Trauma: Specific Injuries and Management

Trauma
Specific injuries and management
Dr. Mahmoud W. Qandeel

Outlines
• Brain injuries
• Cervical spine injuries
• Neck trauma; penetrating and blunt CVI
• Spinal Cord and Spinal Column
• Cardiac Injury; blunt and penetrating
• Blunt thoracic aortic injury
• Esophageal and Tracheal Injury
• Abdominal Trauma
• Genitourinary Trauma
• Pelvic Fracture
• Extremities Trauma; compartment syndrome
Brain injuries
• Identification of a decreased GCS during the primary survey may warn
of potential brain injury.
• Pupil examination: Imperative; a dilated and nonreactive pupil may
indicate increased pressure secondary to intracranial bleeding.
• Rapid assessment with computed tomography (CT ): often necessary to
better characterize the injury
• Initial treatment for intracranial hemorrhage: aimed at decreasing the
ICP while preserving cerebral blood flow

Intrcranial Pressure
Sustained increased ICP leads to decreased brain function and poor outcome
10 mm Hg Normal
> 20 mm Hg Abnormal
> 40 mm Hg Severe

Cerebral Perfusion Pressure (CPP)
MAP – ICP = CPP
Normal 90 10 80
Cushing’s
100 20 80
Response
Hypotension 50 20 30
Caution
CPP ≠ Cerebral Blood Flow
Normal CT
Intracerebral
Hematoma /
Contusion

Diffuse Axonal Injury Dr. Mahmoud W. Qandeel
Mountain Fuji sign in Bilateral Pneumocephalus

Epidural Hematoma Subdural Hematoma
Depressed Skull #
Indications for surgery

• Depression > 1 cm/ or full bone thickness
• Gross wound contamination
• Significant intracranial hematoma
• Gross cosmetic deformity
• Frontal sinus involvement
• Dural penetration (clinical or radiological)

Depressed Skull #
Nonsurgical management may be considered if:

1. All the following are present:
– No depression > 1 cm/ or full bone thickness
– No gross wound contamination
– No significant intracranial hematoma
– No gross cosmetic deformity
– No frontal sinus involvement
– No dural penetration (clinical or radiological)
2. Or if the fracture is over a venous sinus

Signs of skull base fracture
• Raccoon eyes
• Battle sign
• CSF leak: rhinorrhea or otorrhea
• Cranial nerve palsy

Epidural Hematoma
• Associated with skull fracture
• Classic: middle meningeal artery tear
• Lenticular / biconvex
• Lucid interval
• Can be rapidly fatal
• Early evacuation essential

EDH – Indications for surgery
• Volume > 30 cm3, regardless of GCS

– Craniotomy for EDH

EDH – Conservative management
(Serial CT & close neuroobservation)
If all the following are present:

• Volume < 30 cm3
• Thickness < 15 mm
• Midline shift < 5 mm
• GCS > 8
• No focal neurodeficit

Subdural Hematoma
• Venous tear / brain laceration.

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

Acute Subdural Hematoma

Subacute Subdural Hematoma

Chronic Subdural Hematoma

ASDH – Indications for surgery
• Thickness > 10 mm, regardless of GCS

• Midline shift > 5 mm, regardless of GCS
• If thickness < 10 mm & shift < 5 mm, then operate if any of the following is
present:
– GCS drops by ≥ 2 points
– Anisocoria
– ICP > 20 mmHg

SDH – Surgical treatment
Craniotomy for ASDH Burr hole for subacute & chronic SDH

Cervical spine
• Immobilization with a cervical collar should be maintained in all blunt trauma
patients until they are able to be fully evaluated and “cleared,” including during
rolling and any procedures (e.g., oral–tracheal intubation).
• During secondary survey: Cervical spine is palpated to identify tenderness or bony
deformity (step-off ).
• Physical examination: can be used to “clear” the cervical spine if the patient is not
intoxicated, does not have a “distracting” injury, and does not have a decreased GCS
• Imaging: evaluates or the presence of fracture with cervical spine pain or the
conditions listed earlier

Penetrating neck trauma
The neck is divided into three zones
• Zone 1: thoracic inlet to hyoid bone
• Zone 2: Hyoid bone to angle of mandible; classically, injuries here are
treated with operative exploration because of the relatively easy
surgical access (i.e., not hidden in the thorax [zone 1] or base of skull
[zone 3]).
• Zone 3: angle of mandible to cranium

Blunt cerebrovascular injury (BCVI)
• Principally carotid artery injury.
• Risk factors require additional screening for injury identification and
include
– Cervical spine injury,
– Displaced mid face fracture (le fort II and III),
– Pulsatile epistaxis,
– Hanging or clothesline mechanism,
– Basal skull fracture,
– Significant neck hematoma, and
– Neurologic exam not explained by CT of the head.

