1. Primary Survey
Goal of Primary Survey:
Identify and manage life-threatening injuries — NOT to document all injuries.
Life-Threatening Conditions by System
| System | Life Threats |
|---|---|
| A - Airway | Airway obstruction, Aspiration |
| B - Breathing | Tension Pneumothorax, Massive haemothorax, Severe flail chest, Sucking chest wound |
| C - Circulation | Hemorrhagic shock, Cardiac tamponade, Blunt aortic injury |
| D - Disability | Severe head injury, Spinal cord injury |
Trauma Team Roles
| Role | Position | Responsibilities |
|---|---|---|
| Team Leader | Foot of bed | Coordinates, executes management plan |
| Airway Doctor | Head of bed | Airway assessment, intubation |
| Procedure Doctor | Left side | Breathing assessment, chest drains |
| Circulation Doctor | Right side | Fluid resuscitation, circulation assessment |
A - Airway Assessment
- Check oropharynx (open mouth, say "ah")
- Assess vocalisation (hoarse voice = concerning)
- Maintain C-spine precautions
- Suction if blood/vomit present
- Jaw thrust / chin lift if needed
Most common indication for urgent intubation in trauma:
Head injury with GCS (Glasgow Coma Scale) less than 9 (Decreased consciousness → tongue falls back → airway obstruction)
Airway Plan
- Plan A: RSI (Rapid Sequence Intubation) with video laryngoscopy (CMAC)
- Plan B: Bougie-assisted intubation
- Plan C: Laryngeal mask airway (Laryngeal Mask Airway) (temporary ventilation)
- Plan D: Surgical airway (cricothyroidotomy)
B - Breathing Assessment
- Tracheal position (most important first step)
- Chest wall inspection
- Percussion
- Auscultation
- Respiratory rate & SpO₂
Clinical Signs of Chest Pathology
| Tension Pneumothorax | Massive Haemothorax | |
|---|---|---|
| Trachea | Deviated AWAY | Deviated AWAY |
| Percussion | Hyper-resonant | Dull |
| Breath sounds | Absent | Absent |
| JVP (Jugular Venous Pressure) | Raised | Raised |
| BP (Blood Pressure) | Hypotensive | Hypotensive |
Percussion is the key differentiator:
- Hyper-resonant = air (pneumothorax)
- Dull = fluid (haemothorax)
C - Circulation Assessment
Q: In trauma circulation, first assess [___], not the monitor. A: peripheries and capillary refill
Sources of Major Haemorrhage (Primary Survey)
- Scalp / External — visible bleeding
- Chest — haemothorax (CXR (Chest X-Ray), EFAST)
- Abdomen — solid organ injury (EFAST)
- Pelvis — pelvic fracture (pelvic XR)
- Long bones — femur fractures
- Floor (external)
- Chest
- Abdomen
- Pelvis
- Long bones
Cardiac Tamponade
| Signs | Findings |
|---|---|
| Beck's Triad | Hypotension, Raised JVP (Jugular Venous Pressure), Muffled heart sounds |
| ECG (Electrocardiogram) | Low voltage QRS, Electrical alternans |
| EFAST | Pericardial fluid |
D - Disability Assessment
- Pupillary response
- Glasgow Coma Scale (Glasgow Coma Scale)
- Gross motor/sensory exam
- Post-traumatic amnesia testing
Signs of Raised ICP (Intracranial Pressure):
- Decreasing GCS (Glasgow Coma Scale)
- Unequal pupils
- Cushing reflex (bradycardia + hypertension)
- Seizures
- Recurrent vomiting
2. Secondary Survey
Secondary Survey: Head-to-toe examination performed AFTER primary survey stabilisation.
Goal: Document ALL injuries and determine need for further investigations.
- A - Allergies
- M - Medications
- P - Past illnesses
- L - Last meal
- E - Events / Environment
Includes: Full physical exam, log roll, imaging as indicated
3. Hemorrhagic Shock
Q: Shock = inadequate [___]. A: perfusion
Clinical Signs of Hemorrhagic Shock
| Progression | Signs |
|---|---|
| Early | Cold, anxious, grey, sweaty, ↓ cap refill (Capillary Refill Time) |
| Moderate | Tachycardia, ↓ pulse pressure |
| Severe | Hypotension, unresponsive to fluids |
| Late | Lethargy, ↓ mental state |
| Pre-terminal | Bradycardia, cardiac arrest |
Q: In young trauma patients, BP (Blood Pressure) may remain normal until ~[___]% blood volume loss. A: 30
Causes of Hypotension in Trauma
| System | Causes |
|---|---|
| Airway | Sedation/paralysis unmasking hypovolaemia |
| Breathing | Tension Pneumothorax |
| Circulation | Haemorrhage, Cardiac tamponade, Blunt aortic injury |
| Disability | Neurogenic shock (high cervical injury) |
Trauma hypotension: assume haemorrhagic shock until proven otherwise.
