SEVERE HEAD TRAUMA
You are listening to ReachMD XM 157, the Channel for
Medical Professionals. Welcome to the Strength to Heal, brought to you by the
United States Army Medical Department.
Your host is Dr. John Armstrong, trauma surgeon. Dr.
Armstrong is a former army colonel, who served as director of the US Army
Trauma Training Center in Miami, Florida and is Chair of the ACS Army Committee
Management of severe traumatic brain injury at the
cutting edge in Army Medicine. Our guest is Colonel and Dr. Leon Moores,
consultant in Neurosurgery to the Army Surgeon General and former Chief of
Neurosurgery at Walter Reed Army Medical Center.
Welcome Dr. Moores.
Thank you Dr. John, I appreciate the opportunity to speak
with you today.
Dr. Moores, We are in a time of war and we are seeing
injuries in this conflict, which capture the imagination, what can you let us
about the spectrum of injuries ?
One of the things that we are noting is that our forward
resuscitation capabilities are so extraordinary that the survival rates have
increased. This means that our hospitals in Germany and back within the United
States such as the Walter Reed Army Medical Center and the National Naval
Medical Center were seeing a severity of injury, which is unprecedented and that
leaves us with the opportunity to take care of young men and women who
otherwise may not have survived the previous conflicts, but create very
complicated management problems, which we had been working at some pretty significant
DR. JOHN ARMSTRONG:
And what are some of those management problems ?
While the volume of brain injury is significant in many of
these men and women. In comparison to previous conflicts we are able to save
the lives of and return to a reasonable level of functioning in many, many
cases, folks with injuries that have traversed virtually in the entire
hemisphere of brain tissue, sometimes dominant hemisphere brain injuries, which
in the past might not have survived, will survive, and therefore we are able to
not only save them acutely but participate in rehabilitative care for months
and years and getting the folks back to a quality of life, which is
acceptable. Additionally, as you can imagine particularly with penetrating
injuries the degree of soft tissue and bony injury of the overlying brain
creates a reconstructive problem for us, which requires complex solutions and a
multi disciplined area of approach including neurosurgery, plastic surgeons,
facial surgeons, and even our dentists, who participate in some of the facial
So you have the brain injuries themselves, you have the
injuries to the surrounding bone and soft tissue, and I would imagine that the
brain injury initially takes precedence and then there are consequences to
management of the brain injury in terms of further reconstruction?
That's absolutely correct. Initially we are most concerned
about swelling of the brain. Within the first 24 to 96 hours, the brain can
swell tremendously and one of our biggest therapeutic maneuvers in taking care
of that is to remove a much larger portion of bone than the initial penetrating
injury had created. In blunt injuries, we will do that as well and do an
operative procedure to remove a very large portion of the skull and then the
brain can swell without creating injury. As you know, when the brain swells
inside a fixed skull it can create a significant increase in pressure resulting
in decreased blood flow and that can lead to stroke and death. By removing
that large piece of bone we are able to allow that swelling to occur without
that endpoint. Subsequent to that, when the swelling has gone down and the
acute injuries have been treated often several months later we can work on some
of the cosmetic repairs that were secondary. Remember too that these injuries
to the brain and face typically do not occur in isolation. Often these young
men and women have multiple injuries to the torso and extremities, which are
being managed simultaneously with the head injury.
So as a casualty presents with these multidimensional
injuries cutting across injuries to the torso and to the extremities and then
to the head, the initial priorities and management remain the ABC?
They do indeed, you are absolutely right. There is
significant resuscitative effort that takes place far forward and the ability
to rapidly stop blood loss to move the casualties to forward resuscitative
surgical teams in expeditious fashion often comes within minutes to you know an
hour or hour and a half follow those same ABC's that we all know about from our
Advanced Trauma Life Support Systems.
I guess to say it another way the resuscitation of the
disability remains ABC.
It does, it does indeed.
Have there been any lessons from the current conflict in
specifics of resuscitation in patients with known severe traumatic brain injury
that might lessen the consequences of that injury beyond the promotion of
I think that perfusion remains the biggest issue in terms of
the entire body, but specific to the cranium we have learnt that in much larger
removal of bone tissue to allow an unprecedented level of swelling is
therapeutic. We knew from the civilian trauma and stroke literature that
removal of a large portion of bone can be helpful and we become very, very
aggressive removing even larger segments of the skull, often times portions of
the skull from both hemispheres, sometimes both anterior and posterior skull.
When these men and women are injured initially there are often unconscious
potentially because of the blunt or penetrating trauma that they suffered, they
have multiple wounds, and you have to make a decision very quickly about
intervening surgically. You have the capability and theater to intervene with
virtually very case. Some cases clearly when the initial CAT scan is obtained
you recognize that there has been so much tissue disruption that unfortunately
that casualty is not going to survive and you do not perform aggressive
neurosurgical interventions. What we found is we sort of pushed the envelope
forward in terms of the initial exam and initial presentation with which we are
willing to intervene. Folks who come in with the Glasgow coma scale score of 3
or 4 potentially with even dilated pupils because of the blast injury or other
trauma to the eyes, or their eyes are missing because of the penetrating injury
they have undergone, often times we will still performed aggressive
neurosurgical resuscitation and in a months later these folks will walk into
your clinic, which is not something you will typically see.
If you are just tuning in, you are listening to The
Strength to Heal brought to by the United States Army on ReachMD XM 157, the Channel
for Medical Professionals. I am your host, Dr. John Armstrong, and our guest
is Colonel and Dr. Leon Moores. We are discussing the management of severe