Trauma 4
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NEUROLOGIC TRAUMA I.
HEAD INJURIES •
Includes injury to the scalp, skull, or brain
Pathophysiology Primary Injury – The initial damage to the brain that results from traumatic events. (Contusions, lacerations, torn blood vessels from impact, foreign object penetration.) Secondary Injury – An insult to the brain subsequent to the original traumatic event Head Injury
Increase intracranial volume Increase ICP Displacement of the brain against rigid structure of the skull Restriction of blood flow
Ischemia / Infarction Cerebral blood flow ceases Brain Death
A. Scalp Injury •
A minor head injury
•
Trauma may result in abrasion, contusion, laceration, or hematoma beneath the layers of tissue of scalp
•
The area is irrigated before laceration is sutured to remove foreign materials and to remove foreign infections
•
Subgaleal Hematoma – Hematomas below the outer covering of the skull
B. Skull Fractures •
A break in the continuity of the skull caused by forceful trauma
•
May occur with or without damage to the brain
•
Classified as: linear, comminuted, depressed, basilar
Clinical Manifestations •
Battle’s sign – An area of bruising may be seen over the mastoid
•
CSF otorrhea – CSF escapes from the ears (suspected of basal skull fractures)
•
CSF rhinorrhea – CSF escapes from nose
•
Halo sign – Blood stain surrounded by a yellowish stain (suggestive of CSF leak)
Assessment and Diagnostic Findings •
CT scan – can detect less apparent abnormalities
•
MRI – produces more accurate picture of the anatomic nature of the injury
•
Cerebral Angiography- identifies supratentorial, extracerebral, and intracerebral hematomas and cerebral contusions
Medical Managements •
After the skull fragments are elevated, the area is debrided
•
Large defects can be repaired immediately with bone or artificial grafts
II.
•
Nasopharynx and external ear should be kept clean (to asses CSF leakage)
•
The head is elevated 30 degrees
BRAIN INJURY •
Close (blunt) brain injury – occurs when the head accelerates and then rapidly decelerates or collides with another object and brain tissue is damaged, but there is no opening through the skull and dura
•
Open brain injury – occurs when an object penetrates the skull, enters the brain, and damages the soft brain tissue in its path (penetrating injury), or when blunt trauma to the head is so severe that it opens the scalp, skull and dura to expose the brain
A. Concussion - A temporary loss of neurologic functions with no apparent structural damage to the brain •
“Seeing stars” – jarring of the brain cause dizziness and spots before the eyes
•
If frontal lobe is affected – bizarre, irrational behavior
•
If Temporal lobe – temporary amnesia or disorientation
•
Observe patient for postconcussion syndrome such as headache, dizziness, lethargy irritability, and anxiety
B. Contusion - Bruising of the brain surface with possible surface hemorrhage •
Often there is involuntary evacuation of the bowels and the bladder.
•
Patient may be aroused with effort but soon slips back into unconsciousness
C. Diffuse Axonal Injury •
Involves widespread damage to axons in the cerebral hemispheres, corpus callosum, and brain stem
•
Patient has no lucid intervals and experiences immediate coma, decorticate and decerebrate posturing
•
Diagnosis: CT scan and MRI
D. Intracranial Hemorrhage •
Major symptoms are frequently delayed until the hematoma is large enough to cause distortion of the brain and increased ICP 1. Epidural Hematoma •
Collection of blood in the epidural space between the skull and the dura
•
Usually, there is a momentary loss of consciousness at the time of injury, followed by an interval of apparent recovery.
•
Treatment consists of making openings through the skull (burr holes) to decrease ICP emergently, remove the clot and control the bleeding
2. Subdural Hematoma •
A collection of blood between the dura and the brain, a space normally occupied by a thin cushion of fluid
•
The most common cause is trauma, but it may also occur from coagulophaties or rupture from an aneurysm
a. Acute Sudural Hematoma •
Associated with major head injury involving contusion and laceration.
•
S/Sx: change in LOC, pupillary signs, hemiparesis
•
Symptoms develop over 24 – 48 hours
b. Subacute Subdural Hematoma •
Result of less severe contusions and head trauma
•
Symptoms appear between 48 hours to 2 weeks
c. Chronic Subdural Hematoma •
Develop from minor head injuries
•
Seen most frequently in elderly
•
Onset of symptoms: 3 weeks to months
•
Can be mistaken for a stroke
•
Severe head aches tend to come and go
•
Treatment consists of surgical evacuation of clot, carried out through multiple burr holes
3. Intracerebral Hemorrhage and Hematoma •
Bleeding into the substance of the brain.
