Lesson 08


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  • Instructor Notes: Generate discussion using the questions below: What are your primary concerns regarding the patient at this point? What possible injuries could exist?
  • Instructor Notes: Generate discussion using the questions on the slide and information below: This is a critical patient due to the mechanism of injury, compromised airway, impaired ventilations, and neurological deficit. Needed interventions: Airway management with inline manual spinal stabilization, ventilatory support, supplemental oxygen, maintaining body temperature, rapid extrication
  • Instructor Notes: Airway management may be difficult due to combativeness, trismus, facial injuries, the need for inline spinal stabilization Adjuncts and options for airway management include the following: jaw thrust, suction, basic adjuncts, dual lumen (nonvisualized) airways, laryngeal mask airway, endotracheal intubation, cricothyrotomy Intubation is indicated when: the airway can’t be protected (blood, secretions, emesis), GCS of 8 or less,
  • Instructor Notes: The best airway is the one that allows the patient to be ventilated with the fewest complications.
  • Instructor Notes: Proper brain oxygenation relies on an adequate number of circulating red blood cells and an adequate blood pressure, as well as adequate ventilation and oxygenation. Control external hemorrhage; be alert to indications of internal hemorrhage. Hypotension in the trauma patient is hypovolemic until proven otherwise.
  • Instructor Notes: Critical thinking question: “What are the reasons our patient’s mental status may be altered?” “How are these causes managed?” An early check of the pupils will provide a baseline indication of traumatic brain injury.
  • Instructor Notes: Indications: Threat to life identified in primary survey External threat to patient or rescuers Rapid extrication should not be used unless there is an indication for it.
  • Instructor Notes: The skull is composed of numerous bones. Epidural space is a potential space between dura mater and the skull. Dura mater is a heavy protective covering along the skull. Subdural space is a potential space between the dura mater and arachnoid. Arachnoid is a spiderweb-like layer of meninges. Subarachnoid space is an area filled with cerebrospinal fluid (CSF). Pia mater is a meningeal layer adherent to the brain.
  • Instructor Notes: The cerebrum is divided into symmetrical right and left hemispheres. Each hemisphere is further divided into lobes. The brainstem is responsible for vital functions, such as respiration and some control over the heart, and contains part of the reticular activating system, which is responsible for consciousness. The cerebellum is responsible for coordination and balance.
  • Instructor Notes: Primary and Secondary Causes of Brain Injury: Primary injury occurs at the time of impact. It is a direct injury to the brain. Secondary injury occurs after the primary injury, due to systemic and/or intracranial causes. Secondary injury can worsen the patient’s outcome, but the prehospital care provider can make a difference in secondary brain injury. Systemic causes: hypoxia, increased or decreased carbon dioxide, anemia, hypotension, increased/decreased blood glucose Intracranial causes: seizures, cerebral edema, hematoma, intracranial hypertension
  • Instructor Notes: Simple linear fracture — cannot be seen in the field, requires skull x-rays or CT scan for detection. Basilar fracture — fracture to the skull base. May be associated with CSF leakage of the nose (CSF rhinorrhea) or ears (CFS otorrhea). Periorbital ecchymosis (“raccoon’s eyes”) and Battle’s sign take hours to develop. Their absence does not rule out basilar skull fracture. Depressed — deformity seen or noted on palpation. Open skull fracture — CSF and hemorrhage are usually present; brain matter may extrude from the opening.
  • Instructor Notes: Epidural — usually associated with temporal/parietal skull fracture; generally caused by arterial bleeding (middle meningeal artery). The classic presentation after injury is brief loss of consciousness, a lucid interval, then unresponsiveness. Subdural — usually the result of venous bleeding. May have a slow progression. Intracerebral, also known as cerebral contusion , may expand over time. All types may lead to intracranial hypertension and brain herniation
  • Instructor Notes: Hypoxia increases brain cell death and edema. Altered carbon dioxide levels lead to cerebral vasoconstriction or vasodilation, each of which may impair perfusion of the brain. Hypotension and anemia impair oxygen delivery to the brain. The brain is dependent on a constant supply of glucose. Brain cells cannot function without it. Increased glucose is also associated with worse neurological outcome.
