2. HEAD & SPINAL TRAUMA

11. Head Trauma Pathophysiology Primary Injury - occurs at time of injury Secondary Injury - occurs after injury - may be preventable

33. Head Trauma ?

35. Spinal Trauma

45. If spine is protected, its further examination and evaluation can be safely deferred until other life threatening emergencies are dealt with.

47. Cervical Collars

48. Spinal Board

50. LOG ROLLING LOG ROLL AND PROTECTION

52. Spinal Lift & Log-roll

57. HOW TO RULE OUT SPINAL INJURY?

68. Open Mouth & AP Views Occipital condyle Lat mass C1 Lat mass C2 Odontoid Peg Bifid spinous process Unco-vertebral joint C7 T1

73. 1

74. 29 YEAR OLD REFRIGERATOR ENGINEER HAD BEEN OUT HORSE-RIDING, WHEN HIS HORSE HAD BOLTED AND HE WAS THROWN OFF, HITTING HIS HEAD ON THE BRANCH OF A TREE. THE PARAMEDICS HAVE HIM IMMOBILISED ON A SPINAL BOARD WITH A RIGID CERVICAL COLLAR IN PLACE. ACCORDING TO THEM THERE WAS NO LOSS OF CONSCIOUSNESS AT ANY TIME, AND HE IS RESPONDING APPROPRIATELY TO COMMANDS. HE IS COMPLAINING OF MILD NECK PAIN AND TINGLING IN BOTH ARMS . ON GPE U FIND WEAKNESS IN BOTH ARMS, PROXIMALLY MORE THAN DISTALLY, WITH SOME ASSOCIATED LOSS OF LIGHT TOUCH AND PAIN SENSATION . WITH AN ASSISTANT MANUALLY STABILISING HIS NECK, YOU REMOVE THE COLLAR AND EXAMINE THE PATIENT. THERE IS NO BONY TENDERNESS, DEFORMITY OR DEFECT. HIS NECK IS NOT TENDER TO PALPATION .

75. Can you clear this man's cervical spine clinically?

77. SO YOU'VE SUCCESSFULLY INTERPRETED THE LATERAL FILM AS A NORMAL LATERAL CERVICAL SPINE. DO YOU HAVE ENOUGH PLAIN FILMS OR ARE YOU GOING TO TROUBLE THE RADIOGRAPHER FOR MORE VIEWS?

79. AP and Open mouth views are normal as well. What next?

80. YOU SEND THE PT OFF FOR AN MRI SCAN AND YOU GET THE RESULTS BACK - A CENTRAL CORD HAEMATOMA - CONSISTENT WITH THE CENTRAL CORD SYNDROME YOU FOUND ON EXAMINATION. YOU PACK THE PT OFF TO THE SPINAL UNIT WHERE, YOU LATER LEARNED, HE REGAINED FULL FUNCTION AND WAS DISCHARGED.

81. 2

82. YOUR PATIENT, JAMES COOK, A 32 YEAR OLD TRAVEL WRITER CAME OFF HIS MOTORCYCLE WHICH SKIDDED ON SOME ICE . THE PARAMEDICS HAVE HIM IMMOBILISED ON A SPINAL BOARD WITH A RIGID CERVICAL COLLAR IN PLACE. ACCORDING TO THEM THERE WAS NO LOSS OF CONSCIOUSNESS AT ANY TIME , AND HE IS RESPONDING APPROPRIATELY TO COMMANDS. HE IS NOT COMPLAINING OF ANY NECK PAIN . ON GENERAL EXAMINATION YOU FIND NO NEUROLOGY AND NO EVIDENCE OF OTHER INJUR Y . WITH AN ASSISTANT MANUALLY STABILISING HIS NECK, YOU REMOVE THE COLLAR AND EXAMINE THE PATIENT. THERE IS NO BONY TENDERNESS, DEFORMITY OR DEFECT. THINK YOU CAN HANDLE THIS ONE?

83. YOU REMOVE MR. COOK'S SPINAL IMMOBILISATION AND HARD COLLAR. HE LOOKS BETTER ALREADY! YOU RE-EXAMINE HIM OUT OF HIS COLLAR, AND FIND NO NEW SIGNS. HE HAS FULL AND PAIN FREE RANGE OF MOVEMENTS. YOU DISCHARGE MR. COOK WITH ADVICE TO CHANGE HIS MOTORCYCLE FOR A BUS PASS, AND TO 'STAY OUT OF TROUBLE' .