• Diagnosis: CT neck scans with intravenous (IV) contrast or angiography

Grades of carotid artery injury
1. I: luminal irregularity or dissection, less than 25% narrowing

2. II: luminal irregularity or dissection, 25% or greater narrowing
3. III: pseudoaneurysm
4. IV: occlusion
5. V: transection

Spinal Cord and Spinal Column
• Primary survey: During the disability assessment, attention should be

paid to the patient’s ability/inability to move all four extremities; the
patient should also be rolled and the full spinal column assessed for the
presence of pain or bony deformity (step-off ).
• Spinal immobilization (in the pre hospital and in-hospital phases ):

maintain with a backboard and during rolling until determination has
been made that a spinal fracture does not exist

Diagnosis :
• Definitive identification of spinal fracture is most frequently made with
CT imaging.
• MRI: often employed to better define and visualize injury to the spinal
cord itself
Note:
• Steroids: not indicated; shown to increase infectious complications
without decreasing spinal cord edema

Dorsolumbar Spine Fractures
• 64% of them occurs at thoracolumbar junction (T11 – L2)
• 70% of these fractures occur without immediate neurologic injury

Classification
• The Denis classification system is one of the most common ways of
classifying thoracolumbar spine fractures.

Classification
Minor & major injuries
Minor injuries: (usually stable) Major injuries: (4 types)
• Transverse process # • Compression #
• Spinus process # • Burst #
• Articular process # • Seat-belt #
• Lamina # • Fracture-dislocation

Fracture type Column
Anterior Middle Posterior
Compression Compression Intact Intact or

distraction
Burst Compression Compression Intact
Seat-belt Intact or minimal Distraction

compression
Fracture- Compression, Distraction, rotation, shear
dislocation rotation, tear

Anterior Column Injury
(Compression Fracture)
Usually stable & treated by:
• Analgesics & bed rest 1-3 wks
• When pain decreases, ambulate in brace

(12 wks)
• F/U with serial X-rays to rule out progressive

deformity

Unstable & requires surgery if:
• Loss > 50% of the height (one vertebra)

• Kyphotic angulation at one segment > 40°
• ≥ 3 contiguous compression fractures
• Neurologic deficit
• Disrupted posterior column
• Progressive kyphosis

Burst Fracture

Surgery recommended with any of the next:
• Anterior height ≤ 50% of the posterior height
• Residual canal diameter ≤ 50% of normal
• Kyphotic angulation ≥ 20°
• Increased interpediculate distance
• Neurologic deficit
• Progressive kyphosis

Can be treated conservatively esp. if:
• Above T8
• Below L4
• Minimal Middle Column Failure

Seat-belt fracture

• No immediate danger of neurologic injury
• Treat most with hyperextension brace
• Fractures through the bone (Chance fracture) mostly heal well in brace
• Fractures through the ligaments might need surgical fixation later

Fracture-dislocation

Treatment:
• Unstable
• Surgical decompression & stabilization usually needed

Trauma: Specific Injuries and Management

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Trauma

Specific injuries and management

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Indications for surgery

Dr. Mahmoud W. Qandeel

Nonsurgical management may be considered if:

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• Classic: middle meningeal artery tear

• Can be rapidly fatal

• Early evacuation essential

Dr. Mahmoud W. Qandeel

• Volume > 30 cm3, regardless of GCS

Dr. Mahmoud W. Qandeel

If all the following are present:

Dr. Mahmoud W. Qandeel

• Venous tear / brain laceration.

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• Thickness > 10 mm, regardless of GCS

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

1. I: luminal irregularity or dissection, less than 25% narrowing

Dr. Mahmoud W. Qandeel

• Primary survey: During the disability assessment, attention should be

• Spinal immobilization (in the pre hospital and in-hospital phases ):

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• 70% of these fractures occur without immediate neurologic injury

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Anterior Middle Posterior

Compression Compression Intact Intact or

Seat-belt Intact or minimal Distraction

Dr. Mahmoud W. Qandeel

Usually stable & treated by:

• Analgesics & bed rest 1-3 wks

• When pain decreases, ambulate in brace

• F/U with serial X-rays to rule out progressive

Dr. Mahmoud W. Qandeel

• Loss > 50% of the height (one vertebra)

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• Surgical decompression & stabilization usually needed

Dr. Mahmoud W. Qandeel

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