HEAD TRAUMA, SKULL FRACTURES & C-SPINE INJURIES

A MOCK RESUS AND SLIDE PRESENTATION BY THE CASUALTY CREW

A HEAD INJURY SCENARIO

• A 27 YR OLD MALE PT WAS BROUGHT INTO CASUALTY AFTER A STEEL BEAM FROM A SCAFFOLD FELL ON HIS HEAD WHILE HE WAS WORKING , HE HAS AN INITIAL GCS OF E=2 M=3 V=2 7/15, POOR RESPIRATORY EFFORT AND SEVERE EPISTAXIS. HE IS BROUGHT IN BY CO-WORKERS WHO ARE PANICKING AND ARE GIVING A POOR HISTORY OF EVENTS

• INITIAL VITALS, BP=157/65 RR=10 HR=65 HGT=3.5

• WHAT DO YOU DO FIRST?

• HOW HAVE YOU ORGANISED YOURSELF AND YOUR TEAM

• WHAT METHOD OF INTUBATION?

• SHOULD HE HAVE A HARD COLLAR?

• WHAT ABOUT A NASOGASTRIC TUBE?

• WHAT BLOODS DO WE TAKE?

• WHAT SHOULD THE TEAM LEADER BE DOING?

• WHAT ARE YOU CONSIDERING AT THIS POINT COULD BE THE MAIN INJURIES?

• WHO YOU GONNA CALL? GHOSTBUSTERS? :)

IN LINE IMMOBILIZATION

• REMEMBER THE C-SPINE

• THERES NO GOING BACK ONCE YOU DAMAGE THAT SPINAL CORD!!

NGT IN BRAINIF THE CRIBIFORM PLATE IS POSSIBLY COMPROMISED DO AN OROGASTRIC

• A GCS OF 8 OR LESS IS A SEVERE HEAD INJURY

• EASY CLASSIFICATION AVPU

• A=ALERT GCS=15

• V=RESPONSIVE TO VOICE GCS=9-14

• P=RESPONSIVE TO PAIN GCS=5-8

• U=UNRESPONSIVE GCS=3-5

AS WE EXAMINE THE PT WE SEE?…. REMEMBER WE ARE ONLY CONCENTRATING

ON THE SKULL AND C-SPINE THIS TIME

• ALL WOUNDS OF THE SCALP SHOULD BE EXPLORED

• A HIGH GCS DOES NOT MEAN EVERYTHING WILL REMAIN OK

• YOU CAN HAVE COMBINED BASAL AND DEPRESSED FRACTURES

DONT FORGOT THE EYES AND EARS!!

• SO REMEMBER THE CLASSIC OUTWARD SIGNS MAY TAKE TIME TO DEVELOP

• THIS IS A HAEMOTYMPANUM

• PATHOGNOMIC OF BASAL SKULL FRACTURE

WHATS THAT FLUID?

• OTORRHEA AND RHINORHEA MAY BE CSF, NOT SURE IF IT IS…..

• PUT A DROP OF FLUID ON A GLUCOMETER STRIP, IF A GLUCOSE VALUE IS SHOWN THERES A GOOD CHANCE ITS CSF

• TEST OF CHOICE IS BETA2 TANSFERRIN ASSAY, BUT HOW MANY OF US WILL REMEMBER THAT AT THE END OF THIS PRESENTATION!!

SUBCONJUNCTIVAL HAEMMORHAGE

• NOTE THAT THERE IS NO POSTERIOR BORDER

• WE WILL COVER EYE TRAUMA NEXT TIME!

• YOU HAVE STABILISED YOUR PTS CONDITION FROM A HAEMODYNAMIC POINT OF VIEW BUT HE IS STILL IN A CUSHINGS STATE, BREATHING WITH BAGGING IS KEEPING HIS SATS UP AND YOU HAVE COMPLETED MOST OF THE SECONDARY SURVEY INCLUDUNG EYES EARS AND TORSO AND EXTREMITIES, BLOOD RESULTS HAVE COME BACK NORMAL

• YOU NOTE THE SCALP LACERATION, SUSPECTED CRIBIFORM PLATE INJURY, HAEMOTYMPANUM, SUBCONJUNCTIVAL HAEMMORHAGE RIGHT SIDE, WITH R BLOWN PUPIL, BATTLES SIGN, PANDA/RACCOON EYES, HAVE INTUBATED , STABILIZED C-SPINE,AND PASSED AN OROGASTRIC TUBE

• PHEW!!!

• WHAT SHOULD YOUR NEXT INVESTIGATIONS BE?

• WHAT DO YOU TELL THE SURGEON WHO IS RUSHING IN ?

NEURAL ARCH FRACTURE C2MAY ALSO BE PRESENT AT C1

ODONTOID PEG #

OPEN MOUTH VIEWODONTOID PEG #

BURST (JEFFERSON )# C1NOTICE THE OVERHANG OVER THE BODY OF C2

UNILATERAL AND BILATERAL FACET DISLOCATION

NOTE THE % OF MOVEMENT

A WEDGE FRACTURE C4 A TEARDROP FRACTURE C6

HANGMANS FRACTUREHyperextension of the neck transmits the force through to the C2 pedicles. This results in an oblique fracture originating anterior to the inferior facet of C2 and extending supero-posteriorly. Tension causes disruption of the anterior longitudinal ligament causing this injury to be unstable. Will be demonstrated on the lateral view but may be undisplaced

FRONTAL SINUS FRACTURES

• IF YOUR EXPLORATION REVEALS INJURY TO ANTERIOR TABLE THEN AN URGENT CT IS RECOMMENDED

• IF IT REVEALS INJURY AND MOVEMENT OF POSTERIOR TABLE NEUROSURGEONS /SURGEONS MUST BE INVOLVED

HEAD INJURY WITH SUSPECTED

FRACTURE OR NOT

C-A-B APPROACH FIRST IMMOBILIZE C-SPINE

KEEP PT ALIVE BEFORE DEAING WITH

INJURIES- DUH!!!

EXPLORE LACS

GIVE A PROPER GCS SCORE

GIVE AN AVPU SCORE

NOW SECONDARY SURVEY

DONT FORGET THE BACK OF THE

HEAD

CHECK THE EYES

CHECK THE NOSE

CHECK THE EARS

CHECK THE MOUTH

CHECK FOR SIGNS OF FRACTURE

RACCOON EYES

BATTLES SIGN

DO A C SPINE XRAY

SUTURE QUICK IF ACTIVE

BLEED

DELAY SUTURE IF NONE

COMPLETE SECONDARY

SURVEY

13-15 LET A SENIOR DECIDE

8-12 CT!!!

<8 INTUBATE

EMERGENCY CT!!!

SECONDARY SURVEY OF THE

REST OF THE BODY

CHECK VITALS

BLOODS ABG!!!

DILATED PUPIL CHANGES IN POWER TONE

OR REFLEXES SENSORY ABNORMALITIES REPORTED

CT BRAIN +

CT SPINE

SUSPECTED FRACTURE AND/OR

IMMOBILIZE HARD COLLAR

SOFT COLLAR IS A NECK WARMER

ONLY

DONT FORGET TO INFORM SURGEONS/ SURGICAL TEAM ASAP!!!!!

HEAD INJURY APPROACH