Transcript Assessment & Treatment

Approach to Injuries of the Head & Spine
Stephan Brenner, MD, MPH
Teaching Objectives
By the end of this session you will learn:
• How to use the Glasgow Coma Scale (GCS).
• How to immobilize patients with the “Logroll” maneuver.
• When to transfer patients with head or spine
injuries.
• How to prepare a patient with a head or spine
injury for transport.
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Traumatic Head & Spine Injuries
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Anatomy and of the brain and spine.
Mechanisms of head and spine injuries.
Assessment of head and spine injuries.
Treatment of the head or spine injured
patient.
• Referral or Discharge of head and spine
injured patients.
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Anatomy & Mechanism
Case:
• A young man is riding his motorbike when he hits a
bump in the road. He is thrown off the bike.
• He was not wearing a helmet and hit his head against a
rock at the roadside. He is
• unconscious for about 2 minutes.
• He then is able to get up on his
own and stops a passing car.
The driver brings him to your
casualty ward.
How are we going to evaluate and treat this patient?
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Anatomy & Mechanism:
The Skull and Brain
• The brain is surrounded by bones (skull).
• The brain is connected to the spinal cord through a hole
in the base of the skull.
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Anatomy & Mechanism
The Skull and Brain
• Trauma can cause:
– Intracranial bleeding or swelling
of the brain.
– Increased pressure inside the
skull.
• Rising Intra-Cranial Pressure (ICP)
causes:
– Squeezing of brain (=Herniation).
– Altered mental status or coma.
– Neurologic deficits
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Anatomy & Mechanism
Head Injuries
• Causes: RTAs, falls, assaults.
• Head injuries involving the
brain are called Traumatic
Brain Injuries (TBI).
• TBI is a common cause of
death in trauma patients!
• TBI is a major cause of
lifelong disability after
trauma!
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Anatomy & Mechanism
Traumatic Brain Injuries (TBI)
Immediate (= direct) brain damage:
Mild Concussion
Severe
Concussion
Brief LOC followed by memory loss
(amnesia), headache, nausea,
vomiting  usually full recovery!
Prolonged LOC, altered mental
status  death or disability!
Once direct brain injury occurs, only symptomatic relief can
be provided in the Casualty Ward (stabilization, prevention of
further injury).
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Anatomy & Mechanism
Traumatic Brain Injuries (TBI)
Delayed (= indirect) brain damage:
• Preventable brain damage in Casualty Ward after
trauma occurs.
Hypoxemia
 Protect Airway, control Breathing!
Hypoperfusion & Shock  Immediate Fluid Resuscitation!
Brain Swelling (Edema,
Contusion, Bleeding)
 Elevate head of bed to 30°!
Skull Fracture
 Give Antibiotics immediately!
Seizures
 Give Diazepam and Protect Airway!
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Anatomy & Mechanism
Head Trauma in the Casualty Ward
THEREFORE:
•Everyone working in the Casualty Ward needs to be
familiar with the accurate assessment, resuscitation,
and timely referral and transfer of patients with
severe head injuries!
•The survival and quality of life of every patient with
head injury depends on the knowledge and skills of
the Casualty Staff!
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Anatomy & Mechanism
The Spinal column
Spinal column:
• reaches from the upper
neck to the lower back.
• consists of 24 vertebral
bones.
• is divided into 4
sections.
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Anatomy & Mechanism
The Spinal column
Spine Functions: Stability & Weight bearing
Bone Structures
• Vertebral bodies
• Facet joints
• Pedicles
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Anatomy & Mechanism
The Spinal column
Spine Functions: Stability & Flexibility
Non-bony Structures
• Intervertebral Discs
• Longitudinal
Ligaments
• Paraspinal Muscles
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Anatomy & Mechanism
The Spinal column
• Spine Functions: Central Nervous System
Nerve Structures
• Spinal Cord
• Nerve Roots
• Spinal Nerves
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Anatomy & Mechanism
The Spinal Cord
• Protected inside the Spinal
Canal.
• Originates from brain at
the Foramen Magnum.
• Terminates at Vertebra L1.
• Distal nerve roots form the
Cauda Equina inside the
spinal canal below
Vertebra L1.
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Anatomy & Mechanism
The Spinal Cord
The 3 Major Spinal Tracts:
• Corticospinal Tract 
motor control, muscle
contraction.