•
Commonly seen in head injuries when force is exerted to the head over a small area (missile injuries, bullet wounds, stab injury)
•
The hemorrhages within the brain may result from systemic hypertension which causes degeneration and rupture of vessel; rupture of saccular aneurysm; vascular anomalies; intracranial tumors
•
Management includes supportive care, control of ICP, and careful administration of fluids, electrolytes, and antihypertensive medications
•
Surgical intervention by craniotomy or craniectomy
Clinical Manifestations of Brain Injury •
Altered LOC
•
Pupillary abnormality
•
Confusion
•
Altered or absent gag reflex
•
Absent corneal reflex
•
Sensory dysfunction
•
Sudden onset of neurologic
•
Spasticity
deficits
•
Headache
•
Changes in vital signs
•
Vertigo
•
Vision and hearing
•
Movement disorders
impairment
•
Seizures
Management of Brain Injuries •
CT scan, MRI, PET
•
From the scene of injury the patient is transported on a board with the head and neck maintained in alignment with the axis of the body
•
Use cervical collar until spinal cord injury is ruled out
•
Secondary Injury – injury to the brain subsequent to the original traumatic event
•
Treatment includes ventilatory support, seizure prevention, fluid and electrolyte maintenance, nutritional support, and pain and anxiety management
III.
SPINAL CORD INJURY •
SCI is an injury to the spinal cord, vertebral column, supporting soft tissue, or intervertebral disks caused by trauma
•
The vertebrae most frequently involved in SCI are the C5, C6, C7, T12, and L1. These vertebrae are most susceptible because there is a greater range of mobility in the vertebra column in these areas
2 Categories of SCI •
Primary injuries – result of the initial insult or trauma and are usually permanent
•
Secondary injuries – the result of a contusion or tear injury in which the nerve fibers begins to swell and disintegrate.
Clinical Manifestations Types of Injury •
Incomplete spinal cord lesion
•
Complete spinal cord lesion 1. Paraplegia – paralysis of the lower body 2. Quadriplegia – paralysis of all four extremities
Effects of SCI •
Central Cord Syndrome
-
Motor deficits in the upper extremities, bowel or bladder dysfunction.
-
Caused by injury or edema of the central cord, usually of the cervical area
•
Anterior Cord Syndrome
-
Loss of pain, temperature, and motor function is noted below the level of the lesion with preservation of position, vibration, and touch sense.
-
Caused by acute disk herniation or hyperflexion injuries
-
May also occur as a result of injury to the anterior spinal artery, which supplies the anterior two-thirds of the spinal cord
•
Brown – Sequard Syndrome (Lateral Cord Syndrome)
-
Ipsilateral paralysis or paresis
-
Loss of pain and temperature sensation on opposite side
-
Loss of voluntary motor control on the same side as the cord damage
-
Caused by transverse hemisection of the cord
Assessment and Diagnostic Findings •
Diagnostic x-rays and CT scanning are performed initially
•
Continuous electrocardiographic monitoring
Emergency Management •
Initial care must include rapid assessment, immobilization, extrication, stabilization or control of life-threatening injuries, and transportation to the most appropriate medical facility
•
At the scene of injury, the patient must be immobilized on a spinal board, with head and neck in neutral position
•
Control patient’s head to prevent flexion, rotation, or extension
•
Patient must always be maintained in extended positon
Management of Spinal Cord Injuries (Acute Phase) •
High dose Corticosteroids – to improve motor and sensory outcomes
•
Administer oxygen to maintain a high arterial PO2
•
Skeletal fracture reduction and traction
•
Halo vest – A lightweight vest with an attached halo tat stabilizes the cervical spine
•
Surgical management, if: there’s compression of the cord, unstable vertebral body, wound penetrates the cord, there are bony fragments in the spinal canal, neurologic status is deteriorating
Management of Complications of SCI •
Spinal and Neurogenic Shock – close observation is required for early detection of an abrupt onset of fever
•
Deep Vein Thrombosis – low-dose anticoagulation is initiated, along with thigh-high elastic compression stockings
•
Other respiratory complications and autonomic dysreflexia
HEAD INJURIES •
Includes injury to the scalp, skull, or brain
Pathophysiology Primary Injury – The initial damage to the brain that results from traumatic events. (Contusions, lacerations, torn blood vessels from impact, foreign object penetration.) Secondary Injury – An insult to the brain subsequent to the original traumatic event Head Injury
