UTI in Pregnancy

Pregnant women are at increased risk for UTIs. These factors may all contribute to the development of UTIs during pregnancy.

Most pregnant ladies (50-70%) have bacteriuria but it is asymptomatic, until it progresses into PYELONEPHROSIS.

Pyelonephrosis is serious because it can cause abortion, pre-term labour or low birth weight.

Beginning in week 6 and peaking during weeks 22 to 24, approximately 90% of pregnant women develop ureteral dilatation, which will remain until delivery (hydronephrosis of pregnancy).

1) Hormonal changes

This is due to the increased progesterone hormone in pregnancy. Progesterone will decrease the muscle tone (in bladder and ureters).

Therefore, the urine will take longer time to pass through the urinary tract = causing stagnation.
Increased bladder volume and decreased bladder tone, along with decreased ureteral tone, contribute to increased urinary stasis and ureterovesical reflux.

Stasis of urine gives more time for the bacteria to multiply hence increases chance of infection.

2) Anatomical changes

The uterus is anatomically situated above the bladder, thus enlargement of the uterus (due to growth of the baby) will put pressure on the bladder and partially block the ureters.

Hence, pregnant ladies have some kind of obstruction of their urinary tract, which can lead to stasis and infection too.

3) Gestational diabetes

Up to 70 percent of pregnant women develop glycosuria, which encourages bacterial growth in the urine.

Head V - Upper Airway region

Task 1 : Nicholas and Wen Jye
Task 2 : Da Wei, rebekah and Nabila
Task 3 : Pey Chien and Xin Yi
Task 4 : Nabeela and Yi Zhen
Task 5 : Timothy and fahad
Task 6 : Chesvin

UTI definition and epid

Urinary Tract Infection
Definition
A urinary tract infection is an infection of the urinary system. The urinary system is composed of the kidneys, ureters, bladder and urethra.
The upper urinary tract is composed of the kidneys and ureters. Infection in the upper urinary tract generally affects the kidneys (pyelonephritis), which can cause fever, chills, nausea, vomiting, and other severe symptoms.
The lower urinary tract consists of the bladder and the urethra. Infection in the lower urinary tract can affect the urethra (urethritis) or the bladder (cystitis). This is more common than upper UTI.
A urinary tract infection limited to your bladder can be painful and annoying. However, serious consequences can occur if a urinary tract infection spreads to your kidneys.
The main cause agent is Escherichia coli. Although urine contains a variety of fluids, salts, and waste products, it does not usually have bacteria in it. When bacteria get into the bladder or kidney and multiply in the urine, they may cause a UTI.
Symptoms include frequent feeling and/or need to urinate, pain during urination, and cloudy urine.
In men, it’s usually because of a urinary stone or enlarged prostate -- or from a medical procedure involving a catheter
Antibiotics are the typical treatment for a urinary tract infection. But you can take steps to reduce your chance of getting a urinary tract infection in the first place.
Urinary tract infections are usually referred to as simple or complicated.
Simple infections occur in healthy urinary tracts and do not spread to other parts of the body. They usually go away readily with treatment.
Complicated infections are caused by anatomic abnormalities, spread to other parts of the body, are worsened by underlying medical conditions, or are resistant to many antibiotics. They are more difficult to cure.




Prevalence
Infections of the urinary tract (UTIs) are the second most common type of infection in the body after URTI.
Women are at greater risk of developing a urinary tract infection than are men. The reason for this is not well understood, but anatomic differences between the genders (a shorter urethra in women) might be partially responsible.
The most common type of UTI is acute cystitis often referred to as a bladder infection.
Bladder infections are most common in young women with 10% of women getting an infection yearly
UTIs account for 8.3 million doctor visits each year.
Urinary tract infections are much more common in adults than in children, but about 1%-2% of children do get urinary tract infections. Urinary tract infections in children are more likely to be serious than those in adults and should not be ignored.
Urinary tract infection is the most common urinary tract problem in children besides bedwetting
About 40% of women and 12% of men have a urinary tract infection at some time in their life. UTIs in men are not as common as in women but can be very serious when they do occur.
Mortality related to urinary tract infection is exceedingly rare for otherwise healthy children in developed countries.
Morbidity associated with pyelonephritis is characterized by systemic symptoms, such as fever, abdominal pain, vomiting, and dehydration. Bacteremia and clinical sepsis may occur. Children with pyelonephritis also may have cystitis. Long-term complications of pyelonephritis are hypertension, impaired kidney function, end-stage renal disease (ESRD), and complications of pregnancy (eg, urinary tract infection, pregnancy-related hypertension, low-birth-weight neonates).

