Committee on Trauma Presents

Head
Trauma

©ACS
 Anatomy and physiology effects?

 Rigid, nonexpansile skull filled with

brain, CSF, and blood
 CBF autoregulation
 Autoregulatory compensation disrupted
by brain injury
 Mass effect of intracranial hemorrhage
©ACS
 Monro-Kellie Doctrine
Venous Art. Brain CSF
Volume Vol.

Ven. Art.
Brain Mass CSF
Vol. Vol.

75 mL Arterial 75 mL
Brain Mass CSF
Volume

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Volume – Pressure Curve

60- Herniation
55- ICP
50- (mm Hg)
45-
40-
35- Point of
30- Decompensation
25-
20-
15-
10-
5- Compensation
Volume of Mass
©ACS
 Intracranial Pressure (ICP)

 10 mm Hg = Normal
 > 20 mm Hg = Abnormal
 > 40 mm Hg = Severe
 Many pathologic processes affect outcome
 Sustained  ICP leads to  brain function and
outcome

©ACS
 Autoregulation

 If autoregulation is intact, CBF is

maintained with a mean BP of 50 to 160
mm Hg.
 Moderate or severe brain injury:
Autoregulation often impaired
 Brain more vulnerable to episodes of
hypotension  secondary brain injury
©ACS
Mechanisms of Traumatic Brain Injury
• Impact injury
• Cerebral or brainstem contusions
• Cerebral lacerations
• Diffuse axonal injury (DAI)
• Intracranial Hematom

• Secondary injury
• Edema
• Ischemia
 Initial Assessment

Start with ABC’s

History • Physical Exam

– LOC +/- – GCS
– Intoxicants – Level of consciousness
– Seizure – Cranial nerves
– Posttraumatic amnesia – Fundoscopic exam
– Motor exam
 Glasgow Coma Scale (GCS)
• Introduced by Teasdale and Jennett in 1974
• Consists of 3 clinical signs that have
– Prognostic significance
– Good reproducibility between observers
• Scale range 3-15
• GCS < 8 has generally become accepted as
representing coma / severe head injury
 Severe Brain Injury

 GCS Score = 3–8

 Evaluate and resuscitate
 Intubate for airway protection
 Focused neurologic exam
 Frequent reevaluation
 Identify associated injuries

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 Diffuse Brain Injury

 Mild concussion  Severe, ischemic

insult

Normal CT Diffuse Injury ©ACS

 Contusion / Hematoma

 Coup / contracoup injuries

 Most common: Frontal / temporal lobes
 CT changes usually progressive
 Most conscious patients: No operation

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Contusion / Hematoma

Large frontal
contusion with
shift

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 Epidural Hematoma

 Associated with skull fracture

 Classic: Middle meningeal artery tear
 Lenticular / biconvex
 Lucid interval
 Can be rapidly fatal
 Early evacuation essential
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Epidural Hematoma
Temporal
Epidural
Hematoma

Uncal
herniation

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 Subdural Hematoma

 Venous tear / brain laceration

 Covers cerebral surface
 Morbidity / mortality due to underlying
brain injury
 Rapid surgical evacuation
recommended, especially if > 5 mm shift
of midline
©ACS
Subdural Hematoma

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 How to measure “severity”?
• Duration of loss of consciousness
• Initial score on Glasgow Coma Scale (GSC)
• Length of post-traumatic amnesia
• Rancho Los Amigos Scale (1 to 10)
Indications for CT Scan?

All patients with

suspicion of brain
injury

©ACS
 Head Injury Management
• Nonoperative
• Seen in absence of significant intracranial mass lesion.
• Typically consists of assessment and/or treatment of
intracranial pressure (ICP).
• Operative
• Typically required when a significant intracranial mass
lesion is present.
• Decompressive craniectomy or brain resection less
common.
 Priorities

 ABCDE
 Minimize secondary brain injury
· Administer O2
· Maintain blood pressure
(systolic > 90 mm Hg)

©ACS
 Medical Management

 Intravenous fluids
· Euvolemia
· Isotonic
 Controlled ventilation
· Goal: Paco2 at 35 mm Hg