Don't attribute hypotension to "vagal response" or "comorbidities" until haemorrhage excluded.
Active Shock Management
- External bleeding: Direct pressure, packing, tourniquets
- IV (Intravenous) access: 2 large-bore cannulae
- Bloods: Urgent crossmatch (6 units)
- Fluid challenge: 1-2L crystalloid maximum
- Haemothorax: Chest drain
- Pelvic fracture: Pelvic binder
- Long bone fracture: Reduction and splinting
- Contact surgeon EARLY
Permissive Hypotension
In penetrating trauma:
Target SBP (Systolic Blood Pressure) 70-90 mmHg until bleeding controlled. Aggressive resuscitation to "normal" BP (Blood Pressure) → dislodges clots → more bleeding.
4. Massive Transfusion
Massive Transfusion Definition (National Blood Authority):
Replacement of the patient's entire blood volume within 24 hours, OR transfusion of >4 units RBCs within 1 hour with ongoing bleeding expected.
This activates the Massive Transfusion Protocol for streamlined blood product delivery.
The Lethal Triad
Lethal Triad of Trauma:
- Hypothermia → impairs clotting
- Acidosis → from poor perfusion
- Coagulopathy → from tissue damage
Each worsens the others → vicious cycle → death
Acute Traumatic Coagulopathy
Acute traumatic coagulopathy: 25% of major trauma patients arrive already coagulopathic before any fluids are given.
Mortality is 4× higher in coagulopathic patients. Mechanism: tissue injury + shock activates protein C and hyperfibrinolysis.
Mechanism:
- Endothelial damage → thrombomodulin release
- Activated Protein C → anticoagulant effect
- ↑ Plasmin → hyperfibrinolysis (clots break down)
- Result: Can't form clots + clots that form break down
Principles of Massive Transfusion
You can't turn salty water into blood!
Crystalloid resuscitation → dilutional coagulopathy → worse bleeding
1:1:1 Ratio
| Product | Ratio |
|---|---|
| Packed Red Blood Cells | 1 |
| Fresh Frozen Plasma | 1 |
| Platelets | 1 |
Plus: Cryoprecipitate for fibrinogen
US Military data:
High FFP:PRBC ratio (close to 1:1) = significantly improved survival compared to low ratio.
Tranexamic Acid (Tranexamic Acid)
TXA (Tranexamic Acid) = Antifibrinolytic
Blocks plasmin → prevents clot breakdown
CRASH-2 trial: 1.5% absolute mortality reduction in bleeding trauma
Give EARLY (within 3 hours of injury)
Trauma TXA dosing: 1 g IV bolus then 1 g over 8 hours, within 3 hours of injury.
What is the correct TXA (Tranexamic Acid) regimen?
Massive Transfusion Protocol
- Activated when major bleeding expected
- Blood bank provides pre-made "trauma packs"
- Reduces delays in getting products
- 1:1:1 ratio maintained automatically
- O-negative PRBCs + AB plasma for uncrossmatched patients
Code Crimson
Hospital protocol activated for:
- Severe haemodynamic instability unresponsive to initial fluids
- Facilitates immediate OR / interventional radiology access
- Pre-emptive blood bank preparation
5. Traumatic Brain Injury
Primary vs Secondary Brain Injury
| Primary | Secondary |
|---|---|
| Occurs at time of injury | Occurs after initial injury |
| Mechanical damage | Ischaemia, hypoxia, oedema |
| Prevention (seatbelts, helmets) | ICU (Intensive Care Unit) management |
Types of Intracranial Haematoma
| Type | Shape on CT (Computed Tomography) | Mechanism |
|---|---|---|
| Extradural | Biconvex (lens-shaped) | Skull fracture → middle meningeal artery |
| Subdural | Crescent (concave) | Bridging vein tear (elderly, falls) |
| Intracerebral | Within parenchyma | Direct contusion |
CT (Computed Tomography) Head Interpretation
CT (Computed Tomography) density basics:
- Bright (hyperdense) = blood, bone, calcification
- Dark (hypodense) = air, fat, oedema, CSF
- Grey = brain parenchyma
Systematic approach:
- Blood — look for hyperdense areas (fresh blood is WHITE)
- Brain — symmetry, sulci effaced, midline shift
- Bones — fractures in bone window
- CSF — ventricle size, hydrocephalus
CT head systematic check: look for blood (hyperdense acute haemorrhage).
