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Tier 3 Therapy

Failure of fluid therapy, oxygenation and ventilation strategies, and osmotic diuretics to stabilise the patient or improve the neurological status significantly warrants radical therapy. These cases should be considered for advanced imaging such as MRI to evaluate the need for surgical intervention. Hyperventilation and hypothermia treatments discussed below have not been evaluated in veterinary medicine in terms of their efficacy and remain controversial or unproven in human head trauma.

A) Surgery

Surgical intervention is reserved for patients that do not improve or deteriorate despite aggressive medical therapy. Advanced imaging (CT or MRI) is necessary for surgical planning and is also reserved for similar patients. Surgery may be indicated to remove haematomas, relieve intracranial pressure, or address skull fractures. Ventricular obliteration and mass effect identified on advanced imaging should be considered strong indicators for surgical treatment in any animal if they are not responding to medical therapy.

Typically, skull fractures do not require surgical intervention. However, significantly contaminated, comminuted fractures may require surgical debridement, especially if open. In dogs, such fractures of the frontal sinus (Figure 2) may be associated with traumatic pneumocephalus, which should be considered in any dog deteriorating despite aggressive medical therapy. If surgical intervention is pursued, aggressive debridement should include removal of all devitalized tissues and bone and should be guided by imaging. Large bone [...]

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