The decision to perform a neurosurgical intervention in an austere location is best made with the telemedicine support of a neurosurgeon.
Telemedicine consult may be obtained from the closest neurosurgeon in the evacuation chain. In addition, worldwide neurosurgery consultation is available at Advanced Virtual Support for Operational Forces (ADVISOR): Synchronous, 24/7 provider to provider consultation service for operational forces (833) 238-7756 or DSN (312) 429-9089
If CT scan is available, obtaining a stat CT head (without contrast) will greatly facilitate the appropriate treatment and intervention.
When a CT scan is not available, there is a high risk that procedures may be performed without correct localization of pathology. It is therefore necessary to make an accurate diagnosis, appropriately resuscitate, and exhaust all medical interventions prior to performing a procedure in this environment. Regardless of whether a CT scan is available, the indications for surgical intervention are clinical.
When To Perform Cranial Procedures
Perform only:
Indications:
When Not To Perform Cranial Procedures
Checklist/Procedures For Craniectomy
Cranial Procedures For Closed Head Injury14, 15
*If no CT scan is available, an accurate neurological examination must be obtained for the purposes of localizing the lesion. A skull X-ray may improve localization in cases of skull fracture or penetrating brain injury.*
*Proper positioning of the patient is essential.*
*If pre-operative imaging is not available, exploratory burr holes should be made over the frontal, temporal and parietal convexities using the cranial drill for the purposes of identifying a hematoma. Electric drills are carried by some Role 2 teams. Manual drill/saw with Hudson Brace and Gigli saw is an extremely time-consuming and energy intensive process*
*Once the decision to proceed with craniectomy is made, the dura must be carefully separated from the inner table of the skull (Penfield 1-3 instruments) and the burr holes connected with the Gigli saw or electric drill using either a side-cutting bit or a “matchstick” bit.*
*If the brain herniates rapidly after dural opening, close the scalp immediately due to risk of cyclical and catastrophic extracranial herniation, which is associated with a high mortality *
Cranial Procedures For Penetrating Head Injury
Penetrating brain injury is one of the most challenging indications for cranial procedures performed by neurosurgeons.
If cranial contents are herniated from either the entry or exit wound, allow this to continue. Do not close the wound. Recommend coverage with a loose, clean dressing (Kerlix soaked in saline) and initiate and maintain IV antibiotic coverage with central nervous system penetration.
Adequately resuscitate as necessary, and transport at the soonest opportunity.
If evacuation to a higher role of care is not possible, recognize that intervention in this case may be futile.