Wartime neurotrauma: highlights of management Mohammed al-dhahir, md. Neurosurgery department Yemeni german hospital

In memory of Dr. Tomasz Skibinski

Deepest Gratitudes Prof. Ismail Al-Kebsi Dr Deepest Gratitudes Prof. Ismail Al-Kebsi Dr. John Benett All fellow Yemeni neurosurgeons and residents

“He who wishes to be a surgeon, must first go to war”. Hippocrates https://upload.wikimedia.org/wikipedia/commons/7/7c/Hippocrates.jpg

History of war trauma Different weapons used As early as beginning civilization Evolution of the weapons used

War Vs non-war injuries Transport and triage are different Differences in radiology Most commonly are penetrating injuries with blast injury is the most common cause Usually there is polytrauma Associated Burns are more common Serious hemorrhage is more encountered Challenges in the proper assessment of Neural injury in the acute setting Complex craniofacial injuries are oftenly seen Secondary brain injury is a more prone complication Planning and Multiple teams coordination is the key

TBI in the setting of severely multiple organ injury Major extracranial injuries in patients with severe TBI : up to 23–41 % of patients (Leeuwen NV, Lingsma HF, Perel P, et al. Prognostic value of major extracranial injury in traumatic brain injury: an individual patient data meta-analysis in 39,274 patients. Neurosurgery. 2012;70:811–8). Such victims are in need for rapid clinical evaluation, resuscitation and even immediate invasive intervention Chaotic stressful situation plus the complexity of the nature of injuries are the major challenges Team based work and proper frequent communication between involved specialties is crucial

Initial Evaluation at the trauma center : Roles and Duties the trauma center verification process by American College of Surgeons: The Trauma Surgery team conducts the initial resuscitation Level 1 and 2 trauma centers should have a Neurosurgery team readily available to participate in the assessment of the patient if necessary. neurosurgeons should be physically present in the emergency department within 30 min. Source (Resources for the Optimal Care of the Injured Patient. Committee of Trauma of the American College of Surgeons, 2014. pp. 49,53).

Priorities in the Initial Resuscitation * Follow the Advanced Trauma Life Support manual The initial evaluation and management is done promptly with an emphasis on an orderly completion of primary and secondary surveys, along with any indicated imaging studies. Aim for SBP 90 0r more Avoid secondary brain insult by hypoperfusion

Thoraco-abdominal hemorrhage vs Brain CT scan Most important determinant is response to resuscitation in the hypotensive patient Usually victims will fall in one of three categories: 1.non responders: should go directly to operating room 2. transient responders : should go directly to operating room 3. good responders: should do CT scan Low GCS and lateralizing findings argue more favor in CT scan of the head Retrospective reviews have shown that in hypotensive trauma patients, the need for urgent laparotomy/thoracotomy for hemorrhage control is ten times higher than the need for urgent craniotomy

Priotery of procedure, which is first * A certain weighing of risks of timing of non head injury trauma should be kept in mind ( early hypotension and hypoxia secondary brain injury, late delay in surgery can lead to increased rates of pulmonary complications including pneumonia and acute respiratory distress syndrome * proper communication between the trauma surgical, neurosurgical, and anesthesia teams is essential As a general rule * In unresponsive hypotension, control of hemorrhage precedes the cranial pathology management. In other cases priorty goes to head injury management Orthopedic injuries should be treated as safely as possible, a discussion between the anesthesiologist and the orthopedic versus the neurosurgeon should be conducted before ortho surgerys

In Operative room positioning Special care to cervical spine, avoid hyperflexion hyperextension , keep in neutral position Aim for adequate access to all teams ( anesthesia as well as operative) Position should be decided before draping and sterilizing. For most laprotomies supine position is an adequate for both cranial and abdominal procedures Thoracotomy is more challenging due to lateral position implementing. A study found that 82 % of general surgeons and 100 % of neurosurgeons found a “hybrid” craniotomy/laparotomy position acceptable for simultaneous procedures(Hernandez AM, Roguski M, Qiu RS, et al. Surgeons perspectives on optimal patient positioning during simultaneous cranial procedures and exploratory laparotomy. South Med J. 2013;106(12):679–83.

Thanks a lot have a good day