PTCPTC

PTCPTC

HEAD & SPINAL TRAUMAHEAD & SPINAL TRAUMA

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Head TraumaObjectives

To understand the structured approach to the patient with head trauma

To learn how to identify serious and life-threatening head injuries

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Head Trauma

Accounts for 1/3-1/2 of trauma deaths Good outcomes are possible without CT

scans and neurosurgeons Aim to avoid any further injury to the brain Hypoxia and hypotension double mortality

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Head TraumaApproach

Airway

Breathing

Circulation

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Head TraumaPhysiology

CPP = MAP - ICP

CPP = cerebral perfusion pressure

MAP = mean arterial pressure

ICP = intracranial pressure

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Cerebral Blood FlowDepends on:

CPP (MAP-ICP)

PaCO2

PaO2

Local metabolites

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Head TraumaPathophysiology

Primary Injury

- occurs at time of injury

Secondary Injury

- occurs after injury

- may be preventable

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HEAD TRAUMAPrimary injury

Diffuse axonal injury acceleration deceleration

Cerebral contusion Penetrating injury

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HEAD TRAUMA Secondary injury

Hypoxia Hypoperfusion (ICP,

MAP) Hypoglycaemia Hyperthermia (fever) Seizures

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Head TraumaInitial assessment

Airway (+ C-spine)

Breathing

Circulation

Disability (AVPU, pupils)

Exposure

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Head Trauma Examination

Glasgow Coma Score Pupils Corneal reflex Eye position Fundi

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Head Trauma Examination

Tympanic membrane Scalp and skull Respiratory Pattern Muscle tone Posture Tendon reflexes

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Head Trauma Glasgow Coma Score (GCS)

Grades severity of head injury Score out of 15 Subject to inter-observer variation Trend of GCS over time very

useful Important to describe responses

also

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Head Trauma GCS Eye opening

Open spontaneously 4

Open to command3

Open to pain2

None 1

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Head Trauma GCS Best Verbal Response

Oriented 5

Confused 4

Inappropriate words 3

Inappropriate sounds 2

None 1

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Head Trauma GCS Best Motor Response

Obeys command 6

Localises to pain 5

Withdraws to pain 4

Abnormal flexion 3

Extensor response 2

None 1

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Head Trauma Severity of Head Injury

Severe GCS <8

Moderate GCS 9-12

Minor GCS 13-15

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Head Trauma Pupillary signs

Size Reactivity Equality

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Head Trauma Pupillary responses

Fixed, dilated,

unresponsive

Severe hypoxia Hypothermia Seizures

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Head Trauma Pupillary responses

Unilateral, dilated,

unresponsive

Expanding lesion on same side

Tentorial herniation Seizures

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Head TraumaAcute extraduralAcute subdural

potentially life-threatening

immediate recognition essential

require burr-hole decompression

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Head TraumaAcute extradural

LOC lucid interval deterioration

middle meningeal artery bleed overlying skull fracture contralateral hemiparesis fixed pupil on side of injury

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Head TraumaAcute subdural

Tearing of bridging vein between cortex and dura

Severe contusion of underlying brain Usually no lucid interval Worse prognosis than extradural

haematoma

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Head TraumaOther injuries

Base-of-skull fractures Cerebral concussion Depressed skull fracture Intracerebral haematoma

Usually do not require neurosurgery

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AirwayBreathing (ventilation)Circulation + Avoid ICP

Head TraumaManagement

Aim to prevent secondary injury

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Head TraumaSevere (GCS<8)

Intubate Normal CO2

Treat hypotension with fluid Sedation +/- paralysis

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Head TraumaSevere (GCS<8)

Nurse head up 20o

Prevent hyperthermia Complete secondary survey Reassess frequently

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Head TraumaBeware

Deteriorating conscious state Penetrating injury Focal neurological signs

- unequal, dilated pupils

- seizures

- posturing

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Head Trauma

?

