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Head and Spine trauma traumacon 2011.ppt

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management of head and spine trauma ER

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Head and Spine trauma traumacon 2011.ppt

  1. 1. Management of Head & Spine Trauma ER Sumit Sinha Associate Professor of Neurosurgery Jai Prakash Narain Apex Trauma Center All India Institute of Medical Sciences
  2. 2. AIIMS Trauma Workshop Objectives ■ Initial Management A (with C1) – B – C ■ Initial Neuro-Assessment D - Glasgow Coma Scale Pupils ■ Immediate Neurosurgical Management CT Scan - when? Neurosurgical Consult - when? Recognition and treatment of Herniation ■ Other Considerations C-Spine, Bleeding, Extremity #, Rest of Spine ■ Pitfalls TRAUMA 2011
  3. 3. AIIMS Trauma Workshop Primary Aim of ER management ■ Prevent Secondary Brain damage at all costs TREAT AGGRESSIVELY ◻ Hypo tension (MAP > 90mmHg) ◻ Hypoxia (PaO2 < 60mmHg) ◻ Hypoglycemia ◻ Fever ◻ Raised Intra-cranial Pressure ◻ Seizures TRAUMA 2011
  4. 4. AIIMS Trauma Workshop TRAUMA 2011 Concept of ICP & CPP CPP = MAP – ICP Normal : > 70 mm Hg Reduced : 50 -70 mm Hg Critical : < 50 mmHg When will ICP ↑?? Mass Lesions Bleeding EDH, SDH, Intraparenchymal bleed Cerebral Edema Cytotoxic, Vasogenic
  5. 5. AIIMS Trauma Workshop TRAUMA 2011 Monro-Kellie Doctrine Venous Volume Arterial Volume Brain CSF Normal State – ICP Normal Venous Volume Arterial Volume Brain CSFMASS Compensated State – ICP Normal Arterial Volume Brain Venous Volume MASS CSF Uncompensated State – ICP Raised ICP (mmHg) 35 30 25 20 15 10 5 Volume Volume-Pressure Curve Herniation Point of Decompensation TRAUMA 2011
  6. 6. AIIMS Trauma Workshop TRAUMA 2011 Initial Management – Airway with C-Spine PATENT ↓ OKAY Don’t Intubate until patient needs sedation for some other procedure THREATENED Remains Unresponsive GCS ≦ 8 (CANNOT PROTECT AIRWAY) Oral bleeding Base of Skull bleeding OBSTRUCTED Massive Maxillofacial Trauma Maxilla Mandible Associated Neck Injury * If C-Spine Injury is suspected, intubation should be performed by the most experienced person available.
  7. 7. AIIMS Trauma Workshop TRAUMA 2011 Initial Management - Breathing HYPOXIA HYPERCARBIA Maintain PaO2 > 60 mmHg Maintain Normocarbia Maintain SpO2 > 95% PaCO2 - 35-40 mmHg
  8. 8. AIIMS Trauma Workshop TRAUMA 2011 Initial Management - Circulation TREAT HYPOTENTION Maintain Mean Arterial Pressure above 90 mm Hg USE Crystalloids – Ringers Lactate or Normal Saline Ionotrope Infusion if needed
  9. 9. AIIMS Trauma Workshop TRAUMA 2011 Initial Neuro-Assessment ■ Key History ◻ Mechanism of Injury ◻ Response at scene → Neuro-exam at scene → Change in status ■ Note Glasgow Coma Scale (GCS 3-15) ■ Note Pupils : Size / Shape / Reaction Note the symmetry of motor Score Eye Opening Best Verbal Response Best Motor Response 6 Obeys Commands 5 Oriented Localizes Pain 4 Spontaneous Confused Flexed to Pain 3 To Speech Inappropriate Words Flexion of arms with ext of legs(decorticate) 2 To Pain Incomprehensive sounds Extension 1 None No Verbalization None