Common risk factors for UTI in elderly

- atrophic urethritis
- atrophic vaginal mucosa (atrophic vaginitis)
- benign prostatic hyperplasia
- prostate cancer
- catheter use
- chronic bacterial prostatitis
- genitourinary abnormalities (eg, vesicorectal fistulas)
- genitourinary calculi
- renal and perinephric abscess formation
- urinary diversion procedures (eg, ileal bladder diversion)
- urethral strictures

UTI in elderly

hey guys, this includes other aspects of UTI in elderly, though my part is oni pathophysio =)


Introduction
Urinary tract infection (UTI) is a common problem in the elderly. Diagnosis, prevention, and treatment can often be complex because clinical manifestations can be atypical and host defenses diminish with age.

Classification
• according to localization: urethritis, cystitis, or pyelonephritis.
• Or, symptomatic, asymptomatic, frequency of occurrence, presence or absence of complications, and whether associated with catheter use
• Recurrent infections: relapse or reinfection UTI
o Relapse UTI: urine is rendered partially or temporarily sterile by antimicrobial therapy, with the subsequent recurrence of bacteriuria from the uneradicated pathogen, generally within 2 weeks of completion of therapy.
o Reinfection UTI: arises >= 4 weeks after the previous infection has been cured; the bacterial strain is often different from the strain that caused the successfully treated prior infection.
• Complicating factors: urinary calculi, abscess formation, and obstructive uropathy.

Epidemiology
• Prevalence of UTI increases in both sexes with age; the female:male ratio is 2:1 in the elderly.
• Annual incidence of symptomatic bacterial UTIs: 10% in the elderly.
• Because many of these infections are recurrent, the percentage of infected patients is lower.

Etiology
• More types of urinary pathogens are isolated from elderly patients with UTI than from younger patients.
• Escherichia coli
o < 70% of bacteriuria in elderly female outpatients with uncomplicated sporadic cystitis
o 40% in patients with indwelling bladder catheters, complicated infections, or nosocomial infections.
• Other Enterobacteriaceae, enterococci, and staphylococci are often found
• Klebsiella sp, especially K. pneumoniae (gram-negative, aerobic)
• Proteus mirabilis, P. vulgaris, P. inconstans, and Morganella morganiiare
o more common in men than in women because these species tend to dominate the normal aerobic preputial flora.
o patients with calculi, because they grow best in an alkaline milieu
o patients with urogenital tumors.
• Proteus sp,M. morganii, and Providencia sp: chronically catheterized.
• Serratia, Enterobacter, Citrobacter, Acinetobacter, and Pseudomonas sp: nosocomial UTIs.
• Resistant gram-negative bacteria other than E. coli and gram-positive bacteria (enterococci, coagulase-negative staphylococci, and group B streptococci)P: recurrent infections
• Enterococcal superinfection often results from frequent use of antibiotics that are inactive against these organisms (eg, quinolones, cephalosporins, sulfonamides).

Pathogenesis
• In the elderly, the female/male ratio of incidence in UTIs narrows, because
o elderly men often have bladder outlet obstruction due to benign prostatic hyperplasia.
o decrease in sexual activity in elderly women
• Severe UTIs, particularly those complicated by septicemia originating from the urinary tract, become more common with age, in part because of more frequent bladder catheterization and instrumentation and possibly because of changes in the immune system.
• Recurrent and complicated infections are also more common because of the higher frequency of predisposing anatomic and pathophysiologic factors, such as prolapse, urolithiasis, and malignancies in the GU tract and uterus.
• Bacteria proliferate in stagnant bladder urine, and clinically important bacteriuria becomes established. A large amount of postvoiding residual urine is most common with a neurologic disorder, bladder outlet obstruction, or urethral stricture. (Normal residual urine: 5 to 20 mL)
• Foreign bodies, most commonly indwelling bladder catheters, also promote bacterial growth.

Signs & Symptoms
• Many patients are asymptomatic.
• Symptoms that may occur include dysuria, urinary frequency, incontinence of recent onset, flank pain, and fever.
• Confusion and delirium are often attributed to UTI, although without high fever or sepsis, uncomplicated UTI is unlikely to cause serious central nervous system dysfunction.