Increase intracranial volume Increase ICP Displacement of the brain against rigid structure of the skull Restriction of blood flow
Ischemia / Infarction Cerebral blood flow ceases Brain Death
A. Scalp Injury •
A minor head injury
•
Trauma may result in abrasion, contusion, laceration, or hematoma beneath the layers of tissue of scalp
•
The area is irrigated before laceration is sutured to remove foreign materials and to remove foreign infections
•
Subgaleal Hematoma – Hematomas below the outer covering of the skull
B. Skull Fractures •
A break in the continuity of the skull caused by forceful trauma
•
May occur with or without damage to the brain
•
Classified as: linear, comminuted, depressed, basilar
Clinical Manifestations •
Battle’s sign – An area of bruising may be seen over the mastoid
•
CSF otorrhea – CSF escapes from the ears (suspected of basal skull fractures)
•
CSF rhinorrhea – CSF escapes from nose
•
Halo sign – Blood stain surrounded by a yellowish stain (suggestive of CSF leak)
Assessment and Diagnostic Findings •
CT scan – can detect less apparent abnormalities
•
MRI – produces more accurate picture of the anatomic nature of the injury
•
Cerebral Angiography- identifies supratentorial, extracerebral, and intracerebral hematomas and cerebral contusions
Medical Managements •
After the skull fragments are elevated, the area is debrided
•
Large defects can be repaired immediately with bone or artificial grafts
II.
•
Nasopharynx and external ear should be kept clean (to asses CSF leakage)
•
The head is elevated 30 degrees
BRAIN INJURY •
Close (blunt) brain injury – occurs when the head accelerates and then rapidly decelerates or collides with another object and brain tissue is damaged, but there is no opening through the skull and dura
•
Open brain injury – occurs when an object penetrates the skull, enters the brain, and damages the soft brain tissue in its path (penetrating injury), or when blunt trauma to the head is so severe that it opens the scalp, skull and dura to expose the brain
A. Concussion - A temporary loss of neurologic functions with no apparent structural damage to the brain •
“Seeing stars” – jarring of the brain cause dizziness and spots before the eyes
•
If frontal lobe is affected – bizarre, irrational behavior
•
If Temporal lobe – temporary amnesia or disorientation
•
Observe patient for postconcussion syndrome such as headache, dizziness, lethargy irritability, and anxiety
B. Contusion - Bruising of the brain surface with possible surface hemorrhage •
Often there is involuntary evacuation of the bowels and the bladder.
•
Patient may be aroused with effort but soon slips back into unconsciousness
C. Diffuse Axonal Injury •
Involves widespread damage to axons in the cerebral hemispheres, corpus callosum, and brain stem
•
Patient has no lucid intervals and experiences immediate coma, decorticate and decerebrate posturing
•
Diagnosis: CT scan and MRI
D. Intracranial Hemorrhage •
Major symptoms are frequently delayed until the hematoma is large enough to cause distortion of the brain and increased ICP 1. Epidural Hematoma •
Collection of blood in the epidural space between the skull and the dura
•
Usually, there is a momentary loss of consciousness at the time of injury, followed by an interval of apparent recovery.
•
Treatment consists of making openings through the skull (burr holes) to decrease ICP emergently, remove the clot and control the bleeding
2. Subdural Hematoma •
A collection of blood between the dura and the brain, a space normally occupied by a thin cushion of fluid
•
The most common cause is trauma, but it may also occur from coagulophaties or rupture from an aneurysm
a. Acute Sudural Hematoma •
Associated with major head injury involving contusion and laceration.
•
S/Sx: change in LOC, pupillary signs, hemiparesis
•
Symptoms develop over 24 – 48 hours
b. Subacute Subdural Hematoma •
Result of less severe contusions and head trauma
•
Symptoms appear between 48 hours to 2 weeks
c. Chronic Subdural Hematoma •
Develop from minor head injuries
•
Seen most frequently in elderly
•
Onset of symptoms: 3 weeks to months
•
Can be mistaken for a stroke
•
Severe head aches tend to come and go
•
Treatment consists of surgical evacuation of clot, carried out through multiple burr holes
3. Intracerebral Hemorrhage and Hematoma •
Bleeding into the substance of the brain.
