- The document discusses the initial management of head and spine trauma patients in the emergency room. It covers airway management, assessment of neurological status, identification of injuries using CT scans, and treatment to prevent secondary brain damage. Primary goals are to secure the airway, treat shock, and prevent hypoxia and hypotension which can worsen primary injuries.
- Spine trauma management focuses on immobilization, identification of spinal cord injuries, and treatment of neurogenic shock. Radiographic evaluation is important to identify fractures and clear the c-spine. Patients are immobilized on long spine boards and log rolled carefully. Early intubation and IV fluids are used to support blood pressure and respiration.
- Initial surveys assess air
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Head and Spine trauma traumacon 2011.ppt
1. Management of
Head & Spine
Trauma ER
Sumit Sinha
Associate Professor of Neurosurgery
Jai Prakash Narain Apex Trauma Center
All India Institute of Medical Sciences
2. AIIMS Trauma Workshop
Objectives
■ Initial Management
A (with C1) – B – C
■ Initial Neuro-Assessment
D - Glasgow Coma Scale
Pupils
■ Immediate Neurosurgical Management
CT Scan - when?
Neurosurgical Consult - when?
Recognition and treatment of Herniation
■ Other Considerations
C-Spine, Bleeding, Extremity #, Rest of Spine
■ Pitfalls
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Concept of ICP & CPP
CPP = MAP – ICP
Normal : > 70 mm Hg
Reduced : 50 -70 mm Hg
Critical : < 50 mmHg
When will ICP ↑??
Mass Lesions
Bleeding EDH, SDH, Intraparenchymal bleed
Cerebral Edema Cytotoxic, Vasogenic
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Monro-Kellie Doctrine
Venous
Volume
Arterial
Volume Brain CSF
Normal State – ICP Normal
Venous
Volume
Arterial
Volume
Brain CSFMASS
Compensated State – ICP Normal
Arterial
Volume
Brain
Venous
Volume MASS CSF
Uncompensated State – ICP Raised
ICP
(mmHg)
35
30
25
20
15
10
5
Volume
Volume-Pressure Curve
Herniation
Point of
Decompensation
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Initial Management – Airway
with C-Spine
PATENT ↓ OKAY Don’t Intubate until patient
needs sedation for some other procedure
THREATENED
Remains
Unresponsive
GCS ≦ 8
(CANNOT PROTECT AIRWAY)
Oral bleeding
Base of Skull
bleeding
OBSTRUCTED
Massive
Maxillofacial Trauma
Maxilla
Mandible
Associated Neck
Injury
* If C-Spine Injury is suspected, intubation should be performed by the
most experienced person available.
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Initial Management - Circulation
TREAT HYPOTENTION
Maintain Mean Arterial Pressure
above 90 mm Hg
USE
Crystalloids – Ringers Lactate
or Normal Saline
Ionotrope Infusion if needed
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Initial Neuro-Assessment
■ Key History
◻ Mechanism of Injury
◻ Response at scene → Neuro-exam at scene → Change in
status
■ Note Glasgow Coma Scale (GCS 3-15)
■ Note Pupils : Size / Shape / Reaction
Note the symmetry of motor
Score Eye Opening Best Verbal Response Best Motor Response
6 Obeys Commands
5 Oriented Localizes Pain
4 Spontaneous Confused Flexed to Pain
3 To Speech Inappropriate Words Flexion of arms with ext of
legs(decorticate)
2 To Pain Incomprehensive sounds Extension
1 None No Verbalization None
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Classification of Head Injuries
A. Blunt or Penetrating
B. Mild, Moderate, Severe (Based on GCS)
Mild 14-15
Moderate 9-13
Severe 3-8
C. Morphology (Fracture and Intracranial)
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Mild Head Injuries
■ GCS 14-15
■ CT if LOC, Amnesia, Severe Headache,
Anticoagulation
■ Evaluate C-Spine
■ Prognosis is excellent
■ Mortality rate < 1%
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Moderate Head Injuries
■ Patients may be confused, somnolent
■ GCS 9-13
■ Admit observe ,repeat head CT with
frequent neuro checks
■ Prognosis is good
■ Mortality rate < 5 %
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Severe Head Injuries
■ GCS < 8/15
■ Mortality rate > 40%
■ Securing of A,B,C’s highest priority
■ Early Intubation
■ Hypotension associated with twice
mortality
■ Maintain Pco2 25-35 mm/Hg
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Initial Neurosurgical Management
■ WHEN TO GET A CT-SCAN ?
■ Patient Comatose (GCS<13)
■ Penetrating Trauma
■ Suspect Skull #
■ CSF Leak
■ Post Trauma Seizures
■ Focal Neurological signs (Motor/Pupils)
■ WHEN TO CALL A NEUROSURGEON?
■ All of the above
■ Abnormal CT Scan
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Medical Management
■ Recognize and treat ↑ICP / Herniation
Monitor : Decrease in Pulse+Ventilation+ ↑B.P.