Diagnosis
• The diversity of potential uropathogens mandates that urine cultures be obtained in all elderly persons with suspected UTI.
• Rapid tests can provide a semiquantitative determination of bacteriuria. The best is the nitrite test, in which the conversion of nitrate to nitrite by bacteria in the urine is demonstrated by color change on a dipstick. This test has a high degree of sensitivity and specificity but does not demonstrate bacteriuria caused by Pseudomonas sp, staphylococci, or enterococci, which are incapable of reducing nitrate to nitrite.
• Quantitative urine cultures can be performed in bacteriology laboratories to identify the species involved and determine antibiotic susceptibility.
• Recurrent UTIs: In addition to bacteriologic diagnosis, more testing is often necessary, including quantitation of postvoiding residual bladder urine volume and investigation of the architecture of the upper urinary tract via ultrasound or CT in select cases. Urologic consultation may be sought when obstructive uropathy, calculi, abscesses, or GU tract anatomic abnormalities are suspected. Chronic bacterial prostatitis can also result in relapse UTI in elderly men. The diagnosis is suggested when bacterial colony counts from urine or expressed prostate secretion are at least 10-fold greater than counts from the urethral urine sample. Also, the presence of neutrophils in the prostatic secretions substantiates the diagnosis. In relapse UTI, evaluation should include assessment of bladder anatomy and function (ie, postvoiding residual and voiding cystogram or cystoscopy).





http://www.merck.com/mkgr/mmg/sec12/ch100/ch100a.jsp

Pathophysiology - SEXUALLY ACTIVE WOMEN !!!

• During sexual intercourse, the bacteria in the vaginal area may be pushed into the urethra and eventually end up in the bladder
o urine provides a good environment for the bacteria to grow.
• Cystitis commonly occurs in women as a result of sexual intercourse
o Cystitis refers to inflammation of the lining of the bladder.
o It usually occurs when the normally sterile urethra and bladder (lower urinary tract) are infected by bacteria
 become irritated and inflamed.
• anus, a constant source of bacteria, is so close to the female urethra.
• More than 90 percent of cystitis cases are caused by Escherichia coli (E. coli) , a species of bacteria commonly found in the rectal area

E-coli :• inhabit the periurethral vaginal introitus and ascend into the bladder via the urethra
• bladder mucosal invasion
• type 1 fimbriae with adhesion known as FimH.
• Beacterial adhesins are necessary for attachment of bacteria to the mucous membranes of the perineum and urothelium
• Multiply and the bladder becomes inflamed.

Frequent and/or vigorous sex increases the chances of physical damage or bruising, which in turn makes the likelihood of cystitis developing higher

Urine is generally a good culture medium; factors unfavorable to bacterial growth include a low pH (5.5 or less), a high concentration of urea, and the presence of organic acids derived from a diet that includes fruits and protein. Organic acids enhance acidification of the urine.

Normally, a thin film of urine remains in the bladder after emptying, and any bacteria present are removed by the mucosal cell production of organic acids.

Use of a diaphragm increases the risk of developing cystitis, possibly because spermicide used with the diaphragm suppresses the normal vaginal bacteria and allows bacteria that cause cystitis to flourish in the vagina

Sexually transmitted diseases (STDs) may cause UTI-like symptoms, such as pain with urination. This is due to the inflammation and irritation of the urethra or vagina that's sometimes associated with chlamydia and other STDs.

Treatment for UTI

Treatment for UTI

SIMPLE UTI

Antibacterial drugs

-depends on patient’s history and urine test that identify the offending bacteria.

-most common drugs for uncomplicated UTI:

1)trimethoprim (Trimpex)

2)trimethoprim/sulfamethoxazole (Bactrim, Septra, Cotrim)

#Sulfamethoxazole inhibits bacterial synthesis of dihydrofolic acid by competing with PABA. Trimethoprim blocks production of tetrahydrofolic acid by inhibiting the enzyme dihydrofolate reductase.

3)amoxicillin (Amoxil, Trimox, Wymox)

4)nitrofurantoin (Macrodantin, Furadantin) *treat and prevent*

5)ampicillin (Omnipen, Polycillin, Principen, Totacillin)

-quinolones includes four drugs approved in recent years for treating UT, include ofloxacin (Floxin), norfloxacin (Noroxin), ciprofloxacin (Cipro), and trovafloxin (Trovan).

-can be cured with 1, 2 days of treatment if the infection is not complicated but antibiotics are encouraged to be taken for 1,2 week to ensure that the infection has been cured.

