Committee on Trauma Presents

Head Trauma
Initial Assessment and Management

Case Scenario
58-year-old male fell from a roof in a small rural town

Initial GCS score = 12

On admission after 2-hour transfer, GCS score is 6 What injuries would you suspect? What are your priorities in managing this patient?

Objectives
Describe basic intracranial anatomy and physiology. Explain the importance of limiting secondary brain injury. Describe the classification of head injuries. Describe proper stabilization of the patient and arrangements for definitive care.

Anatomy and Physiology

What are the unique features of brain anatomy and physiology, and how do they affect patterns of brain injury?

Anatomy and Physiology

Effects Rigid, nonexpansile skull filled with brain, CSF, and blood
Cerebral blood flow (CBF) usually autoregulated Autoregulatory compensation disrupted by brain injury Mass effect of intracranial hemorrhage

Monro-Kellie Doctrine

Volume-Pressure Curve

Intracranial Pressure (ICP)

10 mm Hg >20 mm Hg >40 mm Hg

= = =

Normal Abnormal Severe

Sustained increased ICP leads to decreased brain function and poor outcome
Hypotension and low saturation adversely affect outcome

Cerebral Perfusion Pressure

MAP Normal 90 100 50 ICP 10 20 20 = CPP 80 80 30

Cushings Response
Hypotension

Caution

CPP Cerebral Blood Flow

Autoregulation
If autoregulation is intact, CBF is maintained constant between a mean BP of 50 to 60 mm Hg.

In moderate or severe brain injury, autoregulation is impaired so CBF varies with mean BP.
The injured brain is more vulnerable to episodes of hypotension, causing secondary brain injury.

Classifications of Head Injury

By Mechanism of Injury Blunt
High and low velocity

Penetrating
GSW and other

Classifications of Head Injury

By Morphology Skull Fractures
Vault Depressed / nondepressed Open / closed

Basilar
With / without CSF leak With / without cranial nerve palsy

Classifications of Head Injury

By Morphology Brain Injuries Focal
Epidural (extradural) Subdural

Intracerebral Diffuse
Concussion Multiple contusions

Hypoxic / ischemic injury

Epidural Hematoma
Associated with skull fracture Classic: middle meningeal artery tear Lenticular / biconvex Lucid interval Can be rapidly fatal Early evacuation essential

Epidural Hematoma
Temporal Epidural Hematoma

Uncal herniation

Subdural Hematoma
Venous tear / brain laceration Covers cerebral surface Morbidity / mortality due to underlying brain injury Rapid surgical evacuation recommended, especially if > 5 mm shift of midline

Subdural Hematoma

Intracerebral Hematoma / Contusion

Coup / contracoup injuries Most common: frontal / temporal lobes CT changes usually progressive Most conscious patients: no operation

Intracerebral Hematoma / Contusion

Large Frontal Contusion with Shift

Diffuse Brain Injury

Normal CT

Diffuse Injury

Range from mild concussion to severe ischemic insult

Classifications of Head Injury

By Severity of Injury Based on GCS Score Mild
Moderate Severe

Mild Brain Injury

GCS score = 13 15 History

Exclude systemic injuries

Neurologic exam X-rays as indicated

Alcohol / drug screens as indicated

Liberal use of head CT
Observe or discharge based on findings

Moderate Brain Injury

GCS score = 9 12 Initial evaluation same as for mild injury

CT scan for all

Admit and observe
Frequent neurologic exams

Repeat CT scan

Deterioration: Manage as severe head injury

Severe Brain Injury

GCS score = 3 8 Evaluate and resuscitate Intubate for airway protection Focused neurologic exam

Frequent reevaluation
Identify associated injuries

Indications for CT Scan

Indications for CT Scan

High Risk
GCS score still < 15 two hours after injury Neurologic deficit Open skull fracture Sign of basal skull fracture Extremes of age

Indications for CT Scan

Moderate Risk
Dangerous mechanism Retrograde amnesia > 30 minutes in duration Severe headache Vomiting > 2 episodes

Management
Priorities ABCDE Minimize secondary brain injury Administer oxygen Maintain adequate ventilation Maintain blood pressure (systolic > 90 mm Hg)

Management
Focused Neurological Exam GCS score Pupils Lateralizing signs
Consult neurosurgeon early