CT head systematic check: assess brain symmetry, sulci/gyri, and grey-white differentiation.
CT head systematic check: inspect bone windows for fractures.
CT head systematic check: review CSF spaces (ventricles, cisterns) for hydrocephalus.
CT head systematic check: assess mass effect (midline shift, herniation).
Key CT (Computed Tomography) findings:
| Finding | Appearance | Significance |
|---|---|---|
| Midline shift | Falx cerebri displaced >5mm | Mass effect → herniation risk |
| Effaced sulci | Loss of normal grooves | Cerebral oedema |
| Hyperdense MCA | Bright vessel | Acute MCA stroke (clot in artery) |
| Loss of grey-white | Poor differentiation | Hypoxic brain injury |
| Uncal herniation | Medial temporal displaced | Neurosurgical emergency |
Cerebral Perfusion Pressure (Cerebral Perfusion Pressure)
CPP (Cerebral Perfusion Pressure) = MAP (Mean Arterial Pressure) − ICP (Intracranial Pressure)
Target CPP (Cerebral Perfusion Pressure): 60-70 mmHg (50-70 acceptable)
- CPP (Cerebral Perfusion Pressure) under 50 → ischaemia
- CPP (Cerebral Perfusion Pressure) over 70 → increased ARDS (Acute Respiratory Distress Syndrome) risk
ICP (Intracranial Pressure) Management
Basic Measures (All TBI (Traumatic Brain Injury))
- Avoid hypoxia (intubate if GCS (Glasgow Coma Scale) under 9)
- Avoid hypotension
- Avoid hypercapnia (target PaCO₂ ~35)
- Avoid hyperthermia
Tiered Therapy
| Tier | Interventions |
|---|---|
| Tier 1 | Head up 30°, Sedation/analgesia, CSF drainage (if EVD), Mild hyperventilation (PaCO₂ 35) |
| Tier 2 | Neuromuscular blockade, Osmotherapy (mannitol, hypertonic saline) |
| Tier 3 | Barbiturate coma, Therapeutic hypothermia, Aggressive hyperventilation, Decompressive craniectomy |
Osmotherapy
| Agent | Mechanism |
|---|---|
| Mannitol | Osmotic diuresis → draws water out of brain |
| Hypertonic saline | Creates osmotic gradient → reduces cerebral oedema |
Secondary Causes of Raised ICP (Intracranial Pressure)
- Hypercapnia → cerebral vasodilation
- Seizures
- Fever
- Cervical collar → venous congestion
The DECRA Trial
Decompressive craniectomy can reduce ICP (Intracranial Pressure) but resulted in worse functional outcomes (DECRA trial). Don't fixate on the ICP (Intracranial Pressure) number alone.
6. Trauma Clinical Skills
Intraosseous (Intraosseous) Access
When IV (Intravenous) access fails in resuscitation, use intraosseous (IO (Intraosseous)) access for rapid vascular access (preferred over endotracheal drug delivery).
Indications
- Failure to gain IV (Intravenous) access in trauma/burns/shock/resuscitation
- Unable to obtain IV (Intravenous) access within 90 seconds (2 attempts) in paediatrics
- Any urgent need for vascular access when cannulation is difficult
Insertion Sites
| Site | Location | Notes |
|---|---|---|
| Proximal tibia | 1-2 cm below tibial tuberosity, medial flat surface | Most common, avoid growth plate in children |
| Distal tibia | Medial malleolus | Alternative site |
| Proximal humerus | Greater tubercle | Good for adults |
Almost any drug or fluid that can go IV (Intravenous) can also go IO (Intraosseous) — including blood products, vasopressors, and anaesthetic agents.
Pelvic Binder
Purpose: Reduce pelvic volume → tamponade bleeding → prevent exsanguination
Apply early if pelvic fracture suspected in shocked patient.
Application
- Position at level of greater trochanters (NOT iliac crests)
- Tighten to close pelvis
- Do NOT remove until haemodynamically stable
- Do NOT log roll if pelvic fracture suspected (open-book → disrupts clot)
Do NOT place pelvic binder over iliac crests!
