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.

Figure 63.1: INTRACRANIAL HAEMORRHAGE. A, an extradural haematoma. B, a subdural haematoma causing coning. After Graham Martin.

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 doctor 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!

Figure 63.2: THE ESSENTIAL NEUROSURGICAL EQUIPMENT. This should be in every hospital and every doctor should know how to use it. Hudson’s brace is the neurosurgical equivalent of a carpenter’s brace.

•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.

•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.

•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.