  • Instructor Notes: If the volume within the skull increases, there is little room for expansion. If the brain swells, blood and CSF are forced out of skull, impairing cerebral oxygen delivery. Cerebral perfusion pressure equals mean arterial pressure minus intracranial pressure (ICP cannot be measured in the prehospital setting). Normal ICP is less than 20 mm Hg. If ICP increases (due to cerebral edema or intracranial hematoma) and MAP is unchanged CPP falls- CPP should be at least 60 – 70 mm Hg.
  • Sedation — Titrate narcotic or benzodiazepines but beware of ventilatory depression. Chemical paralysis — Moderate to long-acting neuromuscular blocking agent (pancuronium, vecuronium). Osmotherapy (mannitol) — Given to decrease increased ICP (0.25 to 1.0 gm/kg). Controlled, mild hyperventilation — ETco 2 , 25 to 30 mm Hg. If ETco 2 is not available, consider ventilation at these rates: adult 20 breaths/min, child 30 breaths/min, infant 35 breaths/min.
  • Instructor Notes: The patient appears to have sustained a high spinal cord injury. Participants should be concerned with airway, breathing, circulation, and inline manual stabilization of the cervical spine.
  • Instructor Notes: Additional Information: MVCs — 48% of spinal injuries -Falls — 21% of injuries -Penetrating injuries — 15% of injuries -Sports injuries — 14% of injuries - Others — 2% of injuries
  • Instructor Notes: Vertebral anatomy: Body Spinous process Vertebral foramen (opening) The spinal cord fills the majority of the vertebral foramen (spinal canal), leaving little room for edema or bone injury.
  • Instructor Notes: Ligaments and muscles maintain the spine in a normal anatomic position with normal curvatures. Injuries occur when the spinal column is stressed beyond normal movement. Breakdown of spinal injuries: 55% cervical, 15% thoracic, 15% thoracolumbar junction, and 15% in the lumbrosacral regions.
  • Instructor Notes: Dermatome assessment can help identify injury location. Nipple line — T4 Umbilicus — T10
  • Instructor Notes: Secondary injuries occur after the initial impact from conditions such as edema, ischemia, or the movement of bony fragments.
  • Instructor Notes: Considerations for spinal immobilization need to be based on a complete specific assessment of the patient that follows an established algorithm. Neurological deficit includes any patient with a GCS score less than 15.
  • Instructor Notes: Unstable spinal fractures from penetrating trauma are extremely rare. Life-threatening conditions take priority. Airway compromise or gross hemorrhage should always be the first priorities for any trauma patient. Spinal precautions should be considered whenever possible. Patients who have sustained penetrating trauma without neurological complaints do not need spinal immobilization. If the patient has any neurologic complaint he or she should be fully immobilized
  • Instructor Notes: Apply padding where needed — Pad behind the head on adults, behind the torso on pediatrics; also may need to pad under lumbar curve and between patient’s legs Do not secure the upper extremities under the chest straps; they should be secured separately.
  • Instructor Notes: An appropriate receiving facility should have a functioning CT scanner and should have prompt availability of neurosurgeon. Frequent reassessment should be done — includes primary survey, including GCS and pupils. The supine position is preferred to maximize CPP; although elevating the head of patient’s bed may moderately decrease intracranial pressure, it is generally associated with a fall in MAP and CPP.
