This document provides guidance on the emergency room management of head injuries and spinal trauma. It discusses the initial assessment, indications for imaging and interventions like intubation. Key points include maintaining airway, breathing and circulation to prevent secondary brain injury, treating hypotension aggressively, and indications for neurosurgical consultation and repeat CT imaging if patients deteriorate. It also outlines the screening and management of potential spinal injuries, including spine precautions during evaluation and transport, and criteria for radiographic evaluation and monitoring.

1. Dr Sumit Sinha
Additional Professor
Department of Neurosurgery,
JPNATC, AIIMS, New Delhi

2. HEAD INJURY IN ER

3. ER Management of Neurotrauma
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

4. Concept of ICP & CPP
CPP = MAP – ICP
CPP- Critical : < 50 mmHg
ICP-
When will ICP ?? -↑
 Mass Lesions- Bleeding EDH, SDH, ICH
 Cerebral Edema Cytotoxic, Vasogenic
10 mm Hg = Normal
>20 mm Hg = Abnormal
>40 mm Hg = Severe

5. Monro-Kellie Doctrine

6. Classification of Head Injuries
A. Blunt or Penetrating
B. Based on GCS-
Mild 14-15
Moderate 9-13
Severe 3-8
C. Morphology (Fracture and Intracranial)

7. MANAGEMENT
A- 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
Associated Neck
Injury
* If C-Spine Injury is suspected, intubation should be performed
by the most experienced person available.

8. MANAGEMENT
B- Breathing
HYPOXIA HYPERCARBIA
Maintain PaO2 > 60 mmHg Maintain Normocarbia
Maintain SpO2 > 95% PaCO2 - 35-40 mmHg

9. MANAGEMENT
C- Circulation
TREAT HYPOTENSION
Maintain MAP > 90 mm Hg
USE
Crystalloids – RL/ NS
Ionotrope Infusion if needed

10. Primary Aim of ER management
Prevent Secondary Brain damage at all costs
TREAT AGGRESSIVELY
Hypotension (MAP > 90mmHg)
Hypoxia (PaO2 < 60mmHg)
Hypoglycemia
Fever
Raised Intra-cranial Pressure
Seizures
Early episodes of hypotension or hypoxia greatly increase
morbidity and mortality from severe head injury

11. MANAGEMENT
D- 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 response-
LATERALIZING SIGNS

12. Head Injury Management
High risk Moderate Risk
● GCS score still < 15 two
hours after injury
● Neurologic deficit
● Open skull fracture
● Sign of basal skull fracture
● Extremes of age
● “Dangerous mechanism”
● Retrograde amnesia > 30
minutes in duration
● Severe headache
● Vomiting > 2 episodes
Indications for CT

13. Head Injury Management
Indications for admission
All Moderate and Severe HI
Mild HI-
 Unlikely to be carefully/ periodically checked at home
 Other significant injuries
 Child
 PTA > 1hr.

14. Head Injury Management
Indications for Repeat CT
 Patients failing to show expected recovery
 Discordant clinical and initial CT findings
 Deterioration
 New deficits

15. Initial Neurosurgical Management
Abnormal CT Scan

16. Medical Management
 Controlled ventilation
 Intubate if GCS<8 (Orotracheal)
 Mannitol- 0.25-1.0 gm/Kg IV over 15 min (Not in
Hypotensives)
 Monitor Urine Output
 Spine Cleared – Elevate the Head to 30°
 Sedation/ Paralysis- Neurological examination before
prolonged sedation / paralysis

17. Other Considerations
Seizure Focus/Post Traumatic Seizures (2-5%)
 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. Surgical Management
● Scalp Wounds
● Possible site of major blood loss
● Direct pressure to control bleeding
● Occasional temporary closure

19. Surgical Management
Intracranial Mass Lesion
● Can be life-threatening if expanding
rapidly
● Immediate neurosurgical consult
● Hyperventilation / mannitol
● Damage control craniotomy: transfer to
neurosurgeon (rural / austere areas)

20. Pitfalls
 Alteration in consciousness is hallmark of head injury.
Never attribute neurological abnormality to alcohol /
drugs.
 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 ↑ICP

21. Summary
 Comatose patient, secure and maintain airway by
ET intubation.
 Treat shock aggressively
 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 patient until the brain can be assessed.

22. Spinal Trauma in ER

23. Spine Trauma
Suspicion of Spinal injury
 Mechanism of injury
 Unconscious Patient
 Neurologic deficits
 Spinal pain and tenderness

24. Spine Protection during evaluation and
transport
Protection is priority;
detection is secondary

25. 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

26. Spine injury Screening
Conscious Cooperative
Patient
Altered Consciousness or
Symptoms
• If no neck or spine pain or
tenderness
• If still no pain or tenderness
with voluntary movement
• No further evaluation or x-
ray necessary
Clear spine and remove
cervical collar.
• Radiographic
visualization of entire
spine
• Plain films
• CT scan of suspicious or
poorly visualized areas

27. Spine injury Screening
 Confirmation of Spine injury
 Clinical Signs
 Radiology- X Ray/ CT/ MR
 Presume Spinal Instability
 Early spine consult
Rule of thumb- N. deficit- Unstable

28. TRAUMA 2011TRAUMA 2011
Radiographic Evaluation
C. Spine: AP, Lat, open mouth (92%)
Thoracic & lumbar spine: AP, Lat
CT
10% of C. Spine pt. have a second # of V. column-10% of C. Spine pt. have a second # of V. column-
complete radiographic screeningcomplete radiographic screening

29. 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

30. TRAUMA 2011TRAUMA 2011
AP- Pedicles,
Facets, Sp. process,
V. body ht.
LAT- V. body height,
Angulation, disc space

31. Neurologic status
 Complete: No motor/ sensory function below the
level of injury
 Incomplete: Any motor/sensory below the level-
prognosis for recovery is better
 Perianal sensation may be the only sign of
incomplete SCI

32. Effects of Spinal Injury
Neurogenic Shock
 Cx and High Thoracic injuries- Cardiovascular
phenomenon
 Vasodilatation & pooling of blood- hypotension
 Bradycardia- No H.R. in response to hypotension
 I.V. fluids- fluid overload/ P. Edema
 Vasopressors / Atropine

33. Effects of Spinal Injury
Spinal Shock
 Neurologic phenomenon- Complete flaccidity &
loss of reflexes
 Gen. lasts 24- 48 hrs
 Anal & bulbo-cavernosus –first to return

34. TRAUMA 2011TRAUMA 2011
Management
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

35. TRAUMA 2011TRAUMA 2011
Management
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

36. Management
Transfer Criteria-
 Unstable Fractures
 Neurologic deficits
AVOID UNNECESSARY DELAY
• Provide respiratory support as
needed
• Exclude other life- threatening
injury
• Properly immobilize entire
patient
• Avoid hypothermia

37. TRAUMA 2011TRAUMA 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

38. TRAUMA 2011TRAUMA 2011
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Jai Prakash Narain Apex Trauma CenterJai Prakash Narain Apex Trauma Center
All India Institute of Medical SciencesAll India Institute of Medical Sciences