84. 3

85. YOUR PATIENT IS MR. HORATIO NELSON, A SURPRISINGLY SHORT 19 YEAR OLD, WHO HAS FALLEN OUT OF A SINGLE STOREY WINDOW WHILE AT A PARTY. HIS MATE ASSURES YOU THAT APART FROM QUITE A LOT OF ALCOHOL HORATIO ONLY TOOK 2 OR 3 ECSTASY TABLETS (THOUGH HORATIO LOOKS BLOODY MISERABLE AT THE MOMENT). SPINAL IMMOBILISATION AND A RIGID CERVICAL COLLAR ARE IN PLACE. ON EXAMINATION YOU ONLY FIND SOME BRUISING AROUND ONE EYE AND A BROKEN HUMERUS . HIS NECK IS CLINICALLY NOT TENDER, WITH NO DEFORMITY OR DEFECT, AND HE HAS NO OBVIOUS NEUROLOGY . Can you clear this man's cervical spine clinically?

87. YOU PASSEDA MR. NELSON'S LATERAL CERVICAL SPINE AS NORMAL. ARE YOU GOING TO DISCHARGE HIM?

88. YOU ORDER THE OPEN MOUTH AND AP FILMS FOR HORATIO, WHO IS NOW REALLY GETTING A LITTLE BIT MUCH. HE'S NOW OFFERING TO SINK BATTLESHIPS AND MOVE WHOLE ARMIES FOR YOU. HIS OTHER X-RAYS ARE ALSO NORMAL. YOU REMOVE HIS HARD COLLAR AND EXAMINE HIS NECK GENTLY. HE COMPLAINS OF NO PAIN OR TENDERNESS.

89. What are your plans?

90. YOU RECOGNISE THAT YOUR PHYSICAL EXAM, WHILE REASSURING, IS NOT RELIABLE GIVEN THE COCKTAIL OF DRUGS AND ALCOHOL HE HAS TAKEN. SO YOU ADMIT HIM. BY MORNING HE HAS SOBERED UP AND PREDICTABLY HE LOOKS TERRIBLE. HIS PHYSICAL EXAMINATION IS ENTIRELY NORMAL AND YOU DISCHARGE HIM INTO HARDY'S CARE WITH ADVICE.

91. 4

92. MR. CHARLES DARWIN IS A 42 YEAR OLD WHOSE CAR VEERED OFF THE ROAD. HE WAS UNCONSCIOUS ON SCENE AND REQUIRED EXTRACTION FROM THE VEHICLE . ACCORDING TO THE PARAMEDICS HE WAS HAEMODYNAMICALLY STABLE THROUGHOUT, WITH A GLASGOW COMA SCORE OF 6 INITIALLY . BOTH PUPILS ARE EQUAL AND REACTIVE . THEY INTUBATED HIM ON SCENE . HIS ONLY EXTERNAL INJURIES APPEAR TO BE BRUISING AND CUTS TO HIS FOREHEAD . SPINAL IMMOBILISATION IS IN PLACE.

93. YOU WISELY DECIDE THAT MR. DARWIN NEEDS HIS COLLAR AT THE MOMENT. EXAMINING HIM YOU CONFIRM THE PARAMEDICS FINDINGS. HE IS INTUBATED AND VENTILATED, HAEMODYNAMICALLY STABLE WITH A GCS NOW OF 4 AND EQUAL, REACTIVE PUPILS. YOU NEED TO MOVE QUICKLY AS HE MAY HAVE AN EVOLVING BRAIN INJURY. YOU ORDER A LATERAL CERVICAL SPINE FILM.

97. MR. DARWIN REMAINS STABLE BOTH HAEMODYNAMICALLY AND NEUROLOGICALLY WHILE YOU FINISH YOUR INITIAL ASSESSMENT AND RESUSCITATION. APART FROM HIS HEAD INJURY YOU FIND NOTHING ELSE. HIS OTHER CERVICAL SPINE X-RAYS ARE ALSO NORMAL. CHEST AND PELVIC X-RAYS ALSO NORMAL AND ABDOMINAL ULTRASOUND DID NOT SHOW ANY FREE INTRAPERITONEAL FLUID.

98. What's your plan?

99. MR. DARWIN COMES BACK FROM CT WITH A HEAD SCAN SHOWING MODERATE DIFFUSE AXONAL INJURY AND A SMALL SUBDURAL THAT WILL NEED SURGERY. CT OF HIS ATLANTO-OCCIPTAL REGION REVEALED AN ODONTOID PEG FRACTURE.

100. You send Mr. Darwin up to theatre for his craniotomy, and arrange for his admission to the intensive care unit. The spinal surgeons can decide whether they want an MRI or not in this case, it's not going to add much to his immediate management.

101. QUESTIONS?