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

2. In memory of Dr. Tomasz Skibinski

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

4. “He who wishes to be a surgeon, must first go to war”. Hippocrates

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

6. 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

7. 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

8. 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, pp. 49,53).

9. 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

10. 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

11. 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

12. 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.

13. Thanks a lot have a good day