Management
Medical Controlled ventilation
Goal: Paco2 at 35 mm Hg

Intravenous fluids
Euvolemia Isotonic

Consult with neurosurgeon

Mannitol Use with signs of tentorial herniation Dose: 0.25 to 1.0 g / kg IV bolus

Management
Medical Other medications
Anticonvulsants
Sedation Paralytics

Neurological examination before prolonged sedation / paralysis

Management
Surgical Scalp Wounds
Possible site of major blood loss Direct pressure to control bleeding Occasional temporary closure

Management
Surgical Intracranial Mass Lesion
Can be life-threatening if expanding rapidly Immediate neurosurgical consult Hyperventilation / mannitol Damage control craniotomy: transfer to neurosurgeon (rural / austere areas)

Summary
Ensure adequate oxygenation Maintain Paco2 near / at 35 mm Hg Maintain mean BP > 90 mm Hg Frequent neurologic assessment

Liberal use of CT
Early neurosurgical consult

Committee on Trauma Presents

Spine and Spinal Cord Trauma

Initial Assessment and Management

Case Scenario
38-year-old male is pulled from a swimming pool.

BP: 80/62; Pulse: 58; RR: 28

GCS score: 15 Breathing is shallow. He is not moving his arms or legs. Discuss the patients diagnosis and management.

Objectives
Describe the evaluation of a patient with suspected spinal injury.
Explain the appropriate management of spinal injury. Discuss appropriate patient disposition.

Spinal Injury
When should you suspect a spine injury?

Spinal Injury
When should you suspect a spine injury? Mechanism of injury
Unconscious patient Neurologic deficit

Spine pain / tenderness

Spinal Injury
How do I protect the spine during evaluation and transport?

Spinal Injury
How do I protect the spine during evaluation and transport? Immobilize entire patient on long spine board with proper padding.
Apply semirigid collar.

Protection is priority; detection is secondary.

Spinal Injury Screening

Clinical
Normal neurologic exam and Absence of spinal pain and tenderness

Caution

Drugs, alcohol, and other injuries can mask spinal injury.

Spinal Injury Screening

If patient is
Conscious Cooperative Able to concentrate on c-spine

If no neck or spine pain or tenderness If still no pain or tenderness with voluntary movement No further evaluation or x-ray necessary Clear spine and remove cervical collar.

Spinal Injury Screening

Altered Consciousness or Symptoms
Radiographic visualization of entire spine
Plain films

CT scan of suspicious or poorly visualized areas

Spinal Injury Screening

How do I confirm a spine injury?

Spinal Injury Screening

How do I confirm a spine injury? Clinical signs of neurological deficit
Radiological investigations
Plain X-ray / CT / MRI

Identify bony fracture / subluxation

Presume spinal instability Early spine service consult

Cervical Spine X-rays

Crosstable lateral film excludes 85% of fractures
Addition of AP and odontoid views excludes most fractures Also may require
Swimmers view CT scan for bony detail MRI

Cervical Spine X-rays

10% of patients with a c-spine fracture have a second, associated noncontiguous vertebral column fracture Identify one abnormality? Look for another!
Radiographic screening of entire spine required in this situation

Pitfalls
Pitfalls

Spinal evaluation complicated by altered sensorium Remove spine board as soon as possible and logroll patient Pressure sores occur early in unconscious or paralyzed patients

Caution

Caution

At least 5% of patients with spinal cord injuries worsen neurologically at the hospital.

Neurologic Status
How do I assess the patients neurologic status?

Neurologic Status
How do I assess the patients neurologic status? Neurologic level
Most caudal level of motor / sensory function Motor and sensory may not be the same Sensory can vary on each side

Bony level
Site of vertebral column damage

Neurologic Status
Complete Injury
No motor or sensory function below injury level

Incomplete Injury
Any motor or sensory preservation below injury level
Sacral sparing may be only residual function

Effects of Spinal Cord Injury

Neurogenic shock Spinal shock Other consequences
Fasciculus gracilis Dorsal column Fasciculus cuneatus Lateral corticospinal tract Spinothalamic

Effects of Spinal Cord Injury

Neurogenic Shock Direct Effects
Cardiovascular phenomenon due to loss of sympathetic tone

Associated with cervical / high thoracic spine injury

Hypotension and slow heart rate

Treatment includes fluid resuscitation and occasional atropine and vasopressors

Effects of Spinal Cord Injury

Spinal Shock Direct Effects
Neurologic, not hemodynamic phenomenon

Occurs shortly after cord injury

Variable duration Flaccidity and loss of reflexes

Effects of Spinal Cord Injury

Other Consequences
Inadequate ventilation Abdominal evaluation compromised Occult compartment syndrome

Management
How do I manage patients with spinal cord injury and limit secondary injury?