  • Lesson 08

    1. 1. Traumatic Brain Injury
    2. 2. Lesson 8 Central Nervous System Trauma: Injuries to the Brain and Spinal Cord
    3. 3. Objectives <ul><li>As a result of active participation in this lesson you should be able to: </li></ul><ul><ul><li>Explain the pathophysiology of CNS trauma to include the kinematics of trauma to the brain and spine. </li></ul></ul><ul><ul><li>Identify the patient with indications for spinal immobilization </li></ul></ul><ul><ul><li>Describe the assessment and treatment of patients with spinal and traumatic brain injuries </li></ul></ul>
    4. 4. Scenario <ul><li>You are called to the scene of an accident where a motor vehicle has struck a utility pole. The patient is a 16-year-old unrestrained male who lost control of the vehicle while being pursued by the police. There is extensive front-end damage to the vehicle, with a starburst windshield and a bent steering wheel. The patient is sitting up with </li></ul><ul><li>his head resting against the head rest. He </li></ul><ul><li>has obvious facial injuries. The scene is safe, </li></ul><ul><li>but a crowd has gathered. </li></ul>
    5. 5. Scenario: Primary Survey <ul><li>Airway: Gurgling due to blood in the oropharynx </li></ul><ul><li>Breathing: Ventilatory rate 36; bilateral breath sounds equal </li></ul><ul><li>Circulation: Pulse 60, regular </li></ul><ul><li>Disability: P atient is slow to respond to your questions but does answer </li></ul><ul><ul><li>GCS: 12 (E-3, V-4, M-5) </li></ul></ul><ul><li>Expose: Significant facial trauma, slight bruising on anterior chest </li></ul>
    6. 6. Scenario: Primary Survey <ul><li>Is this patient critical? </li></ul><ul><li>How do we know? </li></ul><ul><li>What treatments does this patient need at this time? </li></ul>
    7. 7. Scenario: Primary Survey <ul><li>While patient is still in the vehicle </li></ul><ul><ul><li>Manual stabilization of the cervical spine </li></ul></ul><ul><ul><li>Clear airway </li></ul></ul><ul><ul><li>Ventilatory support </li></ul></ul><ul><ul><li>Supplemental oxygen </li></ul></ul><ul><ul><li>Control external hemorrhage </li></ul></ul>
    8. 8. Primary Survey: Airway <ul><li>Why may airway management be difficult in patient with a traumatic brain injury? </li></ul><ul><li>What are your options for airway management? </li></ul><ul><li>What are indications for intubation? </li></ul>
    9. 9. Primary Survey: Airway <ul><li>In some recent research, RSI has been associated with worse patient outcomes </li></ul><ul><li>In the prehospital environment, RSI has been associated with the following: </li></ul><ul><ul><li>Hypercarbia </li></ul></ul><ul><ul><li>Hypoxia </li></ul></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>All are causes of secondary brain injury </li></ul></ul>
    10. 10. Primary Survey: Oxygenation and Ventilation <ul><li>Treat/prevent hypoxia: </li></ul><ul><ul><li>Administer oxygen to maintain SpO 2 at 95% or more) </li></ul></ul><ul><li>Maintain normal PaCO 2 </li></ul><ul><ul><li>Assist ventilations </li></ul></ul><ul><ul><li>Avoid hyperventilation </li></ul></ul><ul><ul><li>Capnography if available (30 – 35 mm Hg) </li></ul></ul><ul><li>Ventilation rates </li></ul><ul><ul><li>Adults:10 breaths/min </li></ul></ul><ul><ul><li>Children: 20 breaths/min </li></ul></ul><ul><ul><li>Infants: 25 breaths/min </li></ul></ul>
    11. 11. Primary Survey: Circulation <ul><li>Prevent anemia: control hemorrhage </li></ul><ul><ul><li>EVERY RBC COUNTS! </li></ul></ul>
    12. 12. Primary Survey: Disability <ul><li>Level of consciousness: GCS </li></ul><ul><li>Pupils </li></ul><ul><li>Inline cervical stabilization </li></ul><ul><li>Control seizures </li></ul><ul><ul><li>Titrate IV benzodiazepines </li></ul></ul><ul><li>Sedation may cause hypotension and ventilatory depression </li></ul>