-single-dose treatment is not recommended for some group of patients, eg: delayed treatment, kidney infection, diabetes, men who have prostate infection, etc.

-severly ill patients with kidney infections may be hospitalized until they can take fluids and drugs on their own.

-longer treatment is needed by patients with infection caused by Mycoplasma (lack of cell wall) or Chlamydia, which are usually treated with tetracycline, trimethoprim/sulfamethoxazole (TMP/SMZ), or doxycycline.

-important to take the full course of treatment because symptoms may disappear before the infection is fully cleared.

OTHERS

-drugs to relieve pain

-phenazopyridine (Pyridium) can be used to relieve burning pain during urination.

-heating pad MAY help

-drinking plenty of fluid to cleanse the UT bacteria.

-quit smoking

RECCURENT INFECTIONS in WOMEN

-one of the following treatment:

· Take low doses of an antibiotic such as TMP/SMZ or nitrofurantoin daily for 6 months or longer. If taken at bedtime, the drug remains in the bladder longer and may be more effective.

· Take a single dose of an antibiotic after sexual intercourse.

· Take a short course (1 or 2 days) of antibiotics when symptoms appear.

-prevention:

• Drink plenty of water every day.
• Urinate when you feel the need; don't resist the urge to urinate.
• Wipe from front to back to prevent bacteria around the anus from entering the vagina or urethra.
• Take showers instead of tub baths.
• Cleanse the genital area before sexual intercourse.
• Avoid using feminine hygiene sprays and scented douches, which may irritate the urethra.
• Some doctors suggest drinking cranberry juice.

INFECTION in PREGNANCY

-should be treated promptly to avoid premature delivery

-some antibiotics are not safe to take during pregnancy e.g TMP/SMZ

-doctors will consider various factors such as the drug's effectiveness, the stage of pregnancy, the mother's health, and potential effects on the fetus.

COMPLICATED INFECTIONS

-find and correct the underlying problem

INFECTIONS in MEN

-identify the infecting organism and the ideal drugs

-lengthier therapy (7 ~ 14 days) to prevent prostate gland infection.

-four weeks of antibiotic may be required if prostate is infected (prostatitis) because antibiotics are unable to penetrate infected prostate tissue effectively.

CHILDREN

-children with uncomplicated cystitis (inflammation of urinary bladder) are given 10 dyas course of antibiotics.

REFENRENCES:

http://kidney.niddk.nih.gov/kudiseases/pubs/utiadult/

http://www.emedicinehealth.com/urinary_tract_infections/page7_em.htm

Gram-staining

Gram Staining

What is being tested?

A Gram stain is used to determine if bacteria are present in an area of the body that is normally sterile. A sample from the infected area is smeared on a glass slide and allowed to dry. A series of stains and a decolorizer is applied. The stained slide is then examined under a microscope where bacteria appear either purple (gram positive) or pink (gram negative).

A Gram stain can predict the type of bacteria causing an infection, such as pneumococcal pneumonia or a staphylococcal abscess. Viruses cannot be seen with a Gram stain since they lack the cell wall, which takes up the stain.

How is it done?

First a bacterial smear must be heat fixed to a microscope slide. A smear is a sample of bacteria suspended in a small amount of water on a slide. That sample is then dried using heat. The heat kills the bacteria and attaches the sample to the slide so that it does not easily wash away.

The Gram staining procedure goes as follows:

1. Flood the slide with Crystal Violet (the primary stain).
2. After 1 minute, rinse the slide with water.
3. Flood the slide with Iodine (Iodine is a mordant that binds with Crystal violet and is then unable to exit the Gram+ peptidoglycan cell wall.)
4. After 1 minute, rinse the slide with water.
5. Flood the slide with Acetone Alcohol. (Alcohol is a decolorizer that will remove the stain from the Gram-negative cells.)
6. After 10 or 15 seconds, rinse the slide with water. (Do not leave the decolorizer on too long or it may remove stain from the Gram-positive cells as well.)
7. Flood slide with Safrinin (the counterstain).
8. After 1 minute, rinse the slide with water.
9. Gently blot the slide dry. It is now ready to be viewed under oil immersion (1000x TM) with a bright-field compound microscope.

After this staining procedure, the Gram + cells will appear purple, having retained the primary stain. The Gram – cells will appear pink, having retained the counterstain after the primary stain was removed by the decolorizer.

***REVIEW

Gram-positive Cells

In Gram-positive cells, peptidoglycan makes up as much as 90% of the thick, compact cell wall, which is the outermost cell wall structure of Gram + cells.