The greater trochanters are the correct level — binding too high is ineffective.
EFAST (Extended Focused Assessment with Sonography in Trauma)
EFAST answers one question: Is there FREE FLUID where it shouldn't be?
Not a complete abdominal exam — just looking for blood/fluid in trauma.
Views
| View | What You're Looking For |
|---|---|
| RUQ (Morison's pouch) | Hepatorenal space — most sensitive for free fluid |
| LUQ (Splenorenal) | Perisplenic and splenorenal fluid |
| Pelvis (Suprapubic) | Retrovesical / rectouterine pouch |
| Subxiphoid/Parasternal | Pericardial effusion (tamponade) |
| Bilateral lungs | Pneumothorax (absent lung sliding) |
Morison's pouch is the most dependent space when supine — fluid accumulates here first. If Morison's is negative, significant haemoperitoneum is unlikely.
Ultrasound Signs
| Finding | Appearance |
|---|---|
| Free fluid | Anechoic (black) stripe between organs |
| Pneumothorax | Absent lung sliding, "barcode sign" on M-mode |
| Tamponade | Pericardial fluid + RV (Right Ventricle) diastolic collapse |
EFAST limitations:
- Cannot quantify bleeding accurately
- Retroperitoneal bleeding not visible
- Hollow viscus injury may not produce free fluid
- Operator-dependent
Needle Thoracostomy
| Parameter | Details |
|---|---|
| Indication | Tension pneumothorax |
| Option 1 | 2nd ICS (Inhaled Corticosteroid) at/just lateral to the mid-clavicular line |
| Option 2 | 4th/5th ICS (Inhaled Corticosteroid) just anterior to the mid-axillary line |
| Device | Long, large-bore cannula (ideally ~8 cm, 12–14G) |
| Endpoint | Rush of air, improved haemodynamics |
| Follow-up | Intercostal catheter (chest drain) |
Lateral sites often have a higher success rate because the chest wall can be thinner than at the 2nd ICS (Inhaled Corticosteroid). In traumatic arrest (and where trained), finger thoracostomy is often preferred to needle decompression.
7. Burns
Classification
| Degree | Depth | Appearance | Sensation |
|---|---|---|---|
| Superficial | Epidermis only | Red, dry, no blisters | Painful |
| Partial thickness | Epidermis + dermis | Blisters, moist, pink | Very painful |
| Full thickness | Through dermis | White/brown, leathery, dry | Painless (nerves destroyed) |
Fluid Resuscitation: Parkland Formula
Parkland Formula:
4 mL × body weight (kg) × %TBSA burned = total fluid in first 24 hours
Use Hartmann's solution (or Ringer's lactate)
Critical Timing for Burns Fluid Administration:
- Give 50% of calculated fluid over 8 hours (from time of injury)
- Give remaining 50% over 16 hours
Time from INJURY, not from presentation!
If a patient presents 4 hours after injury, the first half of fluid must be given in the remaining 4 hours to catch up.
Indications for Referral to Burns Unit
-
Full thickness burns >5% TBSA
-
Partial thickness burns >10% TBSA
-
Burns to face, hands, feet, genitalia, major joints
-
Circumferential burns
-
Chemical, electrical, or inhalation burns
-
Burns with associated trauma
-
Children, elderly, or significant comorbidities
WarningCircumferential full thickness burns can cause compartment syndrome.
Full thickness circumferential burns → eschar has no elasticity → swelling cannot be accommodated → vascular compromise.
May require escharotomy (surgical incision through burn eschar).
8. Haemorrhagic Shock Classification
Haemorrhagic Shock Classes (ATLS):
| Parameter | Class I | Class II | Class III | Class IV |
|---|---|---|---|---|
| Blood loss (mL) | <750 | 750–1500 | 1500–2000 | >2000 |
| Blood loss (%) | <15% | 15–30% | 30–40% | >40% |
| Heart Rate (Heart Rate) | <100 | 100–120 | 120–140 | >140 or bradycardia |
| Blood Pressure (Blood Pressure) | Normal | Normal | Decreased | Very decreased |
| Pulse pressure | Normal | Narrowed | Narrowed | Narrowed |
| Respiratory Rate (Respiratory Rate) | 14–20 | 20–30 | 30–40 | >35 |
| Urine output (mL/hr) | >30 | 20–30 | 5–15 | Negligible |
| Mental status | Slightly anxious | Anxious | Confused | Lethargic/obtunded |
| Fluid replacement | Crystalloid | Crystalloid | Crystalloid + blood | MTP activation |
BP is a LATE sign of shock!