• Spinothalamic Tract 
pain and temperature
sensation.
• Posterior column 
position sense,
vibration, light touch.
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Anatomy & Mechanism
Spine Injuries
Cervical Spine:
• Most vulnerable part of
spine
• Involved in 50% of all
spinal injuries!
• High risk of paralysis
from cord compression!
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Anatomy & Mechanism
Spine Injuries
Thoracic Spine:
• Least vulnerable to injury
(15% of all spinal injuries)
• Relative protection from rib
cage.
Lumbar Spine:
• 30% of all spinal injuries
• Most injuries occur in the
upper part of the L-spine
(thoracolumbar junction)
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Anatomy & Mechanism
Spine Injuries
Causes:
• High-velocity RTAs
• Falls from a height
• Sports injuries
• Occupational injuries
Mechanisms:
• Whip-Lash Injury
• (Flexion-Extension Injury)
• Axial Compression Injury
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Anatomy & Mechanism
Spine Injuries
• Clinical Signs:
Type of Injury:
Symptoms:
Sprains or Strains
Pain
Neurologic
compromise:
no risk
Stable Fractures
Pain
low risk
Unstable Fractures
Pain
HIGH RISK!!
You will never know what type of spine injury you are
dealing with when a patient arrives to the Casualty Ward!!
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Anatomy & Mechanism
Spine Trauma in the Casualty Ward
THEREFORE:
Never transport a patient with suspected spine injury in
the sitting or prone position!!
•Everybody working in the Casualty Ward needs to be
familiar with how to assess and treat a patient with
suspected spine injury!
•The survival and quality of life of every patient with
spine injury depends on the knowledge and skills of the
Casualty Staff!
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Anatomy & Mechanism
Spine Injuries
Strains & Sprains:
• Trauma to spine muscles and
ligaments only.
• Pain due to local soft tissue
inflammation.
Stable Spine Fractures:
• Trauma to bone structures.
• Only one column involved.
• LOW RISK of spinal cord
compression.
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Anatomy & Mechanism
Spine Injuries
Unstable Spine Fractures:
• Trauma to bone structures.
• More than one column
involved.
• HIGH RISK of spinal cord
compression!
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Anatomy & Mechanism
Spine Injuries
Stable Fracture  1 column involved = low risk of spinal cord
compression
Examples of Stable Spine Fractures
Wedge Fracture
Transverse Process Fracture
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Anatomy & Mechanism
Spine Injuries
Unstable Fracture  more than 1 column involved = high risk of
spinal cord compression
Examples of Unstable Spine Fractures:
Compression Fracture
Flexion-Distraction Fracture
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Anatomy & Mechanism
Spine Injuries
REMEMBER!
• In EVERY trauma patient, ALWAYS suspect an unstable
spine fracture!
THEREFORE:
• ALWAYS protect a trauma patient’s spine from bending or
moving (= spine precautions)!
BECAUSE:
• Spinal cord damage is IRREVERSIBLE!!
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Assessment & Treatment
Case:
• The motorbike accident patient arrives at the hospital
and is walked to the Casualty Ward.
• He complains about a headache
and pain in his neck and back.
• He has bruises and abrasions to
his face and forehead,
shoulders and arms.
 Does he have a muscle sprain, or a stable spine
fracture, or an unstable spine fracture?
 What next are the next steps in assessing him?
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Assessment & Treatment
Arrival to the Casualty Ward
In any traumatically injured patient, the Casualty staff
has to make sure that
SPINE PRECAUTIONS
are applied during every single step of the assessment
& treatment process!
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Assessment & Treatment
Spine Precautions
Wrong methods!!
Correct methods!!
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Assessment & Treatment
Spine Precautions
How to correctly apply Spine Precautions?
1) Place the patient in an anatomical position:
 supine on a hard surface
 straighten arms and legs
 always support the head!
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Assessment & Treatment
Spine Precautions
2) Immobilize the C-spine:
 Achieve normal alignment of the cervical spine.
 Instruct the patient not to bend or turn the head.
 One person must support the patient’s head and
neck until a cervical collar or other device is placed.
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Assessment & Treatment
Spine Precautions
Devices used to stabilize the C-spine:
Stiff Cervical Collar
Sandbags (with a rolled
towel beneath neck)
Rolled Towel
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Assessment & Treatment
Spine Precautions
3) “Log-roll” the patient:
 Turn the patient “in one piece” without moving the
spine.