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Head TraumaSummary

ABCs Prevent secondary injury Isolated head trauma doesn’t

cause hypotension Look for other injuries Deterioration reassess

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Spinal Trauma

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Spinal TraumaObjectives

To understand the structured approach to the patient with spinal trauma

To learn how to identify serious and life-threatening spinal injuries

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Spinal TraumaPrimary survey

Airway + Cervical spine

Breathing

Circulation

Disability

Exposure

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Spinal TraumaSecondary survey

Immobilise- stiff neck collar

- sandbags + tapes

- in-line immobilisation Examine in neutral position Log-roll to examine back

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Spinal Trauma Secondary survey

Local tenderness Swelling Deformity and stepping

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Spinal Trauma Assessment of level

Motor response Sensory response

– especially sacral sparing Reflexes Autonomic function

- bowel control

- bladder control

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Spinal Trauma High risk for C-spine

Head injury Paradoxical (diaphragmatic)

breathing Flaccid limbs No reflexes (check rectal

sphincter) Hypotension (+bradycardia)

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Spinal TraumaTransport

Never transport in sitting or prone position STABILISE SPINE PRIOR TO STABILISE SPINE PRIOR TO

MOVEMENTMOVEMENT Log roll for transfer

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If spine is protected, its further examination and evaluation can be

safely deferred until other life threatening emergencies are dealt

with.

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How spine can be protected?

Manual in line traction Roll of newspapers Collars KED/ RED Spinal board Four point fixation of cervical spine Log roll Spinal lift Scoop stretcher

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Cervical Collars

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Spinal Board

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LOG ROLLING

LOG ROLL AND PROTECTION

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PTCPTC52

Spinal Lift & Log-roll

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Primary Survey and Resuscitation

Airway with cervical spine control– Assess – Clear – No head tilt – Definitive Airway

Breathing: Oxygenation – Ventilation– High spinal injury and paralysis of respiratory mls

Circulation with haemorrhage control– Neurgenic shock – bradycarida + hypotension – don’t overload, use inotropes

Disability: Brief neurologic examination– Paraplegia, tetraplegia, radiculopathy

Exposure and environmental control– Logroll, undress, examine spine, check

bulbocavernuous reflex

PTCPTC56

Secondary Survey and Neurological Assessment

AMPLE HISTORYAMPLE HISTORY ATTITUDEATTITUDE GCS AND PUPILSGCS AND PUPILS SENSORY EXAMINATIONSENSORY EXAMINATION MOTOR EXAMINATIONMOTOR EXAMINATION REFLEXESREFLEXES

AALLERGIESLLERGIESMMEDICATIONSEDICATIONSPPAST HISTORY/ AST HISTORY/ PREGNANCYPREGNANCYLLAST MEALAST MEALEENVIRONMENT/ NVIRONMENT/ EVENTS – EVENTS – MECHANISM OF MECHANISM OF SPINAL INJURYSPINAL INJURY

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HOW TO RULE OUT SPINAL INJURY?

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NO NECK PAINNO NECK PAIN NO NEUROLOGICAL NO NEUROLOGICAL

DEFICITDEFICIT– Unlikely to have acute c/spine injury– Remove collar– Palpate spine, if non-tender– Ask to move neck from side to side– Ask to flex and extend neck– Active movements normal = spine is cleared – No x-rays needed

PTCPTC59

NECK PAIN IS PRESENT NECK PAIN IS PRESENT NO NEUROLOGICAL NO NEUROLOGICAL

DEFICITDEFICIT– X-rays – cross table lat/ AP/ open mouth– Flexion/extension views if above are normal– CT if still in doubt

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NEUROLOGICAL DEFICIT NEUROLOGICAL DEFICIT (PARA OR TETRAPLEGIA)(PARA OR TETRAPLEGIA)

– Presumptive evidence of spinal injury– Keep spine protected– Appropriate x-rays– Take these patients off spinal board within

2hrs otherwise high chance of pressure sores

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COMATOSED OR ALTERED COMATOSED OR ALTERED LEVEL OF CONSCIOUSNESS LEVEL OF CONSCIOUSNESS