Class I-II shock (up to 30% blood loss) may have normal blood pressure. Look for subtle signs: anxiety, tachycardia, narrowed pulse pressure, delayed cap refill.
Oxygen Delivery Equation
DO₂ = CO × CaO₂
Where:
- CO = Cardiac Output (HR × SV)
- CaO₂ = (1.34 × Hb × SaO₂) + (0.003 × PaO₂)
Haemorrhagic shock reduces DO₂ by decreasing both CO (hypovolaemia) and CaO₂ (anaemia from blood loss).
9. Anaesthesia in Trauma
Rapid Sequence Induction (RSI) in Trauma
RSI in trauma differs from elective RSI:
- Haemodynamic instability → induction agents unmask hypovolaemia
- Full stomach → aspiration risk (cricoid pressure controversial)
- Cervical spine → MILS (manual in-line stabilisation) limits mouth opening
- Facial/airway trauma → difficult airway expected
Modified RSI for Trauma
| Step | Agent | Notes |
|---|---|---|
| Pre-oxygenation | 100% O₂ for 3 min | Delays desaturation during apnoea |
| Induction | Ketamine 1-2 mg/kg IV | Preserves haemodynamics (sympathomimetic) |
| Paralysis | Rocuronium 1.2 mg/kg IV | Rapid onset (~60 sec); sugammadex reversible |
| Cricoid pressure | Sellick's manoeuvre | Controversial but still used in many centres |
Why ketamine in trauma?
Ketamine is a sympathomimetic — it stimulates catecholamine release, maintaining heart rate and blood pressure. Propofol/thiopentone cause vasodilation → cardiovascular collapse in hypovolaemic patients.
Hemostatic Resuscitation
Principles of Hemostatic Resuscitation:
- Limit crystalloid — max 1-2L (avoid dilutional coagulopathy)
- Early blood products — 1:1:1 ratio (RBC:FFP:Plt)
- Tranexamic acid — 1g bolus within 3 hours (CRASH-2)
- Calcium replacement — citrate in blood products chelates calcium
- Warm all products — prevent hypothermia (lethal triad)
- Point-of-care testing — ROTEM/TEG to guide therapy
ROTEM and TEG
ROTEM (Rotational Thromboelastometry) and TEG (Thromboelastography) are point-of-care viscoelastic tests that assess:
- Clot initiation (clotting time)
- Clot formation (clot firmness)
- Fibrinolysis (clot stability)
Results guide targeted therapy: fibrinogen low → give cryoprecipitate; platelets low → give platelets; hyperfibrinolysis → give TXA.
Permissive Hypotension in Trauma
Target SBP (Systolic Blood Pressure) 80-90 mmHg in penetrating/uncontrolled haemorrhage until surgical haemostasis.
EXCEPTION: Head injury — target SBP (Systolic Blood Pressure) >100 mmHg to maintain cerebral perfusion pressure (Cerebral Perfusion Pressure).
Do NOT use permissive hypotension in TBI!
The brain needs adequate perfusion pressure. A single episode of hypotension doubles mortality in severe TBI.