 Requires at least 2 health care providers.
 Must be used every time the injured patient has to be
moved for examination or transport.
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Assessment & Treatment
Spine Precautions
“Log-roll” maneuver:
• 1 provider stabilizes the head and neck.
• All other providers turn the patient’s shoulders, hips, and legs.
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Assessment & Treatment
Primary Trauma Survey
While applying Spinal Precautions, the Primary Trauma
Survey exam is started.
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A - Airway:
B - Breathing:
C - Circulation:
D - Disability:
E - Exposure:
Is the patient able to talk?
Is the patient able to breath normally?
Are the BP and PULSE normal?
Is the patient able to move all limbs?
Are there any other visible injuries
once the patient is undressed?
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Assessment & Treatment
Primary Trauma Survey
• AIRWAY & BREATHING:
Look for:
• Foreign body in airway
• Labored breathing
• Blue skin (central cyanosis)
Check for:
• Airway obstruction
• Decreased breath sounds
• Wheezing
Act accordingly!
• Obstruction  Clear Airway!
• Labored breathing
 Position Patient! (while
protecting C-spine)
 Intubate! (if appropriate)
• Decreased one-sided breath
sounds

Needle Decompression!
• Wheezing, Cyanosis
 Give Oxygen!
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Assessment & Treatment
Primary Trauma Survey
CIRCULATION:
Look for:
• Cold Skin
• Weak or Fast Pulse
• Capillary Refill > 2 seconds
Check for:
• Low Blood Pressure
• Fast Heart Rate
• Active Bleeding
Act accordingly!
•Cold skin
 Keep patient warm!
•Low BP, fast pulse
 Give 1 L NS or LR IV bolus!
 Repeat fluid bolus as
needed!
•Profuse Bleeding
 Pressure dressing to
wound!
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Assessment & Treatment
Primary Trauma Survey
• DISABILITY & MENTAL
STATUS:
Look for:
• Unconsciousness
• Head Injury
• Patient moving all 4 limbs
Check for:
• AVPU or GCS score
• Possibility of intoxication,
• alcohol or drug abuse
Act accordingly!
• Patient is unconscious
 Manage Airway!
Intubate if appropriate!
 Check blood glucose level!
• Seizure or Convulsion
 Give Diazepam IV or PR!
• Low AVPU or GCS score,
inability to move limbs
 Spinal Precautions at all times!
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Assessment & Treatment
Primary Trauma Survey
AVPU Score:
Assessment of consciousness in non-trauma patients
 focus on a patient’s general responsiveness to certain stimuli.
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•
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A = patient is Alert & Awake
V = patient responds only to Verbal Stimulation
P = patient responds only to Painful Stimulation
U = patient is Unresponsive to any stimulation
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Assessment & Treatment
Primary Trauma Survey
AVPU Example:
A small boy fell off a tree and
hit his head.
In the Casualty Ward, he has
his eyes closed and looks
as if he is asleep.
He does not respond when
his mother calls his name.
When the nurse pinches his
hand, he screams and
pulls his hand away.
What is the boy’s level of
consciousness according to
the AVPU score?
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Assessment & Treatment
Primary Trauma Survey
GCS = Glasgow Coma Scale:
Assessment of consciousness in trauma patients
 assesses the patient’s specific responsiveness to certain
stimuli in 3 elements of patient behavior.
• Eye movements  4 points
• Verbal response  5 points
• Motor function  6 points
A fully conscious patient has a GCS score of 15 points.
Severe head injury is present with a GCS of 8 or below.
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Assessment & Treatment
Primary Trauma Survey
Glasgow Coma Scale:
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Assessment & Treatment
Primary Trauma Survey
GCS Example 1:
A woman was seriously injured in
a RTA and sustained severe
head trauma.
She does not open her eyes when
rubbed on the chest, but she
starts moaning, flexes both
arms, and stretches her legs.
What is this woman’s GCS score?
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Assessment & Treatment
Primary Trauma Survey
GCS Example 2:
A man involved in the same accident
has been unconscious since the
event.
He does not open his eyes when
rubbed on the chest, does not
make any noises, turns both arms
legs inward, and bends his hands
and feet.
What is this man’s GCS score?
