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ER Management of Head & Spine Trauma
- 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. 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. 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. 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. 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. 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. AIIMS Trauma Workshop TRAUMA 2011 Initial Management - Breathing HYPOXIA HYPERCARBIA Maintain PaO2 > 60 mmHg Maintain Normocarbia Maintain SpO2 > 95% PaCO2 - 35-40 mmHg
- 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. 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. 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. 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. 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. 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. 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. AIIMS Trauma Workshop TRAUMA 2011 Initial Neurosurgical Management Abnormal CT Scan
- 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. 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. 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. 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. AIIMS Trauma Workshop TRAUMA 2011 Jai Prakash Narain Apex Trauma Center All India Institute of Medical Sciences
- 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. 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. 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. AIIMS Trauma Workshop TRAUMA 2011 Exclusion ■ Awake: Simple N. intact,Absence of pain, tenderness along whole spine ■ Comatose: X-rays/ C.T. scan
- 25. AIIMS Trauma Workshop TRAUMA 2011 Goals ■ Maintain Immobilization ■ Avoid excessive manipulation ■ Minimize second injury/insult
- 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. 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. 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. AIIMS Trauma Workshop TRAUMA 2011 Spinal Shock ■ Complete flaccidity & loss of reflexes ■ Gen. lasts 24- 48 hrs ■ Anal & bulbo-cavernosus –first to return
- 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. 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. 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. AIIMS Trauma Workshop TRAUMA 2011
- 34. AIIMS Trauma Workshop TRAUMA 2011 AP- Pedicles, Facets, Sp. process, V. body ht.
- 35. AIIMS Trauma Workshop TRAUMA 2011 LAT- V. body height, angulation, disc space
- 36. AIIMS Trauma Workshop TRAUMA 2011 SCIWORA ■ Spinal cord Injury without obvious Radiological Abnormality ◻ Pediatric ??REMEMBER??
- 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. AIIMS Trauma Workshop TRAUMA 2011 Spine Board ■ C. Collar ■ Straps: -Head -Thorax -Iliac crests -Thighs -Just above ankles
- 39. AIIMS Trauma Workshop TRAUMA 2011
- 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. 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. 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. 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. AIIMS Trauma Workshop TRAUMA 2011 Neurologic Examination ■ Sensation:pinprick- level ■ Motor: level ■ Reflexes ■ Document & repeat
- 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. 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. 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. AIIMS Trauma Workshop TRAUMA 2011 Jai Prakash Narain Apex Trauma Center All India Institute of Medical Sciences