Gram-negative Cells

The cell walls of Gram - bacteria are more chemically complex, thinner and less compact. Peptidoglycan makes up only 5 – 20% of the cell wall, and is not the outermost layer, but lies between the plasma membrane and an outer membrane. This outer membrane is similar to the plasma membrane, but is less permeable and composed of lipopolysaccharides (LPS), a harmful substance classified as an endotoxin.

Urine Culture

Urine-culture: Clean-catch method

• A clean catch is a method of collecting a urine sample for various tests, including urinalysis, cytology, and urine culture.

• The clean-catch urine method is used to prevent bacteria from the penis or vagina from getting into a urine sample.

• 1-2 ounces of urine is collected.

Methods
Urine collection technique for women
1. Wash hands with soap and water
2. Spread labia with 1 hand and hold apart for collection
3. Use three povidone-iodine swabs to clean area
- Wipe down one side, front to back, with one swab
- Wipe down other side, front to back, with second swab
- Wipe down center, front to back, with last swab
4. Dry area with sterile gauze
5. Void into toilet for a few seconds and then collect (to clear the urethra of any contaminants)
6. Avoid stopping urine flow while positioning cup
-Stopping flow increases risk of contaminated sample
7. Collect in sterile container
8. Cap and avoid touching inside of container

Urine collection technique for men
1. Wash hands with soap and water
2. Retract foreskin if needed
3. Use povidone-iodine swabs to clean tip of penis
- Clean penis
- Clean urethral opening
4. Dry area with sterile gauze
5. Void into toilet for a few seconds and then collect
6. Collect in sterile container
7. Avoid stopping urine flow while positioning cup
-Stopping flow increases risk of contaminated sample
8. Cap and avoid touching inside of container

Urine collection technique for infants (urine bag)
1. Wash hands with soap and water
2. Use povidone-iodine swabs to clean as above
3. Place sterile urine bag over penis or labia
4. Reclean and replace new urine bag if no urine in 30 min
5. Empty bag into sterile urine container

Sign & Symptoms of Pneumonia

Symptoms of pneumonia caused by bacteria in otherwise healthy people (younger than 65) usually come on suddenly. They often start during or after an upper respiratory infection, such as influenza or a cold, and may include:

• Cough, often producing mucus (sputum) from the lungs. Mucus may be rusty or green or tinged with blood.
• Fever which may be less common in older adults.
• Shaking, "teeth-chattering" chills (one time only or many times).
• Fast, often shallow, breathing and the feeling of being short of breath.
• Chest wall pain that is often made worse by coughing or breathing in.
• Fast heartbeat.
• Feeling very tired (fatigue) or feeling very weak (malaise).
• Nausea and vomiting.
• Diarrhea

Clinical signs of pneumonia are characteristic and are referred to clinically as consolidation :

• Expansion : reduced on the affected side
• Vocal fremitus : increased on the affected side (in other chest disease this sign is of very little use!)
• Percussion : dull
• Breath sounds : bronchial breath sounds
• Additional sounds : medium, late or pan-inspiratory crackles
• Vocal resonance : increased
• Pleural rub : may be present

Urine FEME

http://www.slideshare.net/sudug4rfu/urine-feme

Everything you need to know about FEME is here. I could not copy and paste the important parts as these slides did not allow me to. Have a look at it.

HEAD IV: MANDIBULAR REGIONS

1 BONES
bekah
2 MUSCLES
Nabila & PC
3 VESSELS
Chesvin & Timmy
4 NERVES
Xinyi & Nic
5 JOINT
WenJye
6 SPACES/SURFACE & CLINICAL ANATOMY
Fahad & yizhen & Nabeela
7 RADIOLOGY
Dawei

p/s: i just randomly delegate the tasks since our beloved bekah and dawei din do it. But i bet nobody will do it, including me. =)

Epidural/Extradural Hematoma

Extradural/Epidural hematoma

Definition

Epidural hematoma (EDH) is a traumatic accumulation of blood between the inner table of the skull (calvaria) and the stripped-off periosteal layer of dura membrane. It can also occur in the spinal cord (spinal epidural hematoma-SEDH).

Incidence and Prevalance

United States

Epidural hematoma complicates 2% of cases of head trauma

Mortality/Morbidity

Mortality rate associated with epidural hematoma has been estimated to be 5-50%.