©ACS
 Medical Management

 Mannitol
· Use with signs of tentorial herniation
· Dose: 1.0 g / kg IV bolus
· Consult with neurosurgeon first

©ACS
Therapy for increase Intracranial pressure

• First tier
• Positioning
• Ventricular drainage
• Osmotic diuresis
• Hyperventilation (Level III – temporizing measure)
• Second tier
• Sedation
• Neuromuscular blockade
• Hypothermia
• Barbiturate coma
• Glucocorticoids not recommended (Level I)
 Medical Management

 Other medications
· Anticonvulsants
· Sedation
· Paralytics

©ACS
 Surgical Management

Intracranial Mass Lesion

 May be life-threatening if expanding
rapidly
 Immediate neurosurgical consult
 Hyperventilation / Mannitol
 Damage control craniotomy: Transfer to

neurosurgeon (rural / austere areas)

©ACS
 Recovery
• A multi-stage process
• Continues for years
• Differs for each person
What is the Long-term Impact of a Moderate
or Severe TBI in the Person’s Functioning?
 Impact depends on
• Severity of initial injury
• Rate/completeness of physiological recovery
• Functions affected
• Meaning of dysfunction to the individual
• Resources available to aid recovery
• Areas of function not affected by TBI
 Cognitive functions
• Attention • Perseveration
• Concentration • Impulsiveness
• Memory • Language Processing
• Speed of Processing • “Executive functions”
• Confusion
 Other physical changes
• Physical paralysis/spasticity
• Chronic pain
• Control of bowel and bladder
• Sleep disorders
• Loss of stamina
• Appetite changes
• Regulation of body temperature
• Menstrual difficulties
 Summary: What should I do?

 Maintain mean BP > 90 mm Hg

 Maintain Paco2 near / at 35 mm Hg
 Use isotonic solution for euvolemia
 Frequent neurologic exams
 Liberal use of CT scans
 Early neurosurgical consult
©ACS
 Summary: What should I not do?

 Allow patient to become hypotensive

 Over-aggressively hyperventilate
 Use hypotonic IV fluids
 Use long-acting paralytics

©ACS
 SPINAL CORD INJURIES
Anatomy & Pathophysiology
Dr Roezwir SpS
 Definition

Insult to spinal cord resulting in a change,

in the normal motor, sensory or autonomic
function. This change is either temporary or
permanent.
Mechanisms:

i) Direct trauma
ii) Compression by bone fragments /
haematoma / disc material
iii) Ischemia from damage / impingement on
the spinal arteries
 Anatomy :
Spinal cord:

• Extends from medulla oblongata – L1

• Lower part tapered to form conus medullaris
Hence: 31 pairs of spinal nerves:
8 cervical
12 thoracic
5 lumbar
5 sacral
1 coccygeal
• Dorsal root – sensory fibres

• Ventral root – motor fibres

• Dorsal and ventral roots join at intervertebral

foramen to form the spinal nerve
 Physiology and function
• Grey matter – sensory and motor nerve cells

• White matter – ascending and descending

tracts
• Divided into - dorsal
- lateral
- ventral
 Tracts :

1) Posterior column:

• Fine touch
• Light pressure
• Proprioception
2) Lateral corticospinal tract :

• Skilled voluntary movement

3) Lateral spinothalamic tract :

• Pain & temperature sensation

• Posterior column and lateral corticospinal
tract crosses over at medulla oblongata

• Spinothalamic tract crosses in the spinal cord

and ascends on the opposite side

NB to understand this as it helps to understand

the clinical features of injury patterns and the
neurological deficit
 Dermatomes
• Area of skin innervated by sensory axons
within a particular segmental nerve root
• Knowledge is essential in determining level of
injury
• Useful in assessing improvement or
deterioration
Downloaded from: Rosen's Emergency Medicine (on 29 April 2009 06:34 PM)
© 2007 Elsevier
Downloaded from: Rosen's Emergency Medicine (on 29 April 2009 06:34 PM)
© 2007 Elsevier
 Myotomes :
• Segmental nerve root innervating a muscle
• Again important in determining level of injury