•
Commonly seen in head injuries when force is exerted to the head over a small area (missile injuries, bullet wounds, stab injury)
•
The hemorrhages within the brain may result from systemic hypertension which causes degeneration and rupture of vessel; rupture of saccular aneurysm; vascular anomalies; intracranial tumors
•
Management includes supportive care, control of ICP, and careful administration of fluids, electrolytes, and antihypertensive medications
•
Surgical intervention by craniotomy or craniectomy
Clinical Manifestations of Brain Injury •
Altered LOC
•
Pupillary abnormality
•
Confusion
•
Altered or absent gag reflex
•
Absent corneal reflex
•
Sensory dysfunction
•
Sudden onset of neurologic
•
Spasticity
deficits
•
Headache
•
Changes in vital signs
•
Vertigo
•
Vision and hearing
•
Movement disorders
impairment
•
Seizures
Management of Brain Injuries •
CT scan, MRI, PET
•
From the scene of injury the patient is transported on a board with the head and neck maintained in alignment with the axis of the body
•
Use cervical collar until spinal cord injury is ruled out
•
Secondary Injury – injury to the brain subsequent to the original traumatic event
•
Treatment includes ventilatory support, seizure prevention, fluid and electrolyte maintenance, nutritional support, and pain and anxiety management
III.
SPINAL CORD INJURY •
SCI is an injury to the spinal cord, vertebral column, supporting soft tissue, or intervertebral disks caused by trauma
•
The vertebrae most frequently involved in SCI are the C5, C6, C7, T12, and L1. These vertebrae are most susceptible because there is a greater range of mobility in the vertebra column in these areas
2 Categories of SCI •
Primary injuries – result of the initial insult or trauma and are usually permanent
•
Secondary injuries – the result of a contusion or tear injury in which the nerve fibers begins to swell and disintegrate.
Clinical Manifestations Types of Injury •
Incomplete spinal cord lesion
•
Complete spinal cord lesion 1. Paraplegia – paralysis of the lower body 2. Quadriplegia – paralysis of all four extremities
Effects of SCI •
Central Cord Syndrome
-
Motor deficits in the upper extremities, bowel or bladder dysfunction.
-
Caused by injury or edema of the central cord, usually of the cervical area
•
Anterior Cord Syndrome
-
Loss of pain, temperature, and motor function is noted below the level of the lesion with preservation of position, vibration, and touch sense.
-
Caused by acute disk herniation or hyperflexion injuries
-
May also occur as a result of injury to the anterior spinal artery, which supplies the anterior two-thirds of the spinal cord
•
Brown – Sequard Syndrome (Lateral Cord Syndrome)
-
Ipsilateral paralysis or paresis
-
Loss of pain and temperature sensation on opposite side
-
Loss of voluntary motor control on the same side as the cord damage
-
Caused by transverse hemisection of the cord
Assessment and Diagnostic Findings •
Diagnostic x-rays and CT scanning are performed initially
•
Continuous electrocardiographic monitoring
Emergency Management •
Initial care must include rapid assessment, immobilization, extrication, stabilization or control of life-threatening injuries, and transportation to the most appropriate medical facility
•
At the scene of injury, the patient must be immobilized on a spinal board, with head and neck in neutral position
•
Control patient’s head to prevent flexion, rotation, or extension
•
Patient must always be maintained in extended positon
Management of Spinal Cord Injuries (Acute Phase) •
High dose Corticosteroids – to improve motor and sensory outcomes
•
Administer oxygen to maintain a high arterial PO2
•
Skeletal fracture reduction and traction
•
Halo vest – A lightweight vest with an attached halo tat stabilizes the cervical spine
•
Surgical management, if: there’s compression of the cord, unstable vertebral body, wound penetrates the cord, there are bony fragments in the spinal canal, neurologic status is deteriorating
Management of Complications of SCI •
Spinal and Neurogenic Shock – close observation is required for early detection of an abrupt onset of fever
•
Deep Vein Thrombosis – low-dose anticoagulation is initiated, along with thigh-high elastic compression stockings
•
Other respiratory complications and autonomic dysreflexia
