Head & Spine InjuriesHead & Spine Injuries

Waleed DabbasWaleed Dabbas

Multisystem injuries Multisystem injuries associated with Head & associated with Head &

Spine injuriesSpine injuriesHeadHead SpineSpine

ChestChest 78%78% 10%10%

AbdomenAbdomen 53%53% 3%3%

CardiacCardiac 3%3% 2%2%

musculoskeletalmusculoskeletal 43%43% 18%18%

SpineSpine 6%6%

HeadHead 16%16%

Trauma TeamTrauma Team

General SurgeonGeneral Surgeon Orthopedic SurgeonOrthopedic Surgeon Vascular SurgeonVascular Surgeon Cardiothoracic surgeonCardiothoracic surgeon NeurosurgeonNeurosurgeon AnesthesiologistAnesthesiologist Critical CareCritical Care

Trauma management protocolTrauma management protocolStart treatment before HX and P/EStart treatment before HX and P/E

Primary surveyPrimary survey

-Airway-Airway

-Breathing-Breathing

-Circulation-Circulation Secondary surveySecondary survey

-Hx & complete system by system exam-Hx & complete system by system exam

-X-rays (Chest, C-spine, Skeletal)-X-rays (Chest, C-spine, Skeletal)

-CT (Brain, C-Spine, Chest, Abdomen)-CT (Brain, C-Spine, Chest, Abdomen)

Initial Neurological Initial Neurological examination in head examination in head injuryinjury GCSGCS Pupillary size and response to lightPupillary size and response to light Eye movements;Eye movements;

-Occulocephalic (dolls eyes)-Occulocephalic (dolls eyes)

-Oculovestibular (Caloric)-Oculovestibular (Caloric) Gross motor Gross motor Gross sensoryGross sensory

Head injuryHead injury

Glasgow coma score (GCS)Glasgow coma score (GCS)-Eye opening (E); -Eye opening (E); Spontaneous=4, to voice=3, to pain=2, None=1Spontaneous=4, to voice=3, to pain=2, None=1

-Verbal response (V); -Verbal response (V); oriented=5, confused=4, inappropriate word=3, incomprehensive oriented=5, confused=4, inappropriate word=3, incomprehensive

sounds=2, None=1sounds=2, None=1

-Motor response (M); -Motor response (M); Obeys command=6, localize pain=5, withdraw=4, flexion=3, Obeys command=6, localize pain=5, withdraw=4, flexion=3,

extension=2, None=1extension=2, None=1

13-15 (mild), 9-12 (moderate), 13-15 (mild), 9-12 (moderate), 3-8 (severe)3-8 (severe)

Protocol for mild HI Protocol for mild HI (GCS 13-15)(GCS 13-15)

Initial work-up:Initial work-up:

-History: (mechanism of injury, hx of -History: (mechanism of injury, hx of L.O.C, HA, neck or back pain, L.O.C, HA, neck or back pain, seizures)seizures)

-Neurological exam-Neurological exam

-Physical exam (R/O systemic injuries)-Physical exam (R/O systemic injuries)

-Brain CT scan -Brain CT scan

-C-Spine Xray-C-Spine Xray

-Blood alcohol level-Blood alcohol level

Protocol for mild HIProtocol for mild HI

Admit to hospital:Admit to hospital:-Significant amnesia-Significant amnesia-Hx of L.O.C (> 5 minutes)-Hx of L.O.C (> 5 minutes)-Deteriorating L.O.C-Deteriorating L.O.C-Significant Alcohol-drug intoxication-Significant Alcohol-drug intoxication-Skull # -Skull # -CSF leak-CSF leak-Significant associated systemic injuries-Significant associated systemic injuries-No reliable companion at home-No reliable companion at home-Abnormal Brain CT.-Abnormal Brain CT.

Discharge from ER ifDischarge from ER if-Patient does not meet the above criteria for -Patient does not meet the above criteria for

admissionadmission-Discuss the need to return if any problem developed -Discuss the need to return if any problem developed

(warning sheet)(warning sheet)

Moderate (GCS 9-12) and Moderate (GCS 9-12) and severe (GCS 3-8) HIsevere (GCS 3-8) HI

Admit to hospital even with Admit to hospital even with normal brain CTnormal brain CT

Mechanism of HIMechanism of HI

Closed; Closed;

-High velocity (auto accident)-High velocity (auto accident)

-Low velocity (falls, assault)-Low velocity (falls, assault)

Penetrating;Penetrating;

-Gunshot wounds-Gunshot wounds

-other open injuries-other open injuries

Primary traumatic Primary traumatic injuriesinjuries Skull #;Skull #;-Linear-Linear-Depressed-Depressed-basal skull -basal skull

Diffuse brain lesion;Diffuse brain lesion;-Brain concussion-Brain concussion-Diffuse axonal injury (DAI)-Diffuse axonal injury (DAI)

Focal lesion;Focal lesion;-Epidural hematoma-Epidural hematoma-Subdural hematoma-Subdural hematoma-Intracerebral hgg-Intracerebral hgg-brain contusion, laceration-brain contusion, laceration

Management of traumatic Management of traumatic HIHI

ABCABC Control ICPControl ICP Treat specific lesion (epidural, Treat specific lesion (epidural,

subdural)subdural) Treat associated injuriesTreat associated injuries Long term treatment for disabled Long term treatment for disabled

patientspatients

ICPICP

Monro-Kellie Monro-Kellie doctrine ruledoctrine rule

Management Of High ICPManagement Of High ICP

ICPICP

Clinical casesClinical cases

Skull base fracture

Depressed skull fractures

Epidural hematoma

Subdural hematoma