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Q: Severe head injury questions ( Answered 4 out of 5 stars,   2 Comments )
Subject: Severe head injury questions
Category: Health > Medicine
Asked by: catoms-ga
List Price: $15.00
Posted: 01 Feb 2003 07:03 PST
Expires: 03 Mar 2003 07:03 PST
Question ID: 156032
kevinmd - is it recommended to put patients who have suffered severe
head trauma into drug induced comas?  what kinds of setbacks/problems occur
if there is swelling of/in the brain as a result of severe head

Request for Question Clarification by kevinmd-ga on 01 Feb 2003 09:45 PST
Hello catoms,
Thanks for requesting me to answer your question.  I am currently out
of town - I will research your question later tonight or early

Kevin, M.D.
Subject: Re: Severe head injury questions
Answered By: kevinmd-ga on 01 Feb 2003 21:11 PST
Rated:4 out of 5 stars
Thanks for requesting me to answer this question.  

1) "Is it recommended to put patients who have suffered severe 
head trauma into drug induced comas?"

Drug induced comas are most likely done by barbituates.  From
Principal Health News:
"A barbiturate-induced coma, or barb coma, is a temporary state of
unconsciousness brought on by a controlled dose of a barbiturate drug,
usually pentobarbital or thiopental.

Barbiturate comas are used to protect the brain during major brain
surgery, such as the removal of arteriovenous malformations or
aneurysms. Coma may also be induced to control intracranial
hypertension caused by brain injury.

Barbiturates reduce the metabolic rate of brain tissue, as well as the
cerebral blood flow. With these reductions, the blood vessels in the
brain narrow, decreasing the amount of swelling in the brain. With the
swelling relieved, the pressure decreases and some or all brain damage
may be averted.

Controversy exists, however, over the benefits of using barbiturates
to control intracranial hypertension. Some studies have shown that
barbiturate-induced coma can reduce intracranial hypertension but does
not necessarily prevent brain damage. Furthermore, the reduction in
intracranial hypertension may not be sustained."

Here are the indication for a barbituate-induced coma trom
"Brain damage resulting from head injury is the leading cause of death
among individuals younger than 24 years of age. The most hazardous is
increased ICP. High-dose barbiturates are used to control intracranial
hypertension in selected patients. ICP is decreased due to decrease in
CBV due to vasoconstriction caused by increase in cerebrovascular


- Potentially survivable head injury 
- No surgically treatable lesion accounting for intracranial
hypertension (except when used for preparation for surgery)
- Other conventional therapies of controlling ICP have failed
(posture, hyperventilation, osmotic and tubular diuretics,
- ICP > 20 to 25 mmHg for more than 20 min, or >40 mmHg at any time 
- Unilateral cerebral hemispheric edema with significant (>.7 mm)
shift of midline structures shown on CT
- A low Glasgow Coma score"

Dr. Wetzel of the Children's Hospital in Los Angeles recommends
barbituate-induced coma in the following cases:
"Barbiturate-induced coma should be considered if intracranial
pressure is not controlled by a combination of:

- osmotherapy 
- temperature regulation 
- sedation" suggests using barbituate-induced coma when all
conventional therapies have failed on controlling increased
intra-cranial pressure:
"Barbiturate therapy lowers the ICP and exerts cerebral protection
through several mechanisms: alterations in vascular tone, inhibition
of free radical mediated lipid peroxidation, and suppression of
metabolism. By lowering the metabolic demands, it decreases the
cerebral blood flow and related cerebral blood volume providing
beneficial effects on the ICP and global cerebral perfusion. However
several studies have shown that barbiturate therapy does not improve
outcome when compared to mannitol, empiric coma therapy or when used
as prophylactic treatment of ICP.

The only patients to respond favorably to barbiturate ICP control seem
to be those in which the cerebrovascular autoregulatory response is
preserved. Therefore their use should be reserved only for intractable
increased ICP when all conventional medical therapies have failed. The
goal of barbiturate therapy should be directed to achieve
electroencephalographic burst suppression as maximal reduction in
cerebral blood flow and metabolism occurs at this level. The main side
effect remains hypotension and cardiovascular toxicity. Hence when
used it is generally recommended that invasive hemodynamic monitoring
be in place."

The actual data studying barbituate-induced coma is conflicting.  A
study by Lee et al (1994), suggests that in patients who fail
conservative therapy, there may be a survival benefit when using a
barbituate coma:
"The purpose of this study was to evaluate the role of barbiturate
therapy as an adjunctive treatment for control of intracranial
hypertension when conventional methods failed. To this end, a
retrospective chart review was conducted on 21 neurosurgical trauma
patients with uncontrolled intracranial pressure (ICP) admitted to a
trauma/intensive care unit. In this patient population, the overall
mortality was 48%. Control of ICP was achieved in 67% of patients. The
survival of patients experiencing ICP control with barbiturate coma
was better than those patients who failed therapy (71% vs 14%, p =
0.021). Thus, in a subgroup of neurosurgical trauma patients who are
refractory to conventional management of elevated ICP, barbiturates
appear to improve survival, suggesting that this therapy has an
important role in the management of neurotrauma patients." (1)

However, a systematic review by the Cochrane Database finds otherwise:
"Reviewers' conclusions: There is no evidence that barbiturate therapy
in patients with acute severe head injury improves outcome.
Barbiturate therapy results in a fall in blood pressure in 1 in 4
treated patients. The hypotensive effect of barbiturate therapy will
offset any ICP lowering effect on cerebral perfusion pressure."