• Upper limbs:
C5 - Deltoid
C 6 - Wrist extensors
C 7 - Elbow extensors
C 8 - Long finger flexors
T 1 - Small hand muscles
• Lower Limbs :
L2 - Hip flexors
L3,4 - Knee extensors
L4,5 – S1 - Knee flexion
L5 - Ankle dorsiflexion
S1 - Ankle plantar flexion
 Spinal Cord Injury Classification
• Quadriplegia :
injury in cervical region
all 4 extremities affected

• Paraplegia :
injury in thoracic, lumbar or sacral segments
2 extremities affected
Injury either:

1) Complete

2) Incomplete
Complete:
i) Loss of voluntary movement of parts
innervated by segment, this is irreversible
ii) Loss of sensation
iii) Spinal shock
Incomplete:

i) Some function is present below site of

injury
ii) More favourable prognosis overall
iii) Are recognisable patterns of injury, although
they are rarely pure and variations occur
 Injury defined by ASIA Impairment Scale

ASIA – American Spinal Injury Association :

A – Complete: no sensory or motor function

preserved in sacral segments S4 – S5

B – Incomplete: sensory, but no motor function

in sacral segments
C – Incomplete: motor function preserved below
level and power graded < 3

D – Incomplete: motor function preserved below

level and power graded 3 or more

E – Normal: sensory and motor function normal

 Muscle Strength Grading:
• 5 – Normal strength
• 4 – Full range of motion, but less than
normal strength against resistance
• 3 – Full range of motion against gravity
• 2 – Movement with gravity eliminated
• 1 – Flicker of movement
• 0 – Total paralysis
 Spinal Shock vs Neurogenic Shock

Spinal Shock :

• Transient reflex depression of cord function below level of

injury
• Initially hypertension due to release of catecholamines
• Followed by hypotension
• Flaccid paralysis
• Bowel and bladder involved
• Sometimes priaprism develops
• Symptoms last several hours to days
Neurogenic shock:
• Triad of i) hypotension
ii) bradycardia
iii) hypothermia
• More commonly in injuries above T6
• Secondary to disruption of sympathetic
outflow from T1 – L2
• Loss of vasomotor tone – pooling of blood
• Loss of cardiac sympathetic tone – bradycardia
• Blood pressure will not be restored by fluid infusion
alone
• Massive fluid administration may lead to overload
and pulmonary edema
• Vasopressors may be indicated
• Atropine used to treat bradycardia
 Types of incomplete injuries
i) Central Cord Syndrome

ii) Anterior Cord Syndrome

iii) Posterior Cord Syndrome

iv) Brown – Sequard Syndrome

v) Cauda Equina Syndrome

i) Central Cord Syndrome :

• Typically in older patients

• Hyperextension injury
• Compression of the cord anteriorly by
osteophytes and posteriorly by ligamentum
flavum
• Also associated with fracture dislocation and
compression fractures
• More centrally situated cervical tracts tend to
be more involved hence
flaccid weakness of arms > legs
• Perianal sensation & some lower extremity
movement and sensation may be preserved
ii) Anterior cord Syndrome:
• Due to flexion / rotation
• Anterior dislocation / compression fracture of
a vertebral body encroaching the ventral canal
• Corticospinal and spinothalamic tracts are
damaged either by direct trauma or ischemia
of blood supply (anterior spinal arteries)
Clinically:
• Loss of power
• Decrease in pain and sensation below lesion
• Dorsal columns remain intact
ii) Posterior Cord Syndrome:
Hyperextension injuries with fractures of
the posterior elements of the vertebrae

Clinically:
• Proprioception affected – ataxia and
faltering gait
• Usually good power and sensation
iv) Brown – Sequard Syndrome:
• Hemi-section of the cord
• Either due to penetrating injuries:
i) stab wounds
ii) gunshot wounds
• Fractures of lateral mass of vertebrae
Clinically:
• Paralysis on affected side (corticospinal)
• Loss of proprioception and fine discrimination
(dorsal columns)
• Pain and temperature loss on the opposite
side below the lesion (spinothalamic)
v) Cauda Equina Syndrome:
• Due to bony compression or disc protrusions in
lumbar or sacral region

Clinically
• Non specific symptoms – back pain
- bowel and bladder dysfunction
- leg numbness and weakness
- saddle parasthesia