Evaluation of Head and Neck Trauma

1. Evaluation of Head and Neck Trauma Richard W. Stair, M.D.

2. First and Foremost….ABC’s • Airway • Breathing • Circulation • Disability • Exposure

3. Head Injury • Accounts for half of all trauma deaths • Severe morbidity • Blunt vs. penetrating

4. Anatomic Considerations • Scalp skin, subcutaneous tissue, galea, areolar tissue, pericranium • Skull protective, but rigid • Brain direct injury (primary) and indirect injury (secondary)

5. Secondary Brain Injury • Increased Intracranial Pressure (ICP) • loss of autoregulation of blood vessels • if ICP equals systemic arterial pressure, then no cerebral perfusion pressure = BRAIN DEATH

6. Secondary Brain Injuries • Herniation • cingulate • transtentorial (uncal)

7. Transtentorial (uncal) herniation • Uncus compresses between cerebral peduncle and tentorium • clinically, results in ipsilateral fixed and dilated pupil, contralateral paralysis • may become bilateral

8. Diffuse Brain Lesions • Concussion • Diffuse Axonal Injury

9. Focal Brain Lesions • Brain lacerations • Penetrating Injuries • Contusions • Intracerebral hemorrhage • Epidural hematomas • Subdural hematomas

10. Epidural Hematomas • Blood between inner table of skull and dura • Usually tear of MMA • Hematoma does not cross suture • Lens shaped on CT scan • RARE in elderly

11. Subdural Hematomas • Blood beneath dura overlying brain and arachnoid • Tearing of bridging veins • May cross suture lines • More common in elderly • Acute, subacute, or chronic

12. Assessment of Head Injured Patient • ABC’s • History - EMS, witnesses • Vital signs - Cushing’s Reflex • P.E. - life threatening injuries dealt with first • Neurologic Exam - the Glasgow Coma Scale

13. Glasgow Coma Scale (GCS) • Reproducible method for rapid determination of neurologic injury severity • 3 components: • Motor response • Verbal response • Eye response

14. GCS - Motor Response • 6 Obeys commands • 5 Localizes pain • 4 Flexion - withdrawal • 3 Abnormal flexion (decorticate) • 2 Abnormal extension (decerebrate) • 1 No response

15. GCS - Verbal Response • 5 Oriented and conversant • 4 Disoriented and conversant • 3 Inappropriate words • 2 Incomprehensible speech • 1 No response

16. GCS - Eye Response • 4 Open spontaneously • 3 Open to command • 2 Open to painful stimuli • 1 No response

17. GCS Scores • GCS 13 - 15 Mild head injury • GCS 9 - 12 Moderate head injury • GCS < 8 Severe head injury • (persisting at 6 hours)

18. Diagnostic Tests • C spine xrays • Skull films if penetrating • CT scan • indicated for • LOC • focal neurologic signs • evidence of basilar skull fx or depressed skull fx • neurologic deterioration

19. Management of Severe Head Injuries • Secure airway - role of lidocaine • Hyperventilation • Mannitol 1g/kg • HOB 30o • Seizure prophylaxis • ICP monitors • Craniotomy

20. Delayed Problems in Head Injury • Postconcussive Syndrome • Delayed Posttraumatic CSF leak • Delayed Posttraumatic Seizures

21. C spine Injuries • Various Mechanisms of Injury • flexion • flexion-rotation • extension-rotation • compression • hyperextension • lateral flexion • other

22. Rupture transverse atlantal ligament fracture of dens flexion teardrop bilateral facet dislocation vertebral body burst fx hyperextension fx-dislocation Hangman’s Fx extension teardrop Jefferson Burst fx unilateral facet dislocation anterior subluxation simple wedge fx posterior arch C1 clay shoveler’s fx Stability of C spine injuries (from most to least unstable)

23. Spinal Cord Syndromes • Anterior Spinal Cord Syndrome • Central Spinal Cord Syndrome • Brown - Sequard Syndrome

24. Motor C3,4 trapezius C4 diaphragm C5,6 biceps C7 triceps C8 Flexor digitorum Sensory C2 occiput C4 shoulder tops C6 thumb C7 long finger C8 little finger Innervation

25. Xrays for C spine • Indications • Views • Examination of xrays • lateral view shows 90% of injuries • odontoid view shows 10% of injuries • AP view shows <1%

26. Examination of C spine xrays • “The Lines” • anterior and posterior vertebral body lines, spinolaminar line, tips of spinous processes • Prevertebral soft tissue swelling • Height and shape of bodies • Subluxation • Angulation • Spinous Process fanning • Predental Space

27. More on C spine Imaging • Flexion and extension views • Role of CT scan

28. Evaluation of C spine Trauma • History • Palpation • Neuro exam • To image or not to image?

29. Treatment of C spine Injuries • Immobilization • Orthopedic vs. Neurosurgical consultation • Steroids

30. Neck Trauma • Numerous structures within neck • Triangles and zones • Penetrating vs. Blunt Neck Trauma

31. Causes of Death in Neck Trauma • 1. CNS injury • 2. Exsanguination • 3. Airway compromise

32. Blunt Trauma • Very difficult to assess • Innocuous appearance may quickly worsen • Protecting the airway • intrinsic bleeding • extrinsic compression • tracheal, pharyngeal injury • vomiting

33. If Airway Compromise Occurs • Intubation • Cricothyrotomy • Tracheotomy • Jet Ventilation

34. Management Penetrating Neck Trauma • Depends on essentially 2 factors • violation of platysma • zone of neck injured • Zones I and III - angiography, etc. • Zone II - to the O.R.

35. Management of Blunt Neck Trauma • Airway protection • CT evaluation