Massive Transfusion Protocol (Expanded)
| Component | Details |
|---|---|
| Trigger | Anticipated need for >4 units RBC in 1 hour with ongoing bleeding |
| Initial pack | 4 units PRBCs + 4 units FFP |
| Ongoing | Add platelets (1 adult dose per 4 RBC units) + cryoprecipitate |
| Calcium | 10 mL calcium chloride 10% per 4 units transfused |
| Temperature | Warm all products through fluid warmer |
| Monitoring | ROTEM/TEG, fibrinogen, ionised calcium, pH, lactate |
10. TBI Management in ICU (Expanded)
Primary vs Secondary Brain Injury
| Feature | Primary Injury | Secondary Injury |
|---|---|---|
| Timing | Moment of impact | Hours to days after |
| Mechanism | Mechanical (shearing, contusion) | Ischaemia, hypoxia, oedema, inflammation |
| Prevention | Seatbelts, helmets, road safety | ICU management |
| Reversibility | Irreversible | Potentially preventable |
The "5 H's" to Avoid in TBI
- Hypoxia — PaO₂ <60 mmHg or SpO₂ <90%
- Hypotension — SBP <90 mmHg (single episode doubles mortality)
- Hyperthermia — fever increases cerebral metabolic rate 8% per °C
- Hypercapnia — PaCO₂ >45 → cerebral vasodilation → ↑ICP
- Hypoglycaemia — glucose <4 mmol/L → neuronal injury
CPP-Directed Therapy
CPP = MAP − ICP
| Target | Value | Consequence if violated |
|---|---|---|
| CPP | 60–70 mmHg | <50 → ischaemia; >70 → ↑ARDS risk |
| ICP | <22 mmHg | >22 sustained → start tiered therapy |
| MAP | Titrate to CPP target | Use vasopressors (noradrenaline) if needed |
| PaCO₂ | 35–40 mmHg | <30 → vasoconstriction → ischaemia |
Expanded Tiered ICP Management
| Tier | Intervention | Mechanism | Monitoring |
|---|---|---|---|
| 0 | Head up 30°, neutral neck | ↑ venous drainage | Baseline |
| Adequate sedation (propofol/midazolam + fentanyl) | ↓ metabolic demand | Sedation score | |
| Normocapnia (PaCO₂ 35-40) | Prevent vasodilation | End-tidal CO₂ + ABG | |
| Normothermia | ↓ metabolic demand | Core temperature | |
| Seizure prophylaxis (levetiracetam) | Prevent ↑ICP from seizure | EEG if available | |
| 1 | EVD drainage of CSF | ↓ CSF volume (Munroe-Kellie) | ICP waveform |
| Mild hyperventilation (PaCO₂ 30-35) | Cerebral vasoconstriction | ABG, ETCO₂ | |
| 2 | Osmotherapy: Mannitol 20% (0.25-1 g/kg) | Osmotic gradient → draws water from brain | Serum osmolality <320 |
| Osmotherapy: Hypertonic saline 3% (150-250 mL) | ↑ serum Na → draws water from brain | Serum Na <155 | |
| Neuromuscular blockade | Prevents coughing/bucking → ↓ICP | Train-of-four | |
| 3 | Barbiturate coma (thiopentone) | ↓ cerebral metabolic rate 50% | EEG burst suppression |
| Therapeutic hypothermia (33-35°C) | ↓ metabolic demand | Core temperature | |
| Decompressive craniectomy | ↑ intracranial volume | Surgical decision |
11. Brain Imaging in Trauma
CT Interpretation: Intracranial Haemorrhage Patterns
| Type | CT Appearance | Vessel | Key Feature | Surgical Indication |
|---|---|---|---|---|
| Extradural | Biconvex (lens) | Middle meningeal artery | Doesn't cross sutures | >30 mL, >15mm thick, midline shift >5mm |
| Subdural | Crescent (concave) | Bridging veins | Crosses sutures, not midline | >10mm thick or midline shift >5mm |
| Subarachnoid (Subarachnoid Haemorrhage) | Blood in sulci/cisterns | Berry aneurysm/trauma | Basal cistern blood | Aneurysm: coil/clip |
| Intraparenchymal | Within brain substance | Contusion vessels | Often temporal/frontal | Large with mass effect |
EDH vs SDH — Key Differences
| Feature | Extradural | Subdural |
|---|---|---|
| Shape | Biconvex (lens) | Crescent (concavo-convex) |
| Crosses sutures? | No (dura attached at sutures) | Yes (under dura, free to spread) |
| Typical patient | Young, temporal bone fracture | Elderly, falls, anticoagulants |
| Vessel | Middle meningeal artery (arterial) | Bridging veins (venous) |
| Clinical course | "Lucid interval" → rapid deterioration | Gradual decline (or acute if arterial) |
| Urgency | Neurosurgical emergency | Acute: emergency; Chronic: semi-urgent |
The "Lucid Interval" in EDH:
Impact → loss of consciousness → apparent recovery → rapid deterioration (expanding haematoma → herniation → death).
This is why head injury observation is critical — patients can appear well before catastrophic deterioration.
Surgical Indications for Intracranial Haemorrhage
General indications for neurosurgical evacuation:
- EDH: Thickness >15mm, or midline shift >5mm, or GCS drop
- SDH: Thickness >10mm, or midline shift >5mm
- ICH: Volume >30 mL in accessible location with mass effect
- Any: Pupillary asymmetry (uncal herniation)
12. Practice Questions
What is the most appropriate next step?
What is the most appropriate immediate action?
Week 5 Study Checklist
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