HEAD , SPINE AND

MUSCULOSKELETAL
TRAUMA

PDEI - MUHAMMADIYAH
 Case Scenario

58-year-old male fell from a roof in a

small rural town
Initial GCS score = 12
On admission after 2-hour transfer,
GCS score is 6

What injuries would you suspect?

What are your priorities in managing this

patient?

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 Objectives

Describe basic intracranial anatomy and

physiology.
Explain the importance of limiting
secondary brain injury.
Describe the classification of head
injuries.
Describe proper stabilization of the
patient and arrangements for definitive
care.

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 Anatomy and Physiology

What are the unique

features of brain
anatomy and
physiology, and how do
they aect patterns of
brain injury?

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 Anatomy and Physiology

Eects
Rigid, nonexpansile skull filled with
brain, CSF, and blood
Cerebral blood flow (CBF) usually
autoregulated
Autoregulatory compensation
disrupted by brain injury
Mass eect of intracranial
hemorrhage

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Monro-Kellie Doctrine

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Volume-Pressure Curve

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 Intracranial Pressure (ICP)

10 mm Hg = Normal
>20 mm Hg = Abnormal
>40 mm Hg = Severe

Sustained increased ICP leads to decreased

brain function and poor outcome
Hypotension and low saturation adversely
aect outcome

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Cerebral Perfusion Pressure

MAP ICP = CPP

Normal 90 10 80

Cushings
100 20 80
Response

Hypotension 50 20 30

Caution
CPP Cerebral Blood Flow

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 Autoregulation

If autoregulation is intact, CBF is

maintained constant between a mean BP
of 50 to 60 mm Hg.
In moderate or severe brain injury,
autoregulation is impaired so CBF varies
with mean BP.
The injured brain is more vulnerable to
episodes of hypotension, causing
secondary brain injury.

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 Classifications of Head Injury

By Mechanism of Injury

Blunt Penetrating
High and low GSW and
velocity other

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 Classifications of Head Injury

By Morphology Skull Fractures

Vault
Depressed / nondepressed
Open / closed

Basilar
With / without CSF leak
With / without cranial nerve
palsy
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 Classifications of Head Injury

By Morphology Brain Injuries

Focal
Epidural (extradural)
Subdural
Intracerebral
Diuse
Concussion
Multiple contusions
Hypoxic / ischemic injury
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 Epidural Hematoma

Associated with skull fracture

Classic: middle meningeal artery tear

Lenticular / biconvex

Lucid interval

Can be rapidly fatal

Early evacuation essential

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 Epidural Hematoma

Temporal Epidural Hematoma

Uncal herniation

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 Subdural Hematoma

Venous tear / brain laceration

Covers cerebral surface
Morbidity / mortality due to
underlying brain injury
Rapid surgical evacuation
recommended, especially if > 5 mm
shift of midline

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Subdural Hematoma

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 Intracerebral Hematoma / Contusion

Coup / contracoup injuries

Most common: frontal / temporal lobes

CT changes usually progressive

Most conscious patients: no operation

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 Intracerebral Hematoma / Contusion

Large Frontal Contusion with Shift

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Diffuse Brain Injury

Normal CT Diuse Injury

Range from mild concussion to severe

ischemic insult

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 Classifications of Head Injury

By Severity of Injury Based on GCS Score

Mild
Moderate
Severe

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 Mild Brain Injury

GCS score = 13 15
History
Exclude systemic injuries
Neurologic exam
X-rays as indicated
Alcohol / drug screens as indicated
Liberal use of head CT

Observe or discharge based on findings

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 Moderate Brain Injury

GCS score = 9 12
Initial evaluation same as for mild injury
CT scan for all
Admit and observe
Frequent neurologic exams
Repeat CT scan
Deterioration: Manage as severe head
injury

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 Severe Brain Injury

GCS score = 3 8

Evaluate and resuscitate

Intubate for airway protection

Focused neurologic exam

Frequent reevaluation

Identify associated injuries

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Indications for CT Scan

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 Indications for CT Scan

High Risk

GCS score still < 15 two hours after injury

Neurologic deficit

Open skull fracture

Sign of basal skull fracture

Extremes of age

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 Indications for CT Scan

Moderate Risk
Dangerous mechanism
Retrograde amnesia > 30 minutes in
duration
Severe headache
Vomiting > 2 episodes

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 Management

Priorities
ABCDE
Minimize secondary brain injury
Administer oxygen
Maintain adequate
ventilation
Maintain blood pressure
(systolic > 90 mm Hg)

