Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXII: Craniocerebral Injury

Emergency Management

United States Department of Defense

After the airway is protected, shock is treated or prevented by placing two large-bore venous catheters and infusing plasma, normal saline, or lactated Ringer's solution. The stomach should be emptied and the bladder catheterized. NaHC0₃, 1meq/kg is given for metabolic acidosis, and should be administered empirically when respiration has been compromised.

In the face of neurological deterioration, some time can be gained to prepare for operation upon an expanding intracranial mass by administering furosemide, 40mg IV, followed by mannitol 1gm/kg. This will result in dehydration and must be carefully watched. The osmolarity should not be permitted to rise above 305 mOsm/l. Since the value of steroids is unproven, steroids need not be administered.

Anticonvulsant prophylaxis is begun with phenytoin, 1 gm IV push over 15-20 minutes. Cardiac arrhythmias may result from too rapid administration. If given as an IV solution, phenytoin must only be diluted in 50cc normal saline, and dripped in over 20 minutes. Any other solution of phenytoin will precipitate. A maintenance dose of 400 mg/day is required.

The use of narcotics or sedation in the spontaneously breathing patient is contraindicated.

Intravenous antibiotics are administered in meningeal doses for one week. Although the efficacy of prophylactic antibiotics has not been proven, the use of antibiotics in this setting is considered therapeutic and represents a full course of treatment for contamination of injured tissue and CSF by a foreign body. Which antibiotics to use will depend on local conditions and the types of organisms that are encountered in any given situation.  

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Operational Medicine 2001

Health Care in Military Settings

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