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Assessment & Treatment
Primary Trauma Survey
EXPOSURE (undress the patient!):
Look for:
• Additional wounds &
injuries
Check for:
• Hypothermia
Act accordingly!
•Wounds and Injuries
cover open wounds!
immobilize broken
limbs!
•Hypothermia
 cover the patient!
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Assessment & Treatment
Primary Trauma Survey
Inform the physician or
medical assistant on call
immediately if any of the
ABCDEs are abnormal!!
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Assessment & Treatment
Secondary Trauma Survey
1) Obtain a detailed history from the patient or an eyewitness
(AMPLE History):
A = Allergies?
M = Medications?
P = Past Medical Problems?
L = Time of Last Meal?
E = Event – What happened?
– What mechanism?
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Assessment & Treatment
Secondary Trauma Survey
2) Do a detailed Physical Exam from head to toe,
specifically looking for the following:
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•
•
•
Dilated or unequal pupils.
Leakage of Cerebrospinal Fluid.
Detailed neurologic exam (sensation, motor function, reflexes).
Log-roll to check for trauma to back of head, spine tenderness,
bruising, step-offs.
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Assessment & Treatment
Secondary Trauma Survey
Signs of C-spine Injury:
• Difficulties breathing
 damage to phrenic
nerve
• Flaccid upper extremities
& loss of reflexes
 damage to anterior
spinal cord
• Hypotension &
bradycardia
 damage of the
autonomic nervous system
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Assessment & Treatment
Secondary Trauma Survey
• Decreased abdominal wall
tone
 damage at level of T-spine
• Decreased sensation or
motor function in lower
limbs
 damage at level of L-spine
• Decreased rectal tone
 damage at level of L-spine
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Assessment & Treatment
Secondary Trauma Survey
Abnormal Neurological Findings:
• Decreased strength in arms
and legs
 anterior cord damage
• Decreased sensation in arms
and legs (touch, proprioception,
vibration)
 posterior cord damage
• Decreased pin prick
discrimination in arms
 lateral cord damage
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Assessment & Treatment
Secondary Trauma Survey
Spinal Shock:
= complete shutdown of central neurologic
functions with spontaneous resolution after
severe spinal cord damage.
• Flaccid paralysis and areflexia
• Only diaphragmatic breathing, no chest wall
rise
• Flexed posture of upper limbs
• Priapism
• Hypotension (= Neurogenic Shock)
• Pain sensation only above clavicles
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Assessment & Treatment
Secondary Trauma Survey
Inform the physician or
medical assistant on call
immediately if any of the
above symptoms are
present!
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Assessment & Treatment
Case:
• You applied spine precautions and put a cervical collar
on the patient.
• During the primary survey, you only note more abrasions
along the left side of his body.
• His GCS score is 15, his vital signs
are stable.
• During the secondary survey, you
notice tenderness along the midline
of his spine and decide to leave the
collar on.
What should be the next step in the assessment?
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Assessment & Treatment
Radiographic Evaluation
X-rays evaluation of the spine:
• C-spine x-rays: 4 views
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Assessment & Treatment
Radiographic Evaluation
X-rays evaluation of the spine:
• T-spine/L-spine x-rays: 2 views
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Assessment & Treatment
Radiographic Evaluation
How to read a c-spine x-ray:
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Assessment & Treatment
Radiographic Evaluation
• Look for:
– Loss of alignment
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Assessment & Treatment
Radiographic Evaluation
• Look for:
– Narrowing of spinal canal
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Assessment & Treatment
Radiographic Evaluation
• Look for:
– Increased distance between spinous processes
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Assessment & Treatment
Radiographic Evaluation
• Look for:
– Fracture of the spinous process
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Assessment & Treatment
Radiographic Evaluation
• Look for:
– Fracture of the vertebral body
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Assessment & Treatment
Radiographic Evaluation
• Look for:
- Bony deformities
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Assessment & Treatment
Case:
• The patient was sent to the x-ray department on a stretcher.
• He was given medication for the
pain in his neck and head.
• He continues to be fully
conscious and his vital signs
remain stable.
• While you clean and dress his
wounds, his c-spine film
returns.
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What do you see and what should be done next?
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Assessment & Treatment
Medical Therapy
If a head injured patient becomes less conscious, it might be due to
intracranial swelling (edema, bleed)  increased intracranial pressure
 herniation.