  10. 10. AIIMS Trauma Workshop TRAUMA 2011 Classification of Head Injuries A. Blunt or Penetrating B. Mild, Moderate, Severe (Based on GCS) Mild 14-15 Moderate 9-13 Severe 3-8 C. Morphology (Fracture and Intracranial)
  11. 11. AIIMS Trauma Workshop TRAUMA 2011 Mild Head Injuries ■ GCS 14-15 ■ CT if LOC, Amnesia, Severe Headache, Anticoagulation ■ Evaluate C-Spine ■ Prognosis is excellent ■ Mortality rate < 1%
  12. 12. AIIMS Trauma Workshop TRAUMA 2011 Moderate Head Injuries ■ Patients may be confused, somnolent ■ GCS 9-13 ■ Admit observe ,repeat head CT with frequent neuro checks ■ Prognosis is good ■ Mortality rate < 5 %
  13. 13. AIIMS Trauma Workshop TRAUMA 2011 Severe Head Injuries ■ GCS < 8/15 ■ Mortality rate > 40% ■ Securing of A,B,C’s highest priority ■ Early Intubation ■ Hypotension associated with twice mortality ■ Maintain Pco2 25-35 mm/Hg
  14. 14. AIIMS Trauma Workshop TRAUMA 2011 Initial Neurosurgical Management ■ WHEN TO GET A CT-SCAN ? ■ Patient Comatose (GCS<13) ■ Penetrating Trauma ■ Suspect Skull # ■ CSF Leak ■ Post Trauma Seizures ■ Focal Neurological signs (Motor/Pupils) ■ WHEN TO CALL A NEUROSURGEON? ■ All of the above ■ Abnormal CT Scan
  15. 15. AIIMS Trauma Workshop TRAUMA 2011 Initial Neurosurgical Management Abnormal CT Scan
  16. 16. AIIMS Trauma Workshop TRAUMA 2011 Medical Management ■ Recognize and treat ↑ICP / Herniation Monitor : Decrease in Pulse+Ventilation+ ↑B.P. Decrease in level of Consciousness Dilated Pupil Decrease in motor power (Contralateral - Dilat pupil) ■ Cerebral Resuscitation ◻ Hyperventilation is the mainstay ◻ Hyperventilate with BMV till Intubation ◻ Intubate if (Orotracheal) if GCS<8 in more alert Rapid sequence Intubation [HV till Pco2 = 28-32 mmHg confirmed by ABG] ◻ Mannitol Infusion 0.25-1.0 gm/Kg IV over 15 min (Not in Hypotensives) ◻ Monitor Urine Output ◻ Spine Cleared – Elevate the Head to 30°
  17. 17. AIIMS Trauma Workshop TRAUMA 2011 Other Considerations ■ Seizure Focus/Post Traumatic Seizures (2-5%) SAH, Bleed (Intracerebral, sub or extradural) Witnessed seizure Load Phenytion ≈ 11-15mg/Kg IV slow with cardiac monitoring ■ C-Spine 5%-20% of patients with severe HI will have C-spine injury 5%-10% with one spine # will have another one too Therefore C-Spine motion restriction and log-rolling till full spine cleared ■ Control of Bleeding ■ Immobilize other extremity fractures
  18. 18. AIIMS Trauma Workshop TRAUMA 2011 Pitfalls ■ Never attribute neurological abnormality solely to the presence of alcohol / drugs. Alteration in consciousness is hallmark of head injury. ■ Assume spinal Injury till ruled out ■ No naso-gastric / naso-tracheal tube if base skull # suspected ■ Treat other life threatening bleeding first ■ Systolic pressure < 90 mmHg will lead to secondary brain Injury ■ Poor Ventilation and Oxygenation will Increase the ICP
  19. 19. AIIMS Trauma Workshop TRAUMA 2011 Summary ■ In a comatose patient, secure and maintain the airway by endotracheal intubation. ■ Treat shock aggressiv ■ Hypoxia and hypovolaemia kill more patients than brain injury. ■ Secondary brain injury makes primary brain injury worse ■ If sedation or paralysis makes assessment difficult, then treat the patient until the brain can be assesed.