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 Management

Focused Neurological Exam

GCS score
Pupils
Lateralizing signs

Consult
neurosurgeon
early

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 Management

Medical
Controlled ventilation
Goal: Paco2 at 35 mm Hg
Intravenous fluids
Euvolemia
Isotonic
Consult with neurosurgeon
Mannitol
Use with signs of tentorial herniation
Dose: 0.25 to 1.0 g / kg IV bolus

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 Management

Medical
Other medications
Anticonvulsants
Sedation
Paralytics

Neurological examination before

prolonged sedation / paralysis

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 Management

Surgical

Scalp Wounds
Possible site of major blood loss

Direct pressure to control bleeding

Occasional temporary closure

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 Management

Surgical

Intracranial Mass Lesion

Can be life-threatening if expanding rapidly

Immediate neurosurgical consult

Hyperventilation / mannitol

Damage control craniotomy: transfer to

neurosurgeon (rural / austere areas)

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 Summary

Ensure adequate oxygenation

Maintain Paco2 near / at 35 mm Hg
Maintain mean BP > 90 mm Hg
Frequent neurologic assessment
Liberal use of CT
Early neurosurgical consult

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Committee on Trauma Presents

Spine and
Spinal Cord
Trauma

Initial Assessment and Management

PDEI - MUHAMMADIYAH
 Case Scenario

38-year-old male is pulled from a

swimming pool.
BP: 80/62; Pulse: 58; RR: 28
GCS score: 15
Breathing is shallow.
He is not moving his arms or legs.

Discuss the patients diagnosis

and management.

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 Objectives

Describe the evaluation of a patient with

suspected spinal injury.
Explain the appropriate management of
spinal injury.
Discuss appropriate patient disposition.

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 Spinal Injury

When should you suspect a spine injury?

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 Spinal Injury

When should you suspect a spine injury?

Mechanism of injury
Unconscious patient
Neurologic deficit
Spine pain / tenderness

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 Spinal Injury

How do I protect the spine during evaluation

and transport?

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 Spinal Injury

How do I protect the spine during evaluation

and transport?

Immobilize entire patient on long spine

board with proper padding.
Apply semirigid collar.

Protection is priority; detection

is secondary.

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 Spinal Injury Screening

Clinical
Normal neurologic exam and
Absence of spinal pain and tenderness

Caution

Drugs, alcohol, and other

injuries can mask spinal injury.

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 Spinal Injury Screening

If patient is
Conscious
Cooperative
Able to concentrate on c-spine
If no neck or spine pain or tenderness
If still no pain or tenderness with
voluntary movement
No further evaluation or x-ray necessary

Clear spine and remove cervical collar.

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 Spinal Injury Screening

Altered Consciousness or Symptoms

Radiographic visualization of entire

spine
Plain films
CT scan of suspicious or poorly
visualized areas

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 Spinal Injury Screening

How do I confirm a spine injury?

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 Spinal Injury Screening

How do I confirm a spine injury?

Clinical signs of neurological deficit

Radiological investigations
Plain X-ray / CT / MRI
Identify bony fracture / subluxation
Presume spinal instability
Early spine service consult

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 Cervical Spine X-rays

Crosstable lateral film excludes 85% of

fractures
Addition of AP and odontoid views
excludes most fractures
Also may require
Swimmers view
CT scan for bony detail
MRI

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 Cervical Spine X-rays

10% of patients with a c-spine fracture have

a second, associated noncontiguous
vertebral column fracture
Identify one abnormality? Look for another!
Radiographic screening of entire spine
required in this situation

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 Pitfalls

Pitfalls

Spinal evaluation complicated by altered

sensorium
Remove spine board as soon as possible
and logroll patient
Pressure sores occur early in unconscious
or paralyzed patients

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Caution

Caution

At least 5% of patients with

spinal cord injuries worsen
neurologically at the hospital.

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 Neurologic Status

How do I assess the patients neurologic

status?

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 Neurologic Status

How do I assess the patients neurologic

status?
Neurologic level
Most caudal level of motor / sensory
function
Motor and sensory may not be the same
Sensory can vary on each side

Bony level
Site of vertebral column damage

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 Neurologic Status

Complete Injury
No motor or sensory function below
injury level

Incomplete Injury
Any motor or sensory preservation
below injury level
Sacral sparing may be only residual
function

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 Effects of Spinal Cord Injury

Neurogenic shock
Spinal shock
Other consequences
Fasciculus gracilis
Dorsal column
Fasciculus cuneatus

Lateral corticospinal tract

Spinothalamic

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 Effects of Spinal Cord Injury

Neurogenic Shock Direct Eects

Cardiovascular phenomenon due to
loss of sympathetic tone
Associated with cervical / high
thoracic spine injury
Hypotension and slow heart rate
Treatment includes fluid resuscitation
and occasional atropine and
vasopressors

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 Effects of Spinal Cord Injury

Spinal Shock Direct Eects

Neurologic, not hemodynamic
phenomenon
Occurs shortly after cord injury
Variable duration
Flaccidity and loss of reflexes

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 Effects of Spinal Cord Injury

Other Consequences
Inadequate ventilation
Abdominal evaluation compromised
Occult compartment syndrome

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 Management

How do I manage patients with spinal cord

injury and limit secondary injury?

