Trauma

Question 1

What are the indications for surgery for an epidural hematoma?

Answer 1

-Any EDH with size greater than 30cm3
Otherwise thickness greater than 15mm and midline shift greater than 5mm, GCS 8 or less, focal neurologic deficit should be considered for surgery

Question 2

Who can be monitored for epidural hematoma?

Answer 2

EDH:
-less than 30cm3
-less than 15mm in thickness
-less than 5mm midline shift 
-GCS greater than 8 
-without focal deficit 
should be managed with serial imaging

Question 3

When to perform craniotomy for cerebral contusion?

Answer 3

Progressive neurologic deficit, medically refractory IC-HTN or w significant mass effect

• volume greater than 50cm3
• GCS 6-8 with frontal or temporal ICH volume greater than 20cm3 with midline shift 5mm or greater and or with cistern compression on CT

Question 4

What are the surgical indications for evacuation of acute subdural hematoma?

Answer 4

• any SDH with thickness greater than 10mm or midline shift greater than 5mm
• SDH less than 10mm, midline shift less than 5mm should undergo surgery if:
  1. GCS drops by 2 points from time of injury to admission
  2. Pupils are symmetric or fixed and dilated
  3. ICP greater than or equal to 20

Question 5

Which patients w small SDH need ICP monitoring?

Answer 5

If GCS is less than 9

Question 6

What is the “four hour rule”?

Answer 6

Based on a 1981 series of 82 patients with acute subdural hematoma which showed that patients operated on within 4 hours of injury had 30% mortality compared to 90% if surgery was delayed by more than 4 hours

Question 7

How to identify Kocher’s Point in children?

Answer 7

2-3cm lateral from the midline (midpupillary line)
And 1-2 cm anterior to the coronal suture
In small infants, the corner of the anterior fontanelle can be a good landmark

Question 8

Where to place a Frazier burr hole for EVD or shunt?

What is the trajectory of the catheter?

Answer 8

3cm lateral from the midline and 6cm superior to the inion
Follow a point from the midpupillary line parallel to the sagittal suture until it intersects a line extending posteriorly from the top of the pinna

Trajectory: insert the catheter parallel to the skull vase and aim for the glabella- middle of the forehead

Question 9

Where is Keen’s point?

Answer 9

3cm posterior and superior to the pinna