  20. 20. AIIMS Trauma Workshop TRAUMA 2011 Jai Prakash Narain Apex Trauma Center All India Institute of Medical Sciences
  21. 21. Trauma Alert Spine in E.D. Kamran Farooque M.S., MRCS (U.K.) Assistant Professor of Orthopaedics Jai Prakash Narain Apex Trauma Center All India Institute of Medical Sciences
  22. 22. AIIMS Trauma Workshop TRAUMA 2011 Spine Trauma ■ C. Spine- 55% ■ Thoracic spine- 15% ■ T.L.Junction- 15% ■ L.S. spine-15% ➢ 5% of head injury pt.have spine injury
  23. 23. AIIMS Trauma Workshop TRAUMA 2011 Anatomic Considerations ■ C.spine: Canal is wide Low chance for N. compromise -High chance for resp. failure ■ Thoracic spine: Ribs afford mechanical stability -Narrow spinal canal High chance of N. deficit -T/L Junction: Fulcrum- high frequency of #
  24. 24. AIIMS Trauma Workshop TRAUMA 2011 Exclusion ■ Awake: Simple N. intact,Absence of pain, tenderness along whole spine ■ Comatose: X-rays/ C.T. scan
  25. 25. AIIMS Trauma Workshop TRAUMA 2011 Goals ■ Maintain Immobilization ■ Avoid excessive manipulation ■ Minimize second injury/insult
  26. 26. AIIMS Trauma Workshop TRAUMA 2011 ASCI- Types ■ Complete: No motor/ sensory function below the level of injury ■ Incomplete:Any motor/sensory below the level- prognosis for recovery is better ■ Peri-anal sensation may be the only sign of incomplete SCI
  27. 27. AIIMS Trauma Workshop TRAUMA 2011 Neurogenic Shock ■ Loss of sympathetic outflow from S. cord ■ Loss of vasomotor tone & sympathetic supply to heart ■ Vasodilatation & pooling of blood- hypotension ■ Bradycardia- No H.R. in response to hypotension
  28. 28. AIIMS Trauma Workshop TRAUMA 2011 Neurogenic Shock ■ I.V. fluids alone may not help ■ Danger of fluid overload/P.Edema ■ Vasopressors / Atropine –significant Bradycardia
  29. 29. AIIMS Trauma Workshop TRAUMA 2011 Spinal Shock ■ Complete flaccidity & loss of reflexes ■ Gen. lasts 24- 48 hrs ■ Anal & bulbo-cavernosus –first to return
  30. 30. AIIMS Trauma Workshop TRAUMA 2011 Classification-ASCI ■ N.level: Quadriplegia/ Paraplegia ■ N.Deficit: Complete/ Incomplete ■ S. Cord Syndromes: central/B.S. ■ Morphology: X-ray, C.T.- Stable/ Unstable Rule of thumb- N.deficit- Unstable
  31. 31. AIIMS Trauma Workshop TRAUMA 2011 Radiographic Evaluation ■ C.Spine: AP, Lat, open mouth (92%) ■ Thoracic & lumbar spine: AP, Lat ■ C.T. 10% of C. Spine pt.have a second # of V. column- complete radiographic screening
  32. 32. AIIMS Trauma Workshop TRAUMA 2011 X-ray Evaluation ■ C.spine- 4 lines ■ Height of V. body,contour ■ Pedicles,Sp.process,facets ■ I/V disc space,Sp. Process inter space ■ Pre vertebral soft tissue space <5mm at C3
  33. 33. AIIMS Trauma Workshop TRAUMA 2011
  34. 34. AIIMS Trauma Workshop TRAUMA 2011 AP- Pedicles, Facets, Sp. process, V. body ht.