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 Management

How do I manage patients with spinal cord

injury and limit secondary injury?

Ensure adequate ventilation and

oxygenation
Maintain blood pressure
Maintain perfusion of spinal cord

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 Management

Management of Hypotension
Assess for associated bleeding
Consider neurogenic shock
Monitor urinary output
Stop
the
bleeding!

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 Management

Whom do I transfer?

Unstable fractures
Neurologic deficit

Caution

Avoid transfer delay!

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 Management

Management of Patients Requiring Transfer

Provide respiratory
support as needed
Exclude other life-
threatening injury
Properly immobilize
entire patient
Avoid hypothermia

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 Summary

Treat life-threatening injuries first

Properly immobilize entire patient
Obtain appropriate spine films
Document examination
Obtain neurosurgical / orthopaedic
consult
Transfer unstable fracture / cord injury

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Musculoskeletal Trauma

Initial Assessment and Management

PDEI - MUHAMMADIYAH
 Case Scenario

A wall collapses on a 44-year-old

male worker
BP: 130/75; Pulse: 110; RR: 22
GCS score: 15
Painful, bruised, deformed right leg

What are your priorities?

Is this life- or limb-threatening?

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 Objectives

Describe the principles for assessing patients

with musculoskeletal injuries.

Identify treatment priorities.

Explain the importance of musculoskeletal

injuries in multiply injured patients.

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 Primary Survey

How do musculoskeletal injuries impact on the

primary survey?

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 Primary Survey

How do musculoskeletal injuries impact on the

primary survey?

A B C D E

External bleeding
Occult blood loss
Pelvic fractures
Long bone fractures

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 Primary Survey

What are my priorities and management principles?

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 Primary Survey

What are my priorities and management principles?

During the Primary Survey The 3 Ss

Stop the bleeding! (pressure / tourniquet)

Splint the extremity

Stabilize the pelvis

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 Primary Survey

Rationale for Splinting

Prevents further
blood loss and injury
Can restore or
maintain perfusion
Relieves pain
Important during
evaluation
Do not delay

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 Primary Survey

Stabilization

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 Secondary Survey

Look

Listen

Feel

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 Secondary Survey

Rationale for Splinting

Look Listen Feel
Deformity Doppler Crepitus
signals
Pain Skin flaps
Tendernes Bruit Neurologi
s c deficit
Wound(s) Pulses

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 Secondary Survey

Key Information

Preinjury status and predisposing factors

Mechanism of injury
Time of injury

Associated factors (eg, environment)

Prehospital observations and care

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 Secondary Survey

Early Concerns

Vascular compromise

Open fractures

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 Secondary Survey

Assess and Manage Vascular Compromise

Reduce fracture(s)
Splint fracture(s)
Assess by Doppler

Obtain surgical consult

Time is critical!

Consider angiography

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 Secondary Survey

Managing Open Fractures

Apply appropriate splint
Cleanse / debride
(now or later)
Consider time factor
Obtain orthopedic
consult
Antibiotic / tetanus status

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 Secondary Survey

X-Ray Studies

What x-rays do I need?

Any suspected area
One joint above and below

When do I obtain them?

Patient is hemodynamically
normal

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 Secondary Survey

X-Ray Studies

When should I delay getting

x-rays?
If life-threatening injuries take
priority
If patient transfer will be
delayed

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 Compartment Syndrome

What injuries can cause compartment syndrome?

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 Compartment Syndrome

What injuries can cause compartment syndrome?

Tibia and forearm fractures

Vascular and bony injuries
Injuries immobilized in tight
dressings or casts
Severe crush injuries to
muscle
Burns

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 Compartment Syndrome

How do I recognize compartment syndrome?

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 Compartment Syndrome

How do I recognize compartment syndrome?

Pain
Disproportionate
Passive stretch
Tense compartments
Asymmetry
Paresthesia
Tissue pressures > 35 to 45 mm Hg

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Pitfalls

Pitfalls

Altered sensation
Compartment syndrome
Vascular injury
Crush injuries / myoglobinuria
Occult fractures / soft tissue
injuries
Coagulation disorders

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 Summary

Manage life-threatening injuries first

Stop the bleeding!
Reduce and immobilize fractures and
dislocations
Recognize vascular compromise
Consider compartment syndrome

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