2) What kinds of setbacks/problems occur if there is swelling of/in
the brain as a result of severe head trauma?

Here are some basic effects from Medline Plus:
bulging fontanelle 
separated sutures 

Older children and adults:
changes in behavior 
progressive decreased consciousness, may become coma 

More signs and symptoms can be found on Discovery Health:
"The symptoms of increased intracranial pressure may include: 
headache  ringing in the ears  nausea and vomiting  vision
problems, such as blurry vision or double vision  feeling tired and
wanting to sleep  painful eye movements  neck pain  hearing loss 
unsteadiness while standing or walking, known as ataxia  weakness,
which may occur in only certain parts of the body or throughout the
whole body.

If intracranial pressure is very high, death may occur from brain
injury. Some people have mildly elevated intracranial pressure over a
long time. These people may develop vision or hearing problems."

Herniation of the brain is the most severe effect of increased ICP. 
Here is a description of the effects of herniation of different parts
of the brain:
"1. Consequences of Uncal (Temporal Lobe) Herniation

a.Compression of cranial nerve III. The ipsilateral third nerve, as it
passes between the posterior cerebral and superior cerebellar
arteries, is initially flattened and may show hemorrhage. The first
clinical sign is ipsilateral pupil dilation, since the parasympathetic
fibers are located on the outside of the nerve and are inactivated
first by compression. Complete third nerve paralysis may also occur.
As the herniation progresses, the contralateral oculomotor nerve may
be compressed, producing bilateral pupil dilation.

b.Compression of midbrain cerebral peduncles. Most often the
ipsilateral cerebral peduncle is compressed, resulting in
contralateral hemiparesis or hemiplegia. In addition the cerebral
peduncle on the side opposite the space-occupying lesion may be
compressed against, or indented by, the free edge of the tentorium
cerebelli. This results in ipsilateral hemiparesis or hemiplegia (if
it occurs alone) or quadriplegia (if both peduncles are compressed)

c.Compression of the posterior cerebral artery. Obstruction of the
posterior cerebral artery or its branches, due to compression of the
artery against the free edge of the tentorium, produces hemorrhagic
infarction on the medial and inferior aspects of the ipsilateral
occipital lobe (occasionally the infarction is bilateral). Hemorrhagic
infarction occurs because the compression may be reduced after damage
to arterial walls and blood then enters the infarcted area. The lesion
is often confined to the distribution of the calcarine branches of the
posterior cerebral artery. Clinically, cortical blindness is a common

d.Brainstem compression. The patient becomes comatose and may develop
bradycardia secondary to increasing brainstem compression. Decerebrate
posturing in response to noxious stimuli and hyperventilation may be
seen. Secondary brainstem hemorrhages (Duret hemorrhages) may occur,
probably because of compression and stretching of blood vessels,
especially veins. Brainstem decompensation will gradually progress
caudally. As the lower pons and upper medulla are involved, regular,
shallow respirations appear and the extremities become flaccid.
Finally, as the damage in the medulla causes slow irregular
respirations, an irregular pulse and falling blood pressure, death may
occur due to respiratory arrest.

2. Consequences of Central Herniation (Rostrocaudal deterioration) 

a. General comments. Rostrocaudal deterioration (or rostrocaudal
decompensation) is the progressive decline in neurological status due
to lesions progressively more caudal as a result of a supratentorial
space occupying mass and downward displacement of the brainstem.
Lesions lying medially or in the frontal pole may not compress the
diencephalon and midbrain laterally, but rather result in rostrocaudal
dysfunction of the brainstem with bilateral progression of impairment.
As in uncal herniation, secondary or Duret hemorrhages may occur in
the midbrain and pons as the brainstem is displaced.

b. Clinical Signs. 
i. Changes in consciousness begin with decreasing alertness,
progressing to drowsiness, stupor and coma.

iii. Decorticate rigidity, characterized by leg extension and arm
flexion, results from wide-spread lesions in the cerebral cortex.
Decerebrate rigidity, characterized by extension of both arms and
legs, follows lesions disconnecting the cerebral hemispheres from the
brainstem e.g. lesions in the upper midbrain commonly produce
decerebrate rigidity.

iv. Pupillary changes in a comatose patient can be used to evaluate
the general location of lesions. Examples of abnormalities include:

Small reactive: Compression of the diencephalon impairs sympathetic
fibers which originate there; impairment of sympathetic mediation of
pupil dilation leads to small pupils. Unilateral Dilated, fixed:
Compression of one oculomotor nerve (III nerve) by the uncus impairs
the parasympathetic fibers travelling along the periphery of the III
nerve; inactivation of these parasympathetic fibers leads to dilation
of the ipsilateral pupil and loss of the light reflex in that pupil.
Bilateral Midposition, fixed: Compression of both III nerves or
compression of the midbrain results in bilateral impairment of both
parasympathetic and sympathetic fibers travelling to the pupil; thus
the pupils are midposition (medium size) and fixed (no light reflex in
either pupil).

