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
disrupted
Autoregulatory compensation
by brain injury

Mass effect of intracranial

hemorrhage
Monro-Kellie
Doctrine
Volume-Pressure
Curve
 Intracranial Pressure (ICP)

10 mm Hg = Normal
>20 mm Hg =
Abnormal
>40 mm Hg = Severe

decreased
Sustained increased ICP leads to
brain function and poor
outcome
adversely
Hypotension and low saturation
affect outcome
Cerebral Perfusion
Pressure
MAP ICP =
CPP
Normal 90 10 80
Cushings
100 20 80
Response
Hypotensi
50 20 30
on

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
Penetrating
High and low GSW and
velocity
other
 Classifications of Head
Injury
By Morphology Skull Fractures

Vault
Depressed / nondepressed
Open / closed

Basilar
With / without CSF leak
nerve
With / without cranial
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
neurosurgeo
n 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 Paco near / at 35 mm Hg
2

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
tenderness
Spine pain /
 Spinal Injury

How do I protect the spine during

evaluation and transport?
 Spinal Injury

How do I protect the spine during

evaluation and transport?

spine
Immobilize entire patient on long
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
Clear spine and remove cervical collar.
necessary
 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?

deficit
Clinical signs of neurological

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
consequences
Other
Fasciculus gracilis
Dorsal
column Fasciculus cuneatus

Lateral corticospinal
tract
Spinothalamic
 Effects of Spinal Cord
Injury
Neurogenic Shock Direct Effects

to
Cardiovascular phenomenon due
loss of sympathetic tone
thoracic
Associated with cervical / high
spine injury
Hypotension and slow heart rate
resuscitation
Treatment includes fluid
and occasional
atropine and vasopressors
 Effects of Spinal Cord
Injury
Spinal Shock Direct Effects

phenomenon
Neurologic, not hemodynamic

Occurs shortly after cord injury

Variable duration
Flaccidity and loss of reflexes
 Effects of Spinal Cord
Injury
Other Consequences

Inadequate ventilation
compromised
Abdominal evaluation

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?

oxygenation
Ensure adequate ventilation and

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 life-

threatening injury

Properly
immobilize entire
patient

Avoid
?
 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

Musculoskele
tal 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?

A B C D E

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

S top the bleeding! (pressure /

tourniquet)

S plint the extremity

S tabilize the pelvis

 Primary Survey

Rationale for Splinting

Prevents further
blood loss and
injury

Can restore or
maintain perfusion
Relieves pain
Important
evaluation
during

Do not delay
 Primary Survey

Stabilization
 Secondary Survey

Look
Listen
Feel
 Secondary Survey

Rationale for Splinting

Look Listen Feel

Deformity Dopple Crepitus

r
Pain
signals Skin
ss
Tenderne
Bruit
flaps
icNeurolog
Wound(s) 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