OR OR TOO YOUNG TO DESCRIBE TOO YOUNG TO DESCRIBE

THEIR SYMPTOMSTHEIR SYMPTOMS– X-rays – cross table lat/ AP/ open mouth (if

possible)– Flexion/extension views if above are normal– CT if still in doubt– Review by Neuro/Ortho/Spinal surgeon

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Incidence Stability

– 90% are stable injuries and 10% are unstable Neurological deficit

– 75% unstable injuries have neurological deficit Spinal Cord Injury (< 5% of all spinal column fractures)

– 50/Million/Yr (USA), 15/Million/Yr (UK) Sex

– 4M:1F Age

– Average age is 30 Yrs

MISSED INJURIESMISSED INJURIES– 1/3 CASES OF C/SPINE INJURY ARE MISSED 1/3 CASES OF C/SPINE INJURY ARE MISSED

INITIALLYINITIALLY

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Fracture Level

CERVICAL SPINE CERVICAL SPINE 40%40%– MOST COMMON FRACTURE IS OF C5MOST COMMON FRACTURE IS OF C5– MOST COMMON SUBLUXATION IS C5/6MOST COMMON SUBLUXATION IS C5/6

Thoracic spine (T1-T9) 15% Thoracolumbar spine (T10-L5) 30%

– Most common fracture is of L1

Multi level 15%

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ASSOCIATED INJURIES

• HEAD AND FACE INJURYHEAD AND FACE INJURY 26 %26 %

• Major chest injury 16 %

• Major abdominal injury 10%

• Long bone/pelvic fracture 8%

PTCPTC65

Levels of Spinal Injury

1. SKELETAL: level of bony injury2. NEUROLOGICAL: sensory & motor

level with totally preserved function. Sensory & motor levels may be different on the same as well as on the opposite sides hence 4 levels)

3. LEVEL OF PARTIAL PRESERVATION: presence of partial function below the neurological level,e.g sacral sparing.

PTCPTC66

Other systems

CHEST– Hypoventilation

• Intercostals T1-T12

• Diaphragm C3-C5

– Paradoxical breathing

ABDOMEN– Inability to perceive pain may mask features of acute

abdomen• Reliance on indirect features like referred pain in shoulders or

investigations like DPL, USG, CT and MRI

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C/spine x-rays – lat view

Identify– Occipital condyles– All seven cervical

vertebrae– Superior aspect of body of

T1 Anatomic assessment

– Alignment – 5 lordotic curves

– Bones – contour– Cartilage – discs and facet

joints– Soft tissues – pre-vertebral

and inter-spinous space, ADI

OC

T1

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Open Mouth & AP Views

Occipital

condyle

Lat mass C1

Lat mass C2

Odontoid Peg

Bifid spinous process

Unco-vertebra

l joint

C7

T1

PTCPTC69

Other investigations

CT SCAN– Indications

• To define a suspicious fracture on x-rays

• Inability to see lower cervical spine

MRI– Indications

• Neurological deficit

• Facet dislocations

PTCPTC70

Classification of Spinal Injuries

Spinal Column Injuries– Stable– Unstable

Spinal Cord Injuries– Complete– Incomplete

SCIWORA

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Management of spinal injuries Stable injuries

– Symptomatic. Bed rest. Splinting. Mobilisation Unstable injuries without neurological deficit

– Adequate immobilisation. Cervical spine (hard collar, sand bags, tape). Thoracolumbar spine (spinal board). Logroll. Spinal lift

– Dislocations and fracture dislocation should be reduced as soon as possible • Closed reduction. Cervical spine (Halo traction, Gardner Wells tongs). Thoracolumbar spine

(postural)• ORIF

– Beware of disc prolapse in dislocations. MRI/ anterior approach Unstable injuries with neurological deficit

– Adequate Immobilisation– Decompression– High-dose steroids

• MSP start in first 8 hrs only. 30mg/kg in 15min. Wait for 45 min. 5.4mg/kg/hr/23hrs– Establish as soon as possible whether injury is complete or incomplete– Care of bladder, bowel, lungs and skin– Haemodynamics – brady cardia/ hypotension – don’t over transfuse –

atropine/inotropes

PTCPTC72

Medical Management of SCI

Methylprednisolone (MPS) (Solumedrol) start only in the first 8 hrs of injury– 30mg/kg IV in 15mins, wait for 45mins,