3. Consequences of cerebellar tonsil herniation 

Displacement of the cerebellar tonsils through the foramen magnum
compresses the medullary respiratory centers, leading to death.

4. Consequences of lateral displacement of brain 

Changing levels of consciousness have been correlated with lateral
displacement of diencephalon."

Please use any answer clarification before rating this answer.  I will
be happy to explain or expand on any issue you may have.  
Kevin, M.D.  
Internet search strategy using
barbituate induced coma
induced coma head trauma
effects of intracranial pressure
increased intracranial pressure
barbituate induced coma recommendations

1) Lee, Michael W., et al. "The Efficacy of Barbiturate Coma in the
Management of Uncontrolled Intracranial Hypertension Following
Neurosurgical Trauma." Journal of Neurotrauma 11, no. 3 (1994): 325.

Principal Health News - Barbituate Induced Coma - Barbituate Coma - Intracranial Pressure

Medline Plus - Increased Intracranial Pressure

Discovery Health - Increased Intracranial Pressure

Request for Answer Clarification by catoms-ga on 02 Feb 2003 00:30 PST
I'm not a med or nursing student, so a lot of the terminology is not
really clear.  Are seizures a possibility as a result of swelling due
to head trauma? Please advise if you feel that this is a separate

Clarification of Answer by kevinmd-ga on 02 Feb 2003 06:18 PST
Hello - thanks for asking for clarification.

You asked the following:
"Are seizures a possibility as a result of swelling due to head

The answer is most definitely yes.  Seizure is included in the list of
symptoms of intracranial pressure from Medline Plus:
"- vomiting 
- headache 
- changes in behavior 
- progressive decreased consciousness, may become coma 
- seizures"

Seizures are a sequelae of increased intracranial pressure (this time
from neurologic tumors) as seen here:
"The common symptoms that patients notice are headache, nausea and
vomiting, general confusion and lethargy. When the function of the
brain is disrupted by localized problems associated with a tumor,
symptoms include seizures, speech and language problems, visual
problems, or general weakness."

Seizures are reported here as a not uncommon event of increasing
intracranial pressure:
"Seizures. Should a seizure (convulsion) occur, not an uncommon result
of increasing intracranial pressure, protect the victim from injuring
himself further during the event, place him on his side after the
seizure to keep his airway open, and, as soon as possible, find a

Kevin, M.D.
catoms-ga rated this answer:4 out of 5 stars
My first question was answered to my satisfaction.  My second
question, however, requires clarification.  I apologize if my question
was not clear enough.

Subject: Re: Severe head injury questions
From: surgeon-ga on 01 Feb 2003 11:22 PST
While you are waiting for a thorough answer, I can say yes, with
severe head injury, induced coma is generally done, along with other
measures to reduce swelling, such as giving steroid medication and
causing hyperventillation to lower carbon dioxide levels. As to risks
of swelling, they are severe. The worst occurance is herniation of the
brain, meaning from swelling inside the skull, it pushes downward
through the opening at the bottom of the skull. Mild herniation may be
survivable with significant disability, but it often leads to death
because of pressure on the brainstem which controls vital function.
Mild swelling may cause coma in itself, but if there is no specific
tissue injury, and herniation doesn't occur, it can be followed by
full recovery. Often a pressure monitor is inserted through a small
hole in the skull to aid in determining medication levels needed.
Subject: Re: Severe head injury questions
From: synarchy-ga on 07 Feb 2003 14:40 PST
Seizures can result from swelling at the time of injury (as kevinmd
has summarized above), and can also result later (weeks to months
after the initial injury) due to scar tissue formation in areas of
damaged brain.  The most commonly associated condition is known as
"mesial temporal sclerosis" which translates into layman's terms
roughly as scarring of the underside of the brain (in an area that is
prone to seizures naturally - although other areas can be affected in
presumeably a similar manner).  This is arguably the most common cause
of adult-onset seizures in the developed world (surpassed in
underdeveloped nations by various infections).  Depending on the
location of the scar tissue, surgery may be an option to remove the
scar tissue that is causing the seizures, thereby making them much
more manageable, or even completely resolving them.  I would be happy
to answer any questions that you might have about this, if this fits
with what you were asking.


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