation, apply the above measures. But:
Don't: (1) Apply haemostats to the patient's bleeding sinus, because they will tear out and make bleeding worse. (2) Don't try to sew up a torn sinus. This can increase bleeding, especially if you cannot get at it adequately.
Instead: (1) Tie any smaller sinuses on either side of the tear, or fix them with a silver clip. (2) Push muscle grafts or pieces of surgical gauze between his dura and his skull. Then keep them in place by passing a few interrupted sutures between his epicranium and his dura over the nibbled edge of the bone. These sutures will hitch up his dura, and help to keep the muscle grafts in place. (3) Plug his bleeding sinus with a piece of muscle. If necessary, hold it in place with a deep suture passed under the sinus with a big curved needle.
If blood pours out as a dark venous stream from his sagittal sinus, controlling it can be very difficult. This sinus runs in the midline on the inner surface of the skull from the forehead to the occiput. Several irregular venous spaces (lacunae) join it on the top of the head (63-6). Fortunately, it i s rarely injured, because the skull is more often hit from the side than directly from on top. The transverse sinuses in the occipital region are still less vulnerable, but when they are injured, bleeding is even harder to control.
Plug the patient's torn sagittal sinus with haemostatic gauze. Suture his scalp over it, apply a tight bandage, and refer him. If you don't have any haemostatic gauze, or cannot refer him, use ordinary gauze and remove it cautiously in the theatre 48 hours later. If necessary, replace it with a muscle graft or a patch. Or, cover the gap with a thin piece of bone wax, and close his scalp over this. You can safely obstruct the superior saggital sinus in the first quarter of its length. Obstructing it further back will probably kill him.
Often, a sinus does not bleed until you begin raising a depressed fracture near it-don't!-treat it conservatively! These fractures are for real experts.
BLEEDING FROM THE BRANCHES OF THE MIDDLE MENINGEAL ARTERY
These vessels lie between the dura and the inner table of the skull. Underrun them with silk or cotton on a fine curved needle. This is easier than trying to coagulate them with diathermy.
BLEEDING FROM THE DIPLOE
Push Horsley's bone wax into the bleeding cut surface of the patient's skull. Or, use Bismuth and iodoform paste BPC. Or, use autoclaved beeswax or paraffin (candle) wax. If an artery spurts from the bone, push the sharpened point of a sterile match stick into it.
BLEEDING FROM THE VESSELS OF THE DURA
These tear so easily that you cannot grasp them with haemostats and tie them in the usual way. Instead, control bleeding like this.
(1) Place the wound uppermost, as described above.
(2) Press gently on the patient's injured sinus for about a minute. When you let go, the bleeding will probably have stopped. Pressing too hard may injure the smaller veins joining the sinus and make bleeding worse.
(3) Grasp the bleeding vessels with fine dissecting forceps and touch these with the diathermy electrode.
(4) Grasp the bleeding vessel with fine dissecting forceps, ask your assistant to hold them very still, while you underrun the vessel with 3/0 silk on a small curved atraumatic needle. When the suture is complete, apply a muscle patch, as described below.
(5) USING A MUSCLE PATCH If a piece of some suitable material is pressed over the bleeding area for a few minutes, blood will clot around it and seal it. Synthetic absorbable gauze is best, but if you don't have that, use a piece of muscle, or muscle and fascia squeezed flat. The temporalis muscle is close at hand, so use it. Although these patches will not stop an obviously bleeding vessel, they will stop a steady ooze.
Take a piece of the patient's temporalis muscle, and squeeze it flat between artery forceps until it is a thin sheet, the size of a postage stamp. The muscle will now be dead, but it will readily promote clotting. Press it onto the bleeding vessel, cover it with moist gauze, hold it in place with the sucker and drip saline onto it. The saline will keep the surrounding brain wet, and you will see through the gauze when bleeding has stopped. Leave it for five minutes.
If the flap you have reflected does not contain temporalis muscle, extend it so that you can take some. If you have already prepared the patient's thigh, you can take some muscle from that.
Alternatively, scrape off a piece of the patient's epicranium exposed by the wound, or take a piece from his mastoid process and hammer this flat to make the patch.
BLEEDING FROM THE BRAIN
Diathermy or silver clips will usually stop venous or arterial bleeding from any size of vessel. Use the lowest diathermy current that will cause coagulation, and the finest forceps. If don't have diathermy, or silver clips, avoid using haemostats, because the bleeding vessel too easily pulls out of the brain. Instead, apply a muscle patch, as described above, or soak a pad of cotton wool in hydrogen peroxide and put this on the patient's bleeding brain.
If his brain is bleeding, a warm pack will almost always control it. If necessary, put a piece of haemostatic gauze between his brain and his dura before closing it, and then place more gauze outside this. Don't pack or plug head wounds with ordinary gauze.
ALWAYS OPERATE WITH THE PATIENT'S HEAD ABOVE HIS HEART
63.10 Hyperthermia after a head injury
Injuries to the heat regulating centres in a patient's brain may cause hyperthermia, especially during the first 12 hours after an injury. When he is first admitted his temperature is usually low, and any rise over 39°C is a grave sign. During the first few days a temperature fluctuation of a degree or so is unimportant, but a rise after a day or two is serious, because it may indicate renewed subarachnoid bleeding, pneumonia, or meningitis. Hyperthermia can kill a patient with a head injury who might survive otherwise, so monitor his temperature carefully, and treat him promptly. It can rise very suddenly: it may be 38 °C one moment and 42°C half an hour later.