    13. 13. Scenario: Extrication <ul><li>Is this patient a candidate for rapid extrication? </li></ul><ul><li>What are the indications for rapid extrication? </li></ul><ul><li>When should we avoid rapid extrication? </li></ul>
    14. 14. Traumatic Brain Injury (TBI) <ul><li>Commonly occurs in young adults </li></ul><ul><li>Major contributing cause of trauma deaths </li></ul><ul><li>Many survivors have permanent disability </li></ul>
    15. 15. Anatomy: Skull and Brain Skull Periosteum Dura mater } One functional layer Arachnoid membrane Pia mater Vessels in subarachnoid space Epidural space Subdural space Subarachnoid space
    16. 16. Anatomy and Physiology: The Brain
    17. 17. Pathophysiology: Traumatic Brain Injury <ul><li>Primary brain injury </li></ul><ul><li>Secondary brain injury </li></ul><ul><ul><li>Systemic causes </li></ul></ul><ul><ul><li>Intracranial causes </li></ul></ul>
    18. 18. Primary Brain Injury <ul><li>Concussion </li></ul><ul><ul><li>Abnormal neurological function without structural damage to the brain </li></ul></ul><ul><ul><li>Possible loss of consciousness, anterograde amnesia, repetitive questions or statements, confusion, disorientation, headache, vomiting </li></ul></ul><ul><ul><li>Signs and symptoms may last hours to days </li></ul></ul><ul><ul><li>In some patients, a postconcussive syndrome may last for weeks </li></ul></ul>
    19. 19. Primary Brain Injury <ul><li>Skull fractures may be associated with TBI </li></ul><ul><ul><li>Linear (80%) </li></ul></ul><ul><ul><li>Depressed </li></ul></ul><ul><ul><li>Open/closed </li></ul></ul><ul><ul><li>Basilar </li></ul></ul><ul><li>The presence of skull fracture increases the suspicion for intracranial hematoma </li></ul>
    20. 20. Primary Brain Injury <ul><li>Intracranial hematomas </li></ul><ul><ul><li>Epidural </li></ul></ul><ul><ul><li>Subdural </li></ul></ul><ul><ul><li>Intracerebral </li></ul></ul>
    21. 21. Secondary Brain Injury <ul><li>Systemic causes </li></ul><ul><ul><li>Hypoxia </li></ul></ul><ul><ul><li>Increased or decreased CO 2 </li></ul></ul><ul><ul><li>Anemia </li></ul></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>Increased or decreased blood glucose </li></ul></ul><ul><li>Intracranial causes </li></ul><ul><ul><li>Seizures </li></ul></ul><ul><ul><li>Cerebral edema </li></ul></ul><ul><ul><li>Hematomas </li></ul></ul><ul><ul><li>Increased intracranial hypertension (ICP) </li></ul></ul>
    22. 22. Secondary Brain Injury: Intracranial Hypertension <ul><li>The skull is a rigid container that cannot accommodate bleeding or swelling </li></ul><ul><li>The brain is compressed </li></ul><ul><li>Cerebral perfusion pressure </li></ul><ul><ul><li>CPP = MAP–ICP </li></ul></ul><ul><ul><li>If ICP increases and MAP is unchanged, CPP falls </li></ul></ul>
    23. 23. Intracranial Hypertension <ul><li>Warning signs of possible increasing ICP or impending herniation: </li></ul><ul><ul><li>Decline in GCS score of 2 points or more </li></ul></ul><ul><ul><li>Development of sluggish or nonreactive pupil </li></ul></ul><ul><ul><li>Development of hemiplegia or hemiparesis </li></ul></ul><ul><ul><li>Cushing’s phenomenon </li></ul></ul>
    24. 24. Intracranial Hypertension <ul><li>Signs of intracranial hypertension </li></ul><ul><ul><li>Cushing’s phenomenon </li></ul></ul><ul><ul><ul><li>Bradycardia </li></ul></ul></ul><ul><ul><ul><li>Hypertension </li></ul></ul></ul><ul><ul><ul><li>Alterations in ventilatory patterns (e.g., Cheyne-Stokes) </li></ul></ul></ul><ul><ul><li>Abnormal motor posturing </li></ul></ul><ul><ul><ul><li>Decorticate </li></ul></ul></ul><ul><ul><ul><li>Decerebrate </li></ul></ul></ul>
