Trauma Management & EVD Placement

Overview

This lecture covers recommendations for trauma management, specifically focusing on brain trauma foundation guidelines and practical steps for external ventricular drain (EVD) placement.

Brain Trauma Guidelines

• Refer to the Brain Trauma Foundation guidelines for consensus on trauma management.
• Level 2b evidence supports ICP (intracranial pressure) monitoring to reduce in-hospital mortality, despite lack of level 1 evidence.
• Previous guidelines recommended ICP monitoring for abnormal CT with low GCS (Glasgow Coma Scale) or normal CT with very low GCS and hypotension.
• Institutional practice often follows monitoring for patients with abnormal CT and low GCS, indicating diffuse brain injury.

ICP Monitoring and Patient Assessment

• Diffuse brain injury may only be detected by patient examination and ongoing ICP monitoring.
• Monitoring is important for injuries that may evolve over time.

EVD Placement Procedure

• Place the patient supine with the head of bed elevated (Fowler's position) and head neutral.
• Identify and mark Kocher's point (right frontal area) as the insertion site.
• Make an incision, perform a twist drill, open the dura, pass the catheter, and tunnel it under the scalp.
• Attach the catheter to a manometer.
• Use hand landmarks: index finger at the nasion, thumb aimed at the ear, to find Kocher's point (a few centimeters in front of the coronal suture).
• Aim the catheter perpendicular to the bone and towards the contralateral medial canthus and tragus for correct trajectory.
• Target the right lateral ventricle towards the foramen of Monro for correct EVD placement.

Key Terms & Definitions

• Brain Trauma Foundation Guidelines — Consensus recommendations for the management of traumatic brain injury.
• ICP Monitoring — Tracking intracranial pressure to detect and manage brain injury.
• GCS (Glasgow Coma Scale) — Scale assessing consciousness level in trauma patients.
• Kocher's Point — Standard cranial entry point for ventricular catheter placement.
• EVD (External Ventricular Drain) — Device for draining cerebrospinal fluid from the ventricles to manage ICP.

Action Items / Next Steps

• Review the latest Brain Trauma Foundation guidelines.
• Practice identifying Kocher's point using hand landmarks.
• Understand EVD placement steps and indications for ICP monitoring.