  35. 35. AIIMS Trauma Workshop TRAUMA 2011 LAT- V. body height, angulation, disc space
  36. 36. AIIMS Trauma Workshop TRAUMA 2011 SCIWORA ■ Spinal cord Injury without obvious Radiological Abnormality ◻ Pediatric ??REMEMBER??
  37. 37. AIIMS Trauma Workshop TRAUMA 2011 Immobilization ■ All pt.with suspected spinal injury ■ Pre hospital personnel- before & during transport to definitive facility ■ Till spinal injury excluded by X-rays ■ Neutral position- Supine, Padding ■ Long spine board, cervical restraints,straps
  38. 38. AIIMS Trauma Workshop TRAUMA 2011 Spine Board ■ C. Collar ■ Straps: -Head -Thorax -Iliac crests -Thighs -Just above ankles
  39. 39. AIIMS Trauma Workshop TRAUMA 2011
  40. 40. AIIMS Trauma Workshop TRAUMA 2011 Log Roll ■ 4 persons -1-maintain manual in line immobilization of head & neck -2-shoulders & pelvis -3-Pelvis & legs -4- Directs & move the spine board Maintain neutral alignment of spine
  41. 41. AIIMS Trauma Workshop TRAUMA 2011 Screening for C.Spine ■ Paraplegia/Quadriplegia- Unstable spine ■ Awake/Alert/Sober/ N.neurology-no neck pain -Remove C. Collar-palpate the spine -No tenderness-Voluntary movt. of spine ■ Awake/Alert/Sober/N.neurology- Neck Pain -Mandatory for the doctor to exclude
  42. 42. AIIMS Trauma Workshop TRAUMA 2011 Primary Survey Airway: Protect C. Spine- Intubation if needed Breathing: Oxygen,ventilatory support Circulation: -Hypovolemic shock- BP, HR,cool extremity-fluids -Neurogenic shock- BP, HR, warm extremity- vasopressors Disability: consciousness, GCS, pupils, paresis/paraplegia
  43. 43. AIIMS Trauma Workshop TRAUMA 2011 Secondary Survey ■ History,mechanism of injury ■ Reassess- consciousness, GCS ■ Spine:palpation-entire spine-deformity, Crepitus, tenderness, contusion ■ Pain, paralysis/paresis-absent/present, location, neurologic level
  44. 44. AIIMS Trauma Workshop TRAUMA 2011 Neurologic Examination ■ Sensation:pinprick- level ■ Motor: level ■ Reflexes ■ Document & repeat
  45. 45. AIIMS Trauma Workshop TRAUMA 2011 General Treatment ■ Airway: critical importance in high C.Spine ■ Oxygen to all ■ Early intubation-maintain neck in neutral position ■ I.V. fluids: maintain BP-loss of auto regulation of spinal blood flow ■ Spinal shock: Vasopressors, atropine ■ Urinary Catheter: bladder distension, ouput ■ N.G.tube: Ileus- empty stomach,reduce risk of aspiration
  46. 46. AIIMS Trauma Workshop TRAUMA 2011 Steroids- NASCIS-I,II,III ■ High dose methyl prednisolone ■ <3 hr: Bolus+ Infusion-23hrs. ■ 3-8hr: Bolus+ Infusion-48hrs. ■ Bolus- 30mg/kg over 15 min ■ Infusion-5.4mg/kg -Membrane stabilizer-lipid peroxidation,inflammation
  47. 47. AIIMS Trauma Workshop TRAUMA 2011 Treatment - Summary in E.D. ■ Protect from further injury:Long spine board, C.Collar,log roll-neutral alignment of spine -Minimize time on spine board- Decubitus ulcer ■ Oxygen to all ■ Fluid resuscitation & monitoring:CVP, Urinary catheter,N.G. tube ■ Steroids
  48. 48. AIIMS Trauma Workshop TRAUMA 2011 Jai Prakash Narain Apex Trauma Center All India Institute of Medical Sciences

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