Evaluation of Head and Neck Trauma

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Evaluation of Head and Neck Trauma

• Richard W. Stair, M.D.

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First and Foremost.ABCs

• Airway
• Breathing
• Circulation
• Disability
• Exposure

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Head Injury

• Accounts for half of all trauma deaths
• Severe morbidity
• Blunt vs. penetrating

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Anatomic Considerations

• Scalp skin, subcutaneous tissue, galea,
  areolar tissue, pericranium
  
• Skull protective, but rigid
• Brain direct injury (primary) and indirect
  injury (secondary)

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Secondary Brain Injury

• Increased Intracranial Pressure (ICP)
• loss of autoregulation of blood vessels
• if ICP equals systemic arterial pressure, then no
  cerebral perfusion pressure BRAIN DEATH

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Secondary Brain Injuries

• Herniation
• cingulate
• transtentorial (uncal)

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Transtentorial (uncal) herniation

• Uncus compresses between cerebral peduncle and
  tentorium
  
• clinically, results in ipsilateral fixed and
  dilated pupil, contralateral paralysis
  
• may become bilateral

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Diffuse Brain Lesions

• Concussion
• Diffuse Axonal Injury

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Focal Brain Lesions

• Brain lacerations
• Penetrating Injuries
• Contusions
• Intracerebral hemorrhage
• Epidural hematomas
• Subdural hematomas

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Epidural Hematomas

• Blood between inner table of skull and dura
• Usually tear of MMA
• Hematoma does not cross suture
• Lens shaped on CT scan
• RARE in elderly

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Subdural Hematomas

• Blood beneath dura overlying brain and arachnoid
• Tearing of bridging veins
• May cross suture lines
• More common in elderly
• Acute, subacute, or chronic

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Assessment of Head Injured Patient

• ABCs
• History - EMS, witnesses
• Vital signs - Cushings Reflex
• P.E. - life threatening injuries dealt with
  first
  
• Neurologic Exam - the Glasgow Coma Scale

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Glasgow Coma Scale (GCS)

• Reproducible method for rapid determination of
  neurologic injury severity
  
• 3 components
• Motor response
• Verbal response
• Eye response

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GCS - Motor Response

• 6 Obeys commands
• 5 Localizes pain
• 4 Flexion - withdrawal
• 3 Abnormal flexion (decorticate)
• 2 Abnormal extension (decerebrate)
• 1 No response

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GCS - Verbal Response

• 5 Oriented and conversant
• 4 Disoriented and conversant
• 3 Inappropriate words
• 2 Incomprehensible speech
• 1 No response

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GCS - Eye Response

• 4 Open spontaneously
• 3 Open to command
• 2 Open to painful stimuli
• 1 No response

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GCS Scores

• GCS 13 - 15 Mild head injury
• GCS 9 - 12 Moderate head injury
• GCS
• (persisting at 6 hours)

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Diagnostic Tests

• C spine xrays
• Skull films if penetrating
• CT scan
• indicated for
• LOC
• focal neurologic signs
• evidence of basilar skull fx or depressed skull
  fx
  
• neurologic deterioration

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Management of Severe Head Injuries

• Secure airway - role of lidocaine
• Hyperventilation
• Mannitol 1g/kg
• HOB 30o
• Seizure prophylaxis
• ICP monitors
• Craniotomy

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Delayed Problems in Head Injury

• Postconcussive Syndrome
• Delayed Posttraumatic CSF leak
• Delayed Posttraumatic Seizures

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C spine Injuries

• Various Mechanisms of Injury
• flexion
• flexion-rotation
• extension-rotation
• compression
• hyperextension
• lateral flexion
• other

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Stability of C spine injuries (from most to
least unstable)

• Rupture transverse atlantal ligament
• fracture of dens
• flexion teardrop
• bilateral facet dislocation
• vertebral body burst fx
• hyperextension fx-dislocation

• Hangmans Fx
• extension teardrop
• Jefferson Burst fx
• unilateral facet dislocation
• anterior subluxation
• simple wedge fx
• posterior arch C1
• clay shovelers fx

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Spinal Cord Syndromes

• Anterior Spinal Cord Syndrome
• Central Spinal Cord Syndrome
• Brown - Sequard Syndrome

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Innervation

• Motor
• C3,4 trapezius
• C4 diaphragm
• C5,6 biceps
• C7 triceps
• C8 Flexor digitorum

• Sensory
• C2 occiput
• C4 shoulder tops
• C6 thumb
• C7 long finger
• C8 little finger

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Xrays for C spine

• Indications
• Views
• Examination of xrays
• lateral view shows 90 of injuries
• odontoid view shows 10 of injuries
• AP view shows

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Examination of C spine xrays

• The Lines
• anterior and posterior vertebral body lines,
  spinolaminar line, tips of spinous processes
  
• Prevertebral soft tissue swelling
• Height and shape of bodies
• Subluxation
• Angulation
• Spinous Process fanning
• Predental Space

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More on C spine Imaging

• Flexion and extension views
• Role of CT scan

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Evaluation of C spine Trauma

• History
• Palpation
• Neuro exam
• To image or not to image?

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Treatment of C spine Injuries

• Immobilization
• Orthopedic vs. Neurosurgical consultation
• Steroids

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Neck Trauma

• Numerous structures within neck
• Triangles and zones
• Penetrating vs. Blunt Neck Trauma

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Causes of Death in Neck Trauma

• 1. CNS injury
• 2. Exsanguination
• 3. Airway compromise

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Blunt Trauma

• Very difficult to assess
• Innocuous appearance may quickly worsen
• Protecting the airway
• intrinsic bleeding
• extrinsic compression
• tracheal, pharyngeal injury
• vomiting

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If Airway Compromise Occurs

• Intubation
• Cricothyrotomy
• Tracheotomy
• Jet Ventilation

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Management Penetrating Neck Trauma

• Depends on essentially 2 factors
• violation of platysma
• zone of neck injured
• Zones I and III - angiography, etc.
• Zone II - to the O.R.

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Management of Blunt Neck Trauma

• Airway protection
• CT evaluation