02.Sabtu PAGI, Chapter06-08, Continous Presentation.

7/28/2019 02.Sabtu PAGI, Chapter06-08, Continous Presentation.

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Initial Assessment and Management

Committee on Trauma Presents

Head

Trauma


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Case Scenario

58-year-old male fell from a roof in asmall rural town

Initial GCS score = 12

On admission after 2-hour transfer,GCS score is 6

What in jur ies would you suspect?

What are your p r ior i t ies in m anaging th is

pat ient?


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Objectives

Describe basic intracranial anatomy and

physiology.

Explain the importance of limitingsecondary brain injury.

Describe the classification of head injuries.

Describe proper stabilization of the patientand arrangements for definitive care.


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Anatomy and Physiology

What are the un ique

features o f b rain

anatomy and

phys io logy, and howdo they affect patterns

of brain in jury?


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Anatomy and Physiology

Rigid, nonexpansile skull filled with

brain, CSF, and blood

Cerebral blood flow (CBF) usually

autoregulated

Autoregulatory compensation

disrupted by brain injury Mass effect of intracranial hemorrhage

Effects


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Monro-Kellie Doctrine


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Volume-Pressure Curve


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Intracranial Pressure (ICP)

Sustained increased ICP leads to decreasedbrain function and poor outcome

Hypotension and low saturation adverselyaffect outcome

10 mm Hg = Normal

>20 mm Hg = Abnormal>40 mm Hg = Severe


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Cerebral Perfusion Pressure

Normal 90 10 80

Cushings

Response100 20 80

Hypotension 50 20 30

MAP ICP = CPP

CPP Cerebral Blood FlowCaution


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Classifications of Head Injury

Blunt

High and lowvelocity

By Mechanism of Injury

Penetrating

GSW andother


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Focal

Epidural (extradural)

Subdural

Intracerebral

By Morphology Brain Injuries

Diffuse

Concussion

Multiple contusions

Hypoxic / ischemic injury


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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 tounderlying brain injury

Rapid surgical evacuation

recommended, especially if > 5 mm

shift of midline


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Subdural Hematoma


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Intracerebral Hematoma / Contusion

Coup / contracoup injuries

Most common: frontal / temporal lobes

CT changes usually progressive

Most conscious patients: no operation


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Intracerebral Hematoma / Contusion

Large Frontal Contusion with Shift


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Diffuse Brain Injury

Normal CT Diffuse Injury

Range from mild concussion to severe

ischemic insult


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Mild

Moderate

Severe

By Severity of Injury Based on GCS Score


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Mild Brain Injury

GCS score = 13 15

History

Exclude systemic injuries

Neurologic exam

X-rays as indicated

Alcohol / drug screens as indicated

Liberal use of head CT

Observe or discharge based on findings


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Moderate Brain Injury

GCS score = 9 12

Initial evaluation same as for mild injury

CT scan for all Admit and observe

Frequent neurologic exams

Repeat CT scan

Deterioration: Manage as severe head

injury


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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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Indications for CT Scan


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GCS score still < 15 two hours after injury

Neurologic deficit

Open skull fracture

Sign of basal skull fracture

Extremes of age

High Risk


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Dangerous mechanism

Retrograde amnesia > 30 minutes induration

Severe headache

Vomiting > 2 episodes

Moderate Risk


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Management

Priorities

ABCDE

Minimize secondary brain injury

Administer oxygen

Maintain adequate ventilation

Maintain blood pressure(systolic > 90 mm Hg)


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Management

Focused Neurological Exam

GCS score

Pupils

Lateralizing signs

Consult

neurosurgeon

early


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Management

Medical

Controlled ventilation

Goal: Paco2 at 35 mm Hg

Intravenous fluids

Euvolemia

Isotonic

Consult with neurosurgeon

Mannitol

Use with signs of tentorial herniation

Dose: 0.25 to 1.0 g / kg IV bolus


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Management

Medical

Other medications

Anticonvulsants

Sedation

Paralytics

Neurological examination before

prolonged sedation / paralysis


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Management

Surgical

Scalp Wounds

Possible site of major blood loss

Direct pressure to control bleeding

Occasional temporary closure


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Management

Surgical

Intracranial Mass Lesion

Can be life-threatening if expanding rapidly

Immediateneurosurgical consult

Hyperventilation / mannitol

Damage control craniotomy: transfer toneurosurgeon (rural / austere areas)


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Summary

Ensure adequate oxygenation

Maintain Paco2 near / at 35 mm Hg

Maintain mean BP > 90 mm Hg

Frequent neurologic assessment

Liberal use of CT

Earlyneurosurgical consult


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Spine andSpinal Cord

Trauma


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Case Scenario

38-year-old male is pulled from a

swimming pool.

BP: 80/62; Pulse: 58; RR: 28

GCS score: 15

Breathing is shallow.

He is not moving his arms or legs.

Discuss the patients diagnosis

and management.


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Objectives

Describe the evaluation of a patient with

suspected spinal injury.

Explain the appropriate management ofspinal injury.

Discuss appropriate patient disposition.


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Spinal Injury

When should you suspect a spine in jury?


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Spinal Injury

Mechanism of injury

Unconscious patient Neurologic deficit

Spine pain / tenderness

When should you suspect a spine in jury?


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Spinal Injury

How do I protect the spine dur ing evaluat ion

and transpo rt?


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Spinal Injury

Immobilize entirepatient on long spineboard with properpadding.

Apply semirigid collar.

How do I protect the spine dur ing evaluat ion

and transpo rt?

Protection is priority;

detection is secondary.


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Drugs, alcohol, and other

injuries can mask spinal injury.

Spinal Injury Screening

Clinical

Normal neurologic exam and

Absence of spinal pain and tenderness

Caution


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If patient is

Conscious

Cooperative

Able to concentrate on c-spine

Ifnoneck or spine pain or tenderness

If still nopain or tenderness with

voluntary movement

No further evaluation or x-ray necessary

Clear spine and remove cervical co l lar.


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Radiographic visualization of entire

spine Plain films

CT scan of suspicious or poorly

visualized areas

Altered Consciousness or Symptoms


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How do I conf i rm a spine in jury?


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Clinical signs of neurological deficit

Radiological investigations Plain X-ray / CT / MRI

Identify bony fracture / subluxation

Presume spinal instability

Early spine service consult

How do I conf i rm a spine in jury?


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Cervical Spine X-rays

Crosstable lateral film excludes 85% of

fractures

Addition of AP and odontoid viewsexcludes most fractures

Also may require

Swimmers view

CT scan for bony detail

MRI


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Cervical Spine X-rays

10% of patients with a c-spine fracture have

a second, associated noncontiguous

vertebral column fracture

Identify one abnormality? Look for another !

Radiographic screening of entire spine

required in this situation


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Spinal evaluation complicated by altered

sensorium Remove spine board as soon as possible and

logroll patient

Pressure sores occur early in unconscious

or paralyzed patients

Pitfalls

Pitfalls


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Caution

At least 5% of patients with

spinal cord injuries worsen

neurologically at the hospital.

Caution


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Neurologic Status

How do I assess the patients neurologic status?


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Neurologic Status

Neurologic level

Most caudal level of motor / sensory function Motor and sensory may not be the same

Sensory can vary on each side

Bony level

Site of vertebral column damage

How do I assess the patients neurologic status?


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Neurologic Status

Complete Injury

No motor or sensory function below

injury level

Incomplete Injury

Any motor or sensory preservation

below injury level Sacral sparing may