Management of head injury. The skull and meninges.

Injuries to the skull and meninges frequently occur concomitantly with head trauma. Controversies over the operative versus nonoperative management of depressed skull fractures, frontal sinus fractures, cerebrospinal fluid leaks, and cranial nerve injuries are discussed in this article.     

The atriocaval shunt. Facts and fiction.

During the past 11 years, 31 patients with major juxtahepatic venous injuries were treated with the atriocaval shunt. Penetrating injuries occurred in 27 patients (87%), and injuries from blunt trauma occurred in four patients. Shock was present on admission in 28 patients (90%). Resuscitative thoracotomy for cardiovascular collapse was required in 13 patients (42%). Juxtahepatic venous injuries included the vena cava in 23 patients (74%) and the hepatic veins alone in five patients (16%). One patient had an isolated portal venous injury, and two patients died before their vascular injuries could be delineated. Technical problems related to the shunt occurred in seven patients. Most were related to delays in placement or problems encountered in obtaining vascular control of the suprarenal vena cava. Major hepatic resection was performed in 11 patients (35%). Twenty-five patients died of their injuries. No patient survived who required resuscitative thoracotomy, hepatic resection, or when technical problems with the shunt occurred. Six patients (19%) survived and were discharged from the hospital. All sustained gunshot wounds to the retro-hepatic vena cava. Four of the six survivors had serious postoperative complications, but none were related to the shunt. Major juxtahepatic venous injuries are highly lethal. The atriocaval shunt will permit the salvage of some patients where other methods are not possible. Avoidance of delay and alternative shunting techniques that eliminate difficult maneuvers may improve survival in the future.     

The Brain Trauma Foundation. The American Association of Neurological Surgeons. The Joint Section on Neurotrauma and Critical Care. Age

Age is a strong factor influencing both mortality and morbidity. Despite some contradictions, most literature supports children faring better than adults who have severe brain injury. The significant influence of age upon outcome is not explained by the increased frequency of systemic complications or intracerebral hematomas with age. Increasing age is a strong independent factor in prognosis, with a significant increase in poor outcome above 60 years of age.     

The Brain Trauma Foundation. The American Association of Neurological Surgeons. The Joint Section on Neurotrauma and Critical Care. Hyperventilation

Chronic prophylactic hyperventilation therapy should be avoided during the first 5 days after severe TBI and particularly during the first 24 h. CBF measurements in patients with severe TBI demonstrate that blood flow early after injury is low and strongly suggest that in the first few hours after injury the absolute values approach those consistent with ischemia. These findings are corroborated by AVdO2 and SjO2 and brain tissue O2 measurements. Hyperventilation will reduce CBF values even further, but will not consistently cause a reduction of ICP and may cause loss of autoregulation. The cerebral vascular response to hypocapnia is reduced in those with the most severe injuries (subdural hematomas and diffuse contusions), and there is substantial local variability in perfusion. While the CBF level at which irreversible ischemia occurs has not been clearly established, ischemic cell change has been demonstrated in 90% of those who die following TBI, and there is PET evidence that such damage is likely to occur when CBF drops below 15-20 cc/100 g/min. A prospective randomized clinical trial has determined that outcomes are worse when TBI patients are treated with chronic prophylactic hyperventilation therapy. Within the standard, guideline, and options, specific paCO2 thresholds have been described that are different for each of the three parameters. These individual thresholds were selected based on the preponderance of literature supporting those thresholds in the contexts of the statements which included them. With the exception of the threshold included for the standard in this guideline, it is emphasized that the paCO2 threshold is not as important as the general concept of hyperventilation. The preponderance of the physiologic literature concludes that hyperventilation during the first few days following severe traumatic brain injury, whatever the threshold, is potentially deleterious in that it can promote cerebral ischemia.     

The Brain Trauma Foundation. The American Association of Neurological Surgeons. The Joint Section on Neurotrauma and Critical Care. Nutrition

Data show that starved head-injured patients lose sufficient nitrogen to reduce weight by 15% per week. Class II data show that 100-140% replacement of resting metabolism expenditure with 15-20% nitrogen calories reduces nitrogen loss. Data in non-head injured patients show that a 30% weight loss increased mortality rate. Class I data suggests that nonfeeding of head-injured patients by the first week increases mortality rate. The data strongly support feeding at least by the end of the first week. It has not been established that any method of feeding is better than another or that early feeding prior to 7 days improves outcome. Based on the level of nitrogen wasting documented in head-injured patients and the nitrogen sparing effect of feeding, it is a guideline that full nutritional replacement be instituted by day 7.     

The association of neurofibromatosis and hyperparathyroidism.

Two patients with coexisting neurofibromatosis and hyperparathyroidism are described, bringing the total number of such cases in the world literature to seven. Other more classic examples of the association of tumorous conditions of neuroectodermal and entodermal origin are discussed to support the suggestion that the association of these two diseases may be another variant of multiple endocrine neoplasia type 2 (MEN2b). It may be clinically profitable to investigate all patients with either disease in order to uncover their coexistence.     

The mortality and morbidity of laryngectomy.

Experiences with 147 laryngectomies, 49 with en bloc neck dissection, are presented. One patient died, and 36 suffered postoperative complications serious enough to delay rehabilitation and to prolong hospitalisation.