HYPERTHERMIA Take the patient's temperature regularly. During times of crisis take it every 10 or 25 minutes. If his temperature rises above 39°C, take off his pyjamas, cover him with a wet sheet, and turn a fan on him. Bring his temperature down to 40°C or below, and keep it there. If necessary give him chlorpromazine 50 mg 6 hourly, intramuscularly or by stomach tube.
63.11 Convulsions after a head injury
These can occur following a head injury at any time, and can be of almost infinite variety, either focal or general. They are usually associated with sudden deterioration of consciousness. Prevent them with phenobarbitone. Treat them promptly in the hope of preventing status epilepticus, which may be fatal.
CONVULSIONS Make sure the patient has a good airway. This may stop them.
If improving his airway fails, give him diazepam (A 2-4) intravenously for its immediate effect. Follow this with phenytoin sodium ('Epanutin'), first 250 mg intramuscularly, and then 50 mg, 6 hourly by mouth or tube. Phenytoin causes very little depression of consciousness, so it will not mask the signs of clot compression.
If these fail to stop convulsions, give him paraldehyde into the outer side of his thigh. Give infants under 6 months 1 to 2 ml, older children 2 to 4 ml, adults 7 to 10 ml.
If even these methods fail, give the patient 10% paraldehyde in 0.9% saline (50 ml in 500 ml of saline) by Intravenous drip slowly, as necessary. You can supplement this with phenytoin sodium 250 mg intramuscualrly, or by slow Intravenous injection.
Sedate the patient with phenobarbitone for a month after discharge. You may need to sedate him permanently. Reduce the dose gradually. Never halve it at any one time, instead, cut it by a quarter. The difference between a half and a quarter of a tablet may be critical.
Alternatively, maintain him on phenytoin to control convulsions.
63.12 When CSF leaks from the patient's nose or ears
This is the result of a fracture of the base of a patient's skull, which puts his arachnoid space in communication with his nose or ears. If you are not sure if the fluid is CSF, or merely nasal discharge, test some fresh fluid for glucose with a urine test strip. Only CSF contains glucose. Mop his nose or ears clean, but don't plug them. Don't lumbar puncture him, because this will lower his CSF pressure, and may assist organisms to enter his meninges.
LEAKING CSF FOLLOWING A HEAD INJURY
If the patient's airway and level of consciousness permit, lower his CSF pressure in the wound by nursing him sitting up.
ANTIBIOTICS Give him co-trimoxazole 960 mg 8-12 hourly, or
sulphadimidine 2 g initially followed by 1 g 6 hourly. Also give
him chloramphenicol 50 mg/kg/24 hrs in 6 hourly doses.
NOSE A leak of CSF from a patient's nose is much more common
than a leak from his ears, and rarely lasts more than a
few days. Note which nostril the CSF escapes from. Don't let
him blow his nose, because this may blow bacteria through
the crack in his skull into his meninges.
If CSF leaks from his nose for more than 10 days, refer him for repair of his dura. EARS A leak from the ears is less significant than a leak from the nose. If CSF leaks from a patient's ears for more than 3 days, he is probably bleeding intracranially and needs burr holes.
63.13 Meningitis follows a head injury
A stiff neck soon after an injury can be caused by meningeal bleeding, by a fracture of the patient's cervical spine, or by soft tissue injuries, so it is not of great significance early on. Some days later a stiff neck is more serious. So do a lumbar puncture if: (1) His neck becomes stiff some days after the injury. (2) He has a positive Kernig's sign at any time.
MENINGITIS AFTER A HEAD INJURY
If the organisms have entered from the patient's nose, they are probably pneumococci, and are usually sensitive to penicillin. Give him penicillin 2 megaunits immediately, and then 1 megaunit 6 hourly.
Also, give him intrathecal penicillin 20 000 units immediately, and then 10 000 units daily for 5 days. Give it in a dilution of 2000 units per ml in water for injection because stronger solutions, or larger doses, can cause severe meningeal reactions. Withdraw an equivalent quantity of CSF before you inject. At the same time give him chloramphenicol 50 to 100 mg/kg/day. Or give him sulphadiazine or sulphadimidine orally or by tube, 3 g initially, followed by 1.5 g 4 hourly, together with plenty of fluid.
If the organism is Insensitive to penicillin, give him streptomycin 1g intramuscularly, and 50 mg in 1 ml intrathecally.
63.14 More difficulties with a head injury
We have described most of the difficulties you are likely to meet, but here are a few more. They are not common.
MORE DIFFICULTIES WITH A HEAD INJURY
If a patient has CRANIAL NERVE PALSIES, they are usually the result of fractures of the base of his skull. There i s no specific treatment for them.
If he CAN MOVE HIS HEAD AFTER A HEAD INJURY, BUT NOT THE REST OF HIS BODY, he is quadriplegic as the result of a fracture of his cervical spine. When a patient's head is injured, his broken neck is often missed.
If he STARTS TO SNEEZE he almost certainly has a pneumatococle. This is the slow development of an air filled cavity in his brain connecting with one of his sinuses, usually his frontal sinus. His skull may be resonant to percussion, and an X-ray may show an air filled cavity. He is in great danger of meningitis. Refer him for neurosurgery immediately.
FEW HEAD INJURIES ARE SO SEVERE AS TO BE HOPELESS NO HEAD INJURY IS SO TRIVIAL AS TO TO BE TAKEN LIGHTLY