5.4mg/kg/hr for next 23hrs Analgesia Atropine

– If heart rate <50/min IV fluids and inotropes for hypotension Bladder/ Bowel/ Skin care/ Take pt off spinal

board asap (max 2hrs if paralysed)

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1

PTCPTC

29 YEAR OLD REFRIGERATOR ENGINEER HAD BEEN 29 YEAR OLD REFRIGERATOR ENGINEER HAD BEEN OUT HORSE-RIDING, WHEN HIS HORSE HAD BOLTED OUT HORSE-RIDING, WHEN HIS HORSE HAD BOLTED AND HE WAS AND HE WAS THROWN OFF, HITTING HIS HEAD ON THROWN OFF, HITTING HIS HEAD ON THE BRANCH OF A TREE.THE BRANCH OF A TREE. THE PARAMEDICS HAVE THE PARAMEDICS HAVE HIM IMMOBILISED ON A SPINAL BOARD WITH A HIM IMMOBILISED ON A SPINAL BOARD WITH A

RIGID CERVICAL COLLAR IN PLACE. ACCORDING TO RIGID CERVICAL COLLAR IN PLACE. ACCORDING TO THEM THERE WAS THEM THERE WAS NO LOSS OF CONSCIOUSNESSNO LOSS OF CONSCIOUSNESS AT AT ANY TIME, AND HE IS RESPONDING APPROPRIATELY ANY TIME, AND HE IS RESPONDING APPROPRIATELY TO COMMANDS. HE IS COMPLAINING OF TO COMMANDS. HE IS COMPLAINING OF MILD NECK MILD NECK

PAIN AND TINGLING IN BOTH ARMSPAIN AND TINGLING IN BOTH ARMS. . ON GPE U FIND ON GPE U FIND WEAKNESS IN BOTH ARMS, WEAKNESS IN BOTH ARMS,

PROXIMALLY MORE THAN DISTALLY, WITH SOME PROXIMALLY MORE THAN DISTALLY, WITH SOME ASSOCIATED LOSS OF LIGHT TOUCH AND PAIN ASSOCIATED LOSS OF LIGHT TOUCH AND PAIN SENSATIONSENSATION. WITH AN ASSISTANT MANUALLY . WITH AN ASSISTANT MANUALLY

STABILISING HIS NECK, YOU REMOVE THE COLLAR STABILISING HIS NECK, YOU REMOVE THE COLLAR AND EXAMINE THE PATIENT. THERE IS AND EXAMINE THE PATIENT. THERE IS NO BONY NO BONY

TENDERNESS, DEFORMITY OR DEFECT. HIS NECK IS TENDERNESS, DEFORMITY OR DEFECT. HIS NECK IS NOT TENDER TO PALPATIONNOT TENDER TO PALPATION. .

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Can you clear this man's cervical spine clinically?

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PTCPTC

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

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PTCPTC

AP and Open mouth views are normal as well.

What next?

PTCPTC

YOU SEND THE PT OFF FOR AN MRI SCAN YOU SEND THE PT OFF FOR AN MRI SCAN AND YOU GET THE RESULTS BACK - AND YOU GET THE RESULTS BACK - A A

CENTRAL CORD HAEMATOMA - CENTRAL CORD HAEMATOMA - CONSISTENT WITH THE CENTRAL CORD CONSISTENT WITH THE CENTRAL CORD

SYNDROMESYNDROME YOU FOUND ON YOU FOUND ON EXAMINATION. EXAMINATION.

YOU PACK THE PT OFF TO THE SPINAL YOU PACK THE PT OFF TO THE SPINAL UNIT WHERE, YOU LATER LEARNED, HE UNIT WHERE, YOU LATER LEARNED, HE REGAINED FULL FUNCTION AND WAS REGAINED FULL FUNCTION AND WAS

DISCHARGED. DISCHARGED.