Decrease in level of Consciousness
Dilated Pupil
Decrease in motor power (Contralateral - Dilat pupil)
■ Cerebral Resuscitation
◻ Hyperventilation is the mainstay
◻ Hyperventilate with BMV till Intubation
◻ Intubate if (Orotracheal) if GCS<8 in more alert Rapid
sequence Intubation [HV till Pco2 = 28-32 mmHg confirmed
by ABG]
◻ Mannitol Infusion 0.25-1.0 gm/Kg IV over 15 min
(Not in Hypotensives)
◻ Monitor Urine Output
◻ Spine Cleared – Elevate the Head to 30°
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Other Considerations
■ Seizure Focus/Post Traumatic Seizures (2-5%)
SAH, Bleed (Intracerebral, sub or extradural)
Witnessed seizure
Load Phenytion ≈ 11-15mg/Kg IV slow with cardiac monitoring
■ C-Spine
5%-20% of patients with severe HI will have C-spine injury
5%-10% with one spine # will have another one too
Therefore
C-Spine motion restriction and log-rolling till full spine
cleared
■ Control of Bleeding
■ Immobilize other extremity fractures
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Pitfalls
■ Never attribute neurological abnormality solely to
the presence of alcohol / drugs. Alteration in
consciousness is hallmark of head injury.
■ Assume spinal Injury till ruled out
■ No naso-gastric / naso-tracheal tube if base skull
# suspected
■ Treat other life threatening bleeding first
■ Systolic pressure < 90 mmHg will lead to
secondary brain Injury
■ Poor Ventilation and Oxygenation will Increase
the ICP
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Summary
■ In a comatose patient, secure and maintain the
airway by endotracheal intubation.
■ Treat shock aggressiv
■ Hypoxia and hypovolaemia kill more patients
than brain injury.
■ Secondary brain injury makes primary brain
injury worse
■ If sedation or paralysis makes assessment
difficult, then treat the patient until the brain can
be assesed.
21. Trauma Alert
Spine in E.D.
Kamran Farooque
M.S., MRCS (U.K.)
Assistant Professor of Orthopaedics
Jai Prakash Narain Apex Trauma Center
All India Institute of Medical Sciences
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Spine Trauma
■ C. Spine- 55%
■ Thoracic spine- 15%
■ T.L.Junction- 15%
■ L.S. spine-15%
➢ 5% of head injury pt.have spine injury
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Anatomic Considerations
■ C.spine: Canal is wide Low chance for
N. compromise
-High chance for resp. failure
■ Thoracic spine: Ribs afford mechanical
stability
-Narrow spinal canal High chance of N.
deficit
-T/L Junction: Fulcrum- high frequency of #
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Exclusion
■ Awake: Simple N. intact,Absence of
pain, tenderness along whole spine
■ Comatose: X-rays/ C.T. scan
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ASCI- Types
■ Complete: No motor/ sensory function
below the level of injury
■ Incomplete:Any motor/sensory below the
level- prognosis for recovery is better
■ Peri-anal sensation may be the only sign
of incomplete SCI
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Neurogenic Shock
■ Loss of sympathetic outflow from S. cord
■ Loss of vasomotor tone & sympathetic
supply to heart
■ Vasodilatation & pooling of blood-
hypotension
■ Bradycardia- No H.R. in response to
hypotension
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Neurogenic Shock
■ I.V. fluids alone may not help
■ Danger of fluid overload/P.Edema
■ Vasopressors / Atropine –significant
Bradycardia
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Spinal Shock
■ Complete flaccidity & loss of reflexes
■ Gen. lasts 24- 48 hrs
■ Anal & bulbo-cavernosus –first to return
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Radiographic Evaluation
■ C.Spine: AP, Lat, open mouth (92%)
■ Thoracic & lumbar spine: AP, Lat
■ C.T.
10% of C. Spine pt.have a second # of V.
column- complete radiographic screening
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X-ray Evaluation
■ C.spine- 4 lines
■ Height of V. body,contour
■ Pedicles,Sp.process,facets
■ I/V disc space,Sp. Process inter space
■ Pre vertebral soft tissue space <5mm at
C3
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Immobilization
■ All pt.with suspected spinal injury
■ Pre hospital personnel- before & during
transport to definitive facility
■ Till spinal injury excluded by X-rays
■ Neutral position- Supine, Padding
■ Long spine board, cervical
restraints,straps
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Log Roll
■ 4 persons
-1-maintain manual in
line immobilization of
head & neck
-2-shoulders & pelvis
-3-Pelvis & legs
-4- Directs & move the
spine board
Maintain neutral
alignment of spine
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Screening for C.Spine
■ Paraplegia/Quadriplegia- Unstable spine
■ Awake/Alert/Sober/ N.neurology-no neck
pain
-Remove C. Collar-palpate the spine
-No tenderness-Voluntary movt. of spine
■ Awake/Alert/Sober/N.neurology- Neck
Pain
-Mandatory for the doctor to exclude
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General Treatment
■ Airway: critical importance in high C.Spine
■ Oxygen to all
■ Early intubation-maintain neck in neutral position
■ I.V. fluids: maintain BP-loss of auto regulation of
spinal blood flow
■ Spinal shock: Vasopressors, atropine
■ Urinary Catheter: bladder distension, ouput
■ N.G.tube: Ileus- empty stomach,reduce risk of
aspiration