•Mannitol 20% IV over 30-60 min
– 1 gram/kg for adults and children
(usually not available in pharmacy)
•Dexamethasone (usually not available in pharmacy)
– 12 mg IV then 4mg every 12 hours
– Children: 0.5 mg/kg (maximal 10 mg)
•Furosemide 0.5 mg/kg IV in combination with first dose of
dexamethasone
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Assessment & Treatment
Medical Therapy
If a head injured patient has an open skull fracture,
cover for possible infection.
• Co-amoxiclav
– adults:
600 mg IV every 8 hours
– children: 25 mg/kg IV every 6 hours
• Tetanol 0.5 ml IM
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Assessment & Treatment
Medical Therapy
If a head injured patient is having convulsions, give:
• Diazepam 5-10 mg IV or per rectum
For pain control, use NSAIDs, avoid Pethidine
injections.
• Diclofenac injection
• Paracetamol per rectum
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Assessment & Treatment
Referral & Transfer
• All patients with neurologic deficits need to
be seen by a neurosurgeon or spine surgeon
as soon as possible (= definitive care).
• Once stabilized (ABCs controlled), transfer to a
higher-level health facility must be arranged.
• If an injured patient is transferred, spinal
precautions must be continued until arrival at
the receiving facility!
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Assessment & Treatment
Discharge & Follow-Up
• All patients who
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–
–
are neurologically stable
have no loss of consciousness
have no deterioration in mental status
have no evidence of unstable spine injuries
are not intoxicated
can safely be discharged home after all other injuries are
taken care of.
• Head injured patients with above symptoms need to be
observed in the hospital or might even require transfer.
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Assessment & Treatment
Discharge & Follow-Up
• All discharged patients need to be informed to return
immediately if the following occurs:
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–
–
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Drowsiness, confusion, strange behavior
Vomiting and nausea
Convulsions and seizures
Clear fluid dripping from nose or ears
Severe or worsening headaches
Weakness or sensation loss in limbs
• All discharged patients have to be seen in OPD after 1
week for re-evaluation.
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Case Report 1
• A woman is fetching water from a
well and carries the vessel on her
head. On the way back to the
house, she stumbles and falls.
• The load on her head falls
backwards and violently extends
her head (= cervical
hyperextension injury).
• She is unable to move and
complains about weakness in both
arms and legs (= quadriparesis).
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Case Report 1
• C-spine films taken in the
hospital show no fracture and
no narrowing of the spinal canal.
• Spine precautions are in place
since she is still unable to move
her limbs.
What is the prognosis?
What is the treatment?
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Case Report 2
• A 45-year-old carpenter fell off the roof of a 3-storey
building and landed on his head.
• He is fully conscious, able to move all 4
limbs, and is taken to the nearest Casualty
Ward by a taxi in sitting position.
• He initially has normal vital signs and
appears to be stable.
• While waiting on a bench to be seen by a
health provider, he starts feeling weakness
in all 4 limbs.
• Over the next hours, the patient develops
tetraplegia and respiratory failure.
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Case Report 2
• What made the patient deteriorate suddenly?
• Which things were done wrong in this case?
• ALWAYS follow spine precautions in head or spine injured
patients, even if they appear to be stable initially.
• ALWAYS perform C-spine immobilization in patients involved
in RTAs or falls.
• ALWAYS do a timely assessment and early transfer to higher
level facility if any signs of brain or spinal cord damage.
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Case Report 3
• A 10-year-old boy was struck by a car
and thrown in the air, then hit the
ground with his head and back.
• He sustained cuts and abrasions to his
head and face.
• His family carried him to the Casualty
Ward since he could not be aroused.
How should this boy be assessed?
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Case Report 3
Primary & Secondary Trauma Survey reveal:
• Airway protected.
• Bilateral breath sounds, RR 20.
• No acute bleeding, pulse 100, BP 110/60.
• Not opening eyes, no verbal response, withdraws arms to
pain.
• No other injuries or bone deformities after being
undressed.
• What is the boys AVPU and GCS score?
• What next?
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Review Questions
• What is the most common spine injury?
• What are spine precautions?
• What do we do when we “log roll” a patient?
• When do we stop spinal precautions?
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ANY QUESTIONS?
Resources and Literature used:
• Ghana Standard Treatment Guidelines 2010
• Management of Accidents and Emergencies, Ghana 2004
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