    25. 25. Intracranial Hypertension: Management <ul><li>Potential management options: </li></ul><ul><ul><li>Maintain blood pressure </li></ul></ul><ul><ul><li>Sedation </li></ul></ul><ul><ul><li>Chemical paralysis </li></ul></ul><ul><ul><li>Osmotherapy (mannitol) </li></ul></ul><ul><ul><li>Controlled, mild hyperventilation </li></ul></ul>
    26. 26. Spinal Trauma
    27. 27. Scenario <ul><li>You have been called to a home on a lakeshore for an injured person. Your patient is a 32-year-old male who dove into the lake from a dock into about 5 feet of water and struck his head on the bottom. Friends pulled him from the water and he is lying on his back with his arms extended and elbows bent so that his hands are resting next to his head. </li></ul>
    28. 28. Scenario: Primary Survey <ul><li>Airway: open </li></ul><ul><li>Breathing: shallow and rapid, with minimal chest rise and “belly breathing” </li></ul><ul><li>Circulation: Skin is warm and dry; radial pulse is present at a normal rate </li></ul><ul><li>Disability: GCS 15, anxious, minimal motor ability in upper extremities, no motor ability of lower extremities, no sensation below the shoulders </li></ul><ul><li>Expose: no additional injuries noted </li></ul>
    29. 29. Scenario: Primary Survey <ul><li>What is your general impression of this patient? </li></ul><ul><li>What interventions does he require right now? </li></ul>
    30. 30. Spinal Trauma <ul><li>Significant kinetic energy can produce injury to the spine and spinal cord </li></ul><ul><li>Improper assessment and management can result in permanent paralysis </li></ul><ul><li>Spinal injuries have substantial lifelong social and financial impact on the victim and his/her family </li></ul>
    31. 31. Epidemiology: Spinal Trauma <ul><li>15,000 to 20,000 spinal injuries occur annually </li></ul><ul><li>Common in ages 16 to 35 years old </li></ul><ul><li>Causes </li></ul><ul><ul><li>MVCs </li></ul></ul><ul><ul><li>Falls </li></ul></ul><ul><ul><li>Penetrating injuries </li></ul></ul><ul><ul><li>Sports injuries </li></ul></ul>
    32. 32. Anatomy: Spinal Column
    33. 33. Anatomy: Spinal Column <ul><li>Cervical (7) </li></ul><ul><li>Thoracic (12) </li></ul><ul><li>Lumbar (5) </li></ul><ul><li>Sacrum (5) </li></ul><ul><li>Coccyx (4) </li></ul>
    34. 34. Anatomy and Physiology: Dermatomes
    35. 35. Pathophysiology: Spinal Trauma <ul><li>The spinal cord contains the motor and sensory nerve tracts </li></ul><ul><li>Damage may result in: </li></ul><ul><ul><li>Weakness or paralysis </li></ul></ul><ul><ul><li>Pain, paresthesia (numbness), or total loss of sensation </li></ul></ul>
    36. 36. Pathophysiology: Spinal Trauma <ul><li>High cervical injuries: loss of total ability to breathe </li></ul><ul><li>Lower cervical injuries: diaphragm still functions, loss of intercostal muscles </li></ul>
    37. 37. Pathophysiology: Spinal Trauma <ul><li>Hypotension associated with cervical or high thoracic spinal cord injury </li></ul><ul><ul><li>Disruption of sympathetic nervous system results in unopposed parasympathetic tone </li></ul></ul><ul><ul><ul><li>Vasodilation </li></ul></ul></ul><ul><ul><ul><li>Bradycardia </li></ul></ul></ul><ul><ul><ul><li>Warm, dry, skin </li></ul></ul></ul><ul><li>However, the most likely cause of hypotension in any trauma patient is hypovolemia </li></ul>
    38. 38. Immobilization Algorithm: Blunt Trauma Altered level of consciousness (GCS less than 15) No Yes IMMOBILIZE Rapid transport Spinal pain or tenderness? or Neurological deficit or complaint? or Anatomic deformity of spine? No Yes IMMOBILIZE Rapid transport Concerning mechanism of injury?