Management
How do I manage patients with spinal cord injury and limit secondary injury? Ensure adequate ventilation and oxygenation
Maintain blood pressure Maintain perfusion of spinal cord

Management
Management of Hypotension
Assess for associated bleeding Consider neurogenic shock Monitor urinary output

Stop the bleeding!

Management
Whom do I transfer? Unstable fractures
Neurologic deficit

Caution

Avoid transfer delay!

Management
Management of Patients Requiring Transfer
Provide respiratory support as needed
Exclude other lifethreatening injury Properly immobilize entire patient

Avoid hypothermia

Summary
Treat life-threatening injuries first Properly immobilize entire patient Obtain appropriate spine films Document examination

Obtain neurosurgical / orthopaedic consult

Transfer unstable fracture / cord injury

Committee on Trauma Presents

Musculoskeletal Trauma

Initial Assessment and Management

Case Scenario
A wall collapses on a 44-year-old male worker

BP: 130/75; Pulse: 110; RR: 22

GCS score: 15 Painful, bruised, deformed right leg

What are your priorities? Is this life- or limb-threatening?

Objectives
Describe the principles for assessing patients with musculoskeletal injuries.
Identify treatment priorities. Explain the importance of musculoskeletal injuries in multiply injured patients.

Primary Survey
How do musculoskeletal injuries impact on the primary survey?

Primary Survey
How do musculoskeletal injuries impact on the primary survey?

External bleeding Occult blood loss

Pelvic fractures

Long bone fractures

Primary Survey
What are my priorities and management principles?

Primary Survey
What are my priorities and management principles?
During the Primary Survey The 3 Ss

Stop the bleeding!

(pressure / tourniquet)

Splint the extremity Stabilize the pelvis

Primary Survey
Rationale for Splinting
Prevents further blood loss and injury

Can restore or maintain perfusion

Relieves pain
Important during evaluation Do not delay

Primary Survey
Stabilization

Secondary Survey
Look
Listen

Feel

Secondary Survey
Rationale for Splinting
Look Deformity Pain Tenderness Wound(s) Listen Doppler signals Bruit Feel Crepitus Skin flaps Neurologic deficit

Pulses

Secondary Survey
Key Information
Preinjury status and predisposing factors Mechanism of injury Time of injury Associated factors (eg, environment)

Prehospital observations and care

Secondary Survey
Early Concerns
Vascular compromise Open fractures

Secondary Survey
Assess and Manage Vascular Compromise
Reduce fracture(s) Splint fracture(s) Assess by Doppler Obtain surgical consult Time is critical! Consider angiography

Secondary Survey
Managing Open Fractures
Apply appropriate splint Cleanse / debride (now or later) Consider time factor Obtain orthopedic consult Antibiotic / tetanus status

Secondary Survey
X-Ray Studies
What x-rays do I need?
Any suspected area One joint above and below

When do I obtain them?

Patient is hemodynamically normal

Secondary Survey
X-Ray Studies
When should I delay getting x-rays?
If life-threatening injuries take priority If patient transfer will be delayed

Compartment Syndrome
What injuries can cause compartment syndrome?

Compartment Syndrome
What injuries can cause compartment syndrome?

Tibia and forearm fractures

Vascular and bony injuries Injuries immobilized in tight dressings or casts Severe crush injuries to muscle Burns

Compartment Syndrome
How do I recognize compartment syndrome?

Compartment Syndrome
How do I recognize compartment syndrome?
Pain
Disproportionate Passive stretch

Tense compartments

Asymmetry
Paresthesia Tissue pressures > 35 to 45 mm Hg

Pitfalls
Pitfalls

Altered sensation Compartment syndrome Vascular injury Crush injuries / myoglobinuria Occult fractures / soft tissue injuries

Coagulation disorders

Summary
Manage life-threatening injuries first Stop the bleeding! Reduce and immobilize fractures and dislocations

Recognize vascular compromise

Consider compartment syndrome