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2

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YOUR PATIENT, JAMES COOK, A 32 YEAR OLD YOUR PATIENT, JAMES COOK, A 32 YEAR OLD TRAVEL WRITER TRAVEL WRITER CAME OFF HIS MOTORCYCLE CAME OFF HIS MOTORCYCLE

WHICH SKIDDED ON SOME ICEWHICH SKIDDED ON SOME ICE. THE PARAMEDICS . THE PARAMEDICS HAVE HIM IMMOBILISED ON A SPINAL BOARD WITH HAVE HIM IMMOBILISED ON A SPINAL BOARD WITH A RIGID CERVICAL COLLAR IN PLACE. ACCORDING A RIGID CERVICAL COLLAR IN PLACE. ACCORDING

TO THEM THERE WAS TO THEM THERE WAS NO LOSS OF NO LOSS OF CONSCIOUSNESS AT ANY TIMECONSCIOUSNESS AT ANY TIME, , AND HE IS AND HE IS

RESPONDING APPROPRIATELY TO COMMANDS. HE RESPONDING APPROPRIATELY TO COMMANDS. HE IS IS NOT COMPLAINING OF ANY NECK PAINNOT COMPLAINING OF ANY NECK PAIN. . ON GENERAL EXAMINATION YOU FIND ON GENERAL EXAMINATION YOU FIND NO NO

NEUROLOGY AND NO EVIDENCE OF OTHER INJURNEUROLOGY AND NO EVIDENCE OF OTHER INJURYY. . WITH AN ASSISTANT MANUALLY STABILISING HIS WITH AN ASSISTANT MANUALLY STABILISING HIS NECK, YOU REMOVE THE COLLAR AND EXAMINE NECK, YOU REMOVE THE COLLAR AND EXAMINE THE PATIENT. THERE IS NO BONY TENDERNESS, THE PATIENT. THERE IS NO BONY TENDERNESS,

DEFORMITY OR DEFECT. DEFORMITY OR DEFECT. THINK YOU CAN HANDLE THIS ONE? THINK YOU CAN HANDLE THIS ONE?

PTCPTC

YOU REMOVE MR. COOK'S SPINAL YOU REMOVE MR. COOK'S SPINAL IMMOBILISATION AND HARD COLLAR. HE LOOKS IMMOBILISATION AND HARD COLLAR. HE LOOKS BETTER ALREADY! YOU RE-EXAMINE HIM OUT OF BETTER ALREADY! YOU RE-EXAMINE HIM OUT OF HIS COLLAR, AND FIND NO NEW SIGNS. HE HAS HIS COLLAR, AND FIND NO NEW SIGNS. HE HAS FULL AND PAIN FREE RANGE OF MOVEMENTS. FULL AND PAIN FREE RANGE OF MOVEMENTS.

YOU DISCHARGE MR. COOK WITH ADVICE TO YOU DISCHARGE MR. COOK WITH ADVICE TO CHANGE HIS MOTORCYCLE FOR A BUS PASS, AND CHANGE HIS MOTORCYCLE FOR A BUS PASS, AND

TO 'STAY OUT OF TROUBLE' . TO 'STAY OUT OF TROUBLE' .

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3

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YOUR PATIENT IS MR. HORATIO NELSON, A YOUR PATIENT IS MR. HORATIO NELSON, A SURPRISINGLY SHORT 19 YEAR OLD, WHO HAS SURPRISINGLY SHORT 19 YEAR OLD, WHO HAS

FALLEN OUT OF A SINGLE STOREY WINDOWFALLEN OUT OF A SINGLE STOREY WINDOW WHILE AT A PARTY. HIS MATE ASSURES YOU WHILE AT A PARTY. HIS MATE ASSURES YOU

THAT APART FROM THAT APART FROM QUITE A LOT OF ALCOHOLQUITE A LOT OF ALCOHOL HORATIO ONLY TOOK HORATIO ONLY TOOK 2 OR 3 ECSTASY TABLETS2 OR 3 ECSTASY TABLETS (THOUGH HORATIO LOOKS BLOODY MISERABLE (THOUGH HORATIO LOOKS BLOODY MISERABLE