    39. 39. <ul><li>When in doubt, immobilize! </li></ul>Presence of: Evidence of alcohol/drugs or Distracting injury or Inability to communicate Concerning Mechanism of Injury No Yes IMMOBILIZATION NOT INDICATED Rapid transport Transport No Yes IMMOBILIZATION NOT INDICATED Transport IMMOBILIZE
    40. 40. Concerning Mechanism of Injury <ul><li>Violent impact to the head, neck, torso, or pelvis </li></ul><ul><li>Sudden acceleration, deceleration, or lateral bending forces to neck or torso </li></ul><ul><li>Falls </li></ul><ul><li>Ejection or fall from any motorized or human-powered transport device </li></ul><ul><li>Shallow-water diving incident </li></ul>
    41. 41. Distracting Injuries <ul><li>Any injury that may impair the patient’s ability to appreciate other injuries </li></ul><ul><ul><li>Long bone fracture </li></ul></ul><ul><ul><li>Suspected visceral injury </li></ul></ul><ul><ul><li>Large laceration, degloving, or crush injury </li></ul></ul><ul><ul><li>Large burns </li></ul></ul><ul><ul><li>Any other injury that produces acute functional impairment </li></ul></ul>
    42. 42. Inability to Communicate <ul><li>Speech or hearing impaired </li></ul><ul><li>Speaks a foreign language </li></ul><ul><li>Small children </li></ul>
    43. 43. <ul><li>Unstable spinal fractures from penetrating trauma are extremely rare </li></ul><ul><li>Life-threatening conditions take priority </li></ul>Immobilization Algorithm: Penetrating Trauma No Yes IMMOBILIZE IMMOBILIZATION NOT INDICATED Rapid transport Rapid transport NEUROLOGICAL DEFICIT/COMPLAINT?
    44. 44. Cervical Collar <ul><li>Adjunct only: DOES NOT IMMOBILIZE! </li></ul><ul><li>Apply after returning head to neutral inline position unless contraindicated </li></ul><ul><li>Must be rigid and properly sized </li></ul><ul><li>Should not impair opening of mouth </li></ul>
    45. 45. Spinal Immobilization <ul><li>Maintain manual stabilization </li></ul><ul><li>Assess neurological function </li></ul><ul><li>Apply cervical collar </li></ul><ul><li>Use an interim (short) immobilization device if indicated </li></ul>
    46. 46. Spinal Immobilization <ul><li>Position patient on long backboard </li></ul><ul><li>Use padding </li></ul><ul><li>Secure torso first, then head </li></ul><ul><li>Reassess primary survey and neurological function </li></ul>
    47. 47. Transport <ul><li>Appropriate receiving facility </li></ul><ul><ul><li>In this area, what is an appropriate receiving facility? </li></ul></ul><ul><li>Frequent reassessment </li></ul><ul><li>Supine position preferred </li></ul>
    48. 48. Summary <ul><li>Identify the mechanism of injury </li></ul><ul><li>Primary survey: identify and treat life-threatening conditions first </li></ul><ul><li>Assess indications for immobilization </li></ul><ul><li>When in doubt, immobilize </li></ul>
    49. 49. Summary <ul><li>Shock is a late finding in patients with TBI; consider the possibility of hypovolemia </li></ul><ul><li>Manage the patient to minimize secondary brain and spinal cord injury </li></ul><ul><li>Perform rapid extrication only when indicated </li></ul><ul><li>Transport patients with CNS trauma to an appropriate facility </li></ul>
    50. 50. <ul><li>QUESTIONS? </li></ul>