references : shwartz

1. HEAD , NECK , AND SPINAL
INJURY
Dr. Ibrahim Albujays

2. ASSESSMENT
Assessment includes examination of scalp , ears , nose , mouth ,
facial bones , and intracranial structures .
A. Eyes : pupillary size and reactivity , visual acuity , and hemmorge
B. Tympanic membrane : rupture , or otorrhea
C. Anterior facial structures : sensation , abnormal dental closure
(mal-alignment) , nasal fracture ( bleeding in posterior pharynx)
D. Oral cavity : open fracture , loose tooth , sublingual hematoma
E. Lateralizing finding ( unilateral dilated pupil , asymmetric
movement of extremities , unilateral babiski reflex ) : suggest
intrcranial mass lesion

5. CONTINUE
For who ct scan should be done ?
1. All pt with significant closed head injury ( GCS <14)
2. Pt on anti-platlets or anticoagulants , despite GCS 15
Types of injury :
Hematoma , contusion , hemorrhage , diffuse axial injury (DAI)
Stroke syndrome : look for carotid or vertebral injury through CT
angiography

6. CONTINUE
Subdural hematoma
Epidural hematoma
• Between dura and cortex
• Venous disruption of
parenchema
• So it is worsed than
epidural
• Blood accumulates
between skull and dura
• Disruption of middle
meningeal artery

9. MANAGEMENT OF HEAD INJURY
Inracranial injury :
All pt with intracranial hemorrhage are admitted to SICU.
Close monitoring is mandatory for :
Pt with abnormal ct finding and GCS <8 , ICP is monitored by wither fibrer-optic
intra-paranchemal devices or intra-ventricular catheter.
Normal ICP(8-10) , management initiated if >20
Indication for operative intervention to remove occupying hematoma dependes
on :
1. Amount of midline shift ( >5 mm )
2. Location ( e.g. : posterior fossa)
3. GCS and ICP .

10. EPIDURAL HEMATOMA
Some of the cases are life threatening .
Presentation :
1. Initial loss of consciousness
2. Lucid interval
3. Recurrent loss of consciousness with epsilateral fixed dilated pupil.
Emergent evacuation within 70 minutes .
Burr hole placement

12. POST HEAD INJURY CARE
Avoid hypotension (SBP <100)
Avoid hypoxia ( PAo2 <60 or Sat <90 )
Mainatin ceberal perfusion is more important ( MAP-ICP) , Target :
>50 mmhg
CPP increased either : lowering ICP , or raising MAP
PAco2 maintained in normal range (35-40 mmhg)
Anticonvulsnt therapy ( phenytoin ) is indicated for next 7 days .

13. MANAGEMENT OF HEAD INJURY
Maxillofacial injury :
Multidipenery decision
Maxillofacial complex divided intio 3 regions:
1) Upper face : frontal sinus , and brain (low impact force )
2) Middle face : orbit , nose and zygomaticmaxillary (low impact-
force )
3) Lower face : mandible (low impact force )
 tooth fracture considered open fracture and needs Abx
Packing and tamponade are 1st after proper assessment

15. ASSESSMENT
Vary in severity , and dependes in the level
Pt has complete loss of motor function and sensation “two or more
more levels below bony injury”
Pt with high spinal cord disruption are at high risk of shock , due ti
disruption of sympathetic fibers

16. SYNDROMES
Brown sewuard
syndrome
Anterior cord
syndrome
Central cord
syndrome
Ipsilateral loss of
motor function ,
proprioception and
vibrtory sensation
While , pain and
tempratrue lost in
contralateral side
Motor function ,
pain , temperature
diminished below
level of injury
While position ,
vibratoery sensation
and crude touch
maintained
Motor function ,
pain , and
temperature
preserved in lower
extermeties
While diminished in
upper

17. MANAGEMENT OF CERVICAL
INJURY
Spine :
Based on level of injury , stability of spine , presence of luxation ,
extent of angulation , level of neurologic deficit , and overall
condition of pt .
Surgical fusion is performed in pt with neurological deficit (
angulation > 11 degree or translation > 3.5 mm )
Indication for immediate operation :
1. Deterioration in neurological function
2. Dislocation with incomplete deficit

18. CONTINUE
Predinsalone administration in acute spinal injury ???
Urgent decompression in acute cervical injury is safe , performing
that within 24 hrs , decreases hospital stay and complications
Complete spinal cord injury , still untreatable .

19. MANAGEMEN
T OF
CERVICAL
INJURY
Vascular:

21. VASCULAR
Options for carotid injury repair :
1) End to end primary repair
2) Graft interposition
3) Transpoistion
All carotid injury must be repaired except
in pt presented with coma with delay
transportation
Role of carotid stenting in grade 3 ,
contraversal !
Tangitional wounds of internal jagular
should be repaired by lateral venography ,
extensive wounds need ligation
DO NOT ligate both jagular at time ,
intracranial HTN !!
Vertebral artery injury ! Go for
angioembolization

22. CONTINUE ..
Antithrombotic can be admistered if no contraindicatios ( intrcranial
he , fall in hgb level with soilid organ injury or pelvic fracture )
Heparin , started without a loading dose at 15 unit/kg /hr , then
tittered to achieve PTT (40-50)
aspirin 325 mg/d Or clopidogrel 75 mg/d
Duration at least 6 months

23. MANAGEMENT OF CERVICAL
INJURY
Aerodigestive :
Subclinical fracture of larynx and trachea manifest as emphysema
Tracheal injury :
After debridment of devitalized tissue , end to end repair , with single
inyerupted absorbable suture
Esophageal injury :
After debridment , repair initiated and closed suction drain is placed