AT THE MOMENT). AT THE MOMENT). SPINAL IMMOBILISATION AND A RIGID CERVICAL SPINAL IMMOBILISATION AND A RIGID CERVICAL

COLLAR ARE IN PLACE. ON EXAMINATION YOU COLLAR ARE IN PLACE. ON EXAMINATION YOU ONLY FIND SOME ONLY FIND SOME BRUISING AROUND ONE EYE BRUISING AROUND ONE EYE

AND A BROKEN HUMERUSAND A BROKEN HUMERUS. HIS . HIS NECK IS NECK IS CLINICALLY NOT TENDER, WITH NO DEFORMITY CLINICALLY NOT TENDER, WITH NO DEFORMITY

OR DEFECT, AND HE HAS NO OBVIOUS OR DEFECT, AND HE HAS NO OBVIOUS NEUROLOGYNEUROLOGY. .

Can you clear this man's cervical spine clinically?

PTCPTC

PTCPTC

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

PTCPTC

YOU ORDER THE OPEN MOUTH AND AP FILMS YOU ORDER THE OPEN MOUTH AND AP FILMS FOR HORATIO, WHO IS NOW REALLY GETTING A FOR HORATIO, WHO IS NOW REALLY GETTING A LITTLE BIT MUCH. HE'S NOW OFFERING TO SINK LITTLE BIT MUCH. HE'S NOW OFFERING TO SINK

BATTLESHIPS AND MOVE WHOLE ARMIES FOR BATTLESHIPS AND MOVE WHOLE ARMIES FOR YOU. YOU.

HIS OTHER X-RAYS ARE ALSO NORMAL. YOU HIS OTHER X-RAYS ARE ALSO NORMAL. YOU REMOVE HIS HARD COLLAR AND EXAMINE HIS REMOVE HIS HARD COLLAR AND EXAMINE HIS NECK GENTLY. HE COMPLAINS OF NO PAIN OR NECK GENTLY. HE COMPLAINS OF NO PAIN OR

TENDERNESS.TENDERNESS.

PTCPTC

What are your plans?

PTCPTC

YOU RECOGNISE THAT YOUR PHYSICAL EXAM, YOU RECOGNISE THAT YOUR PHYSICAL EXAM, WHILE REASSURING, IS NOT RELIABLE GIVEN WHILE REASSURING, IS NOT RELIABLE GIVEN

THE COCKTAIL OF DRUGS AND ALCOHOL HE HAS THE COCKTAIL OF DRUGS AND ALCOHOL HE HAS TAKEN. SO YOU ADMIT HIM.TAKEN. SO YOU ADMIT HIM.

BY MORNING HE HAS SOBERED UP AND BY MORNING HE HAS SOBERED UP AND PREDICTABLY HE LOOKS TERRIBLE. HIS PREDICTABLY HE LOOKS TERRIBLE. HIS

PHYSICAL EXAMINATION IS ENTIRELY NORMAL PHYSICAL EXAMINATION IS ENTIRELY NORMAL AND YOU DISCHARGE HIM INTO HARDY'S CARE AND YOU DISCHARGE HIM INTO HARDY'S CARE

WITH ADVICE.WITH ADVICE.

PTCPTC

4

PTCPTC

MR. CHARLES DARWIN IS A 42 YEAR OLD WHOSE MR. CHARLES DARWIN IS A 42 YEAR OLD WHOSE CAR VEERED OFF THE ROAD. HE WAS CAR VEERED OFF THE ROAD. HE WAS

UNCONSCIOUS ON SCENE AND REQUIRED UNCONSCIOUS ON SCENE AND REQUIRED EXTRACTION FROM THE VEHICLEEXTRACTION FROM THE VEHICLE. .