Pathophysiology

Usually traumatic in nature; associated with calvarial fractures. Epidural hematoma usually results from a brief linear contact force to the calvaria that causes separation of the periosteal dura from bone and disruption of interposed vessels due to shearing stress.

Common arterial sources

70-80% of epidural hematomas (EDHs) are located in the temporoparietal region and the middle meningeal artery are involved most commonly (66%), although the anterior ethmoidal artery may be involved in frontal injuries.

Common venous sources

Usually, venous epidural hematomas only form with a depressed skull fracture.

Torn venous sinuses cause an epidural hematoma, particularly in the parietal-occipital region or posterior fossa (eg, transverse or sigmoid sinus). Hematoma in the posterior fossa represent only 5% of cases.. Disruption of the superior sagittal sinus may cause vertex EDH.

Etiology

· Traumatic

· Thrombolysis/anticoagulants

· Hypertension

Presentation

Symptoms of epidural hematoma include the following:

• Headache
• Nausea/vomiting
• Seizures
• Focal neurologic deficits (eg, visual field cuts, aphasia, weakness, numbness)

The physical examination should include a thorough evaluation for evidence of traumatic sequelae and associated neurological deficits, including the following:

• Bradycardia and/or hypertension indicative of elevated intracranial pressure
• Cerebrospinal fluid (CSF) otorrhea or rhinorrhea resulting from skull fracture with disruption of the dura
• Hemotympanum
• Instability of the vertebral column
• Alteration in level of consciousness (ie, Glasgow Coma Scale score)

• Anisocoria (eg, ipsilateral dilation of the pupil due to uncal herniation with compression of the oculomotor nerve)
• Facial nerve injury
• Weakness (eg, contralateral hemiparesis due to compression of the cerebral peduncle)
• Other focal neurological deficits (eg, aphasia - Aphasia is an acquired disorder of language due to brain damage., visual field defects, numbness, ataxia - Ataxia is defined as an inability to maintain normal posture and smoothness of movement.)

Investigation

Laboratory test

• Complete blood count (CBC) with platelets - To monitor for infection and assess hematocrit and platelets for further hemorrhagic risk.
• Prothrombin time (PT)/activated partial thromboplastin time (aPTT) - To identify bleeding diathesis. bleeding diathesis is an unusual susceptibility to bleeding
• Serum chemistries, including electrolytes, blood urea nitrogen (BUN), creatinine, and glucose - To characterize metabolic derangements that may complicate clinical course.
• Toxicology screen and serum alcohol level - To identify associated causes of head trauma and establish need for surveillance with regard to withdrawal symptoms.
• Type and hold an appropriate amount of blood - To prepare for necessary transfusions needed because of blood loss or anemia.

Imaging test

Plain radiography

CT scan. Advantage is that both fracture and the hematoma are visible.

Angiography – to visualise any lacerated vessels

MRI

Treatment and Management

Emergency care

 Establish IV access, administer oxygen, monitor, and administer IV crystalloids(normal saline) as necessary to maintain adequate blood pressure.

 Intubate using rapid sequence induction (RSI), to facilitate oxygenation, protect the airway, and allow for hyperventilation as needed.

 Elevate head of the bed 30° after the spine is cleared, to reduce ICP and increase venous drainage.

 Administer mannitol(Mannitol is used clinically to reduce acutely raised intracranial pressure until more definitive treatment can be applied). This reduces both ICP (by osmotically reducing brain edema) and blood viscosity, which increases cerebral perfusion.

 Hyperventilation to partial pressure of carbon dioxide (PCO₂) of 30-35 mm Hg treats signs of increasing ICP. This procedure reduces ICP by hypocarbic vasoconstriction and reduces risks of hypoperfusion and death of injured cells.

 Phenytoin reduces the incidence of early posttraumatic seizures, although it does not affect late-onset seizures or the development of a persistent seizure disorder.

Operative care

Craniotomy or laminectomy is followed by evacuation of the hematoma, coagulation of bleeding sites, and inspection of the dura. The dura is then tented to the bone.

Mininally invasive techniques involve the use of burr holes and drainage by negative pressure.

Burr holes procedure: The surgeon will make an incision, and reflect the scalp over the area of the hematoma. Then, an air powered drill is used to make a hole in the skull. The dura mater (tough covering of the brain) is then opened. The hematoma (blood clot) is now seen, and the surgeon will irrigate some of it out, and may pass a drain around the brain to provide post-operative drainage

References
www.emedicine.medscape.com