ACCORDING TO THE PARAMEDICS HE WAS ACCORDING TO THE PARAMEDICS HE WAS HAEMODYNAMICALLY STABLE THROUGHOUT, HAEMODYNAMICALLY STABLE THROUGHOUT,

WITH A GLASGOW COMA SCORE OF 6 INITIALLYWITH A GLASGOW COMA SCORE OF 6 INITIALLY. . BOTH PUPILS ARE EQUAL AND REACTIVEBOTH PUPILS ARE EQUAL AND REACTIVE. THEY . THEY

INTUBATED HIM ON SCENEINTUBATED HIM ON SCENE. . HIS ONLY EXTERNAL HIS ONLY EXTERNAL INJURIES APPEAR TO BE INJURIES APPEAR TO BE BRUISING AND CUTS TO BRUISING AND CUTS TO HIS FOREHEADHIS FOREHEAD. SPINAL IMMOBILISATION IS IN . SPINAL IMMOBILISATION IS IN

PLACE.PLACE.

PTCPTC

YOU WISELY DECIDE THAT MR. DARWIN NEEDS YOU WISELY DECIDE THAT MR. DARWIN NEEDS HIS COLLAR AT THE MOMENT. EXAMINING HIM HIS COLLAR AT THE MOMENT. EXAMINING HIM YOU CONFIRM THE PARAMEDICS FINDINGS. HE YOU CONFIRM THE PARAMEDICS FINDINGS. HE

IS INTUBATED AND VENTILATED, IS INTUBATED AND VENTILATED, HAEMODYNAMICALLY STABLE WITH A GCS NOW HAEMODYNAMICALLY STABLE WITH A GCS NOW OF 4 AND EQUAL, REACTIVE PUPILS. YOU NEED OF 4 AND EQUAL, REACTIVE PUPILS. YOU NEED

TO MOVE QUICKLY AS HE MAY HAVE AN TO MOVE QUICKLY AS HE MAY HAVE AN EVOLVING BRAIN INJURY. EVOLVING BRAIN INJURY.

YOU ORDER A LATERAL CERVICAL SPINE FILM.YOU ORDER A LATERAL CERVICAL SPINE FILM.

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PTCPTC

MR. DARWIN REMAINS STABLE BOTH MR. DARWIN REMAINS STABLE BOTH HAEMODYNAMICALLY AND NEUROLOGICALLY HAEMODYNAMICALLY AND NEUROLOGICALLY

WHILE YOU FINISH YOUR INITIAL ASSESSMENT WHILE YOU FINISH YOUR INITIAL ASSESSMENT AND RESUSCITATION. APART FROM HIS HEAD AND RESUSCITATION. APART FROM HIS HEAD

INJURY YOU FIND NOTHING ELSE. INJURY YOU FIND NOTHING ELSE. HIS OTHER CERVICAL SPINE X-RAYS ARE ALSO HIS OTHER CERVICAL SPINE X-RAYS ARE ALSO

NORMAL. CHEST AND PELVIC X-RAYS ALSO NORMAL. CHEST AND PELVIC X-RAYS ALSO NORMAL AND ABDOMINAL ULTRASOUND DID NOT NORMAL AND ABDOMINAL ULTRASOUND DID NOT

SHOW ANY FREE INTRAPERITONEAL FLUID. SHOW ANY FREE INTRAPERITONEAL FLUID.

PTCPTC

What's your plan?

PTCPTC

MR. DARWIN COMES BACK FROM CT WITH A MR. DARWIN COMES BACK FROM CT WITH A HEAD SCAN SHOWING MODERATE DIFFUSE HEAD SCAN SHOWING MODERATE DIFFUSE

AXONAL INJURY AND A SMALL SUBDURAL THAT AXONAL INJURY AND A SMALL SUBDURAL THAT WILL NEED SURGERY. WILL NEED SURGERY.

CT OF HIS ATLANTO-OCCIPTAL REGION CT OF HIS ATLANTO-OCCIPTAL REGION REVEALED AN ODONTOID PEG FRACTURE.REVEALED AN ODONTOID PEG FRACTURE.

PTCPTC

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.

PTCPTC101

QUESTIONS?

PTCPTC

Spinal TraumaSummary

Immobilise until injury is excluded

Initial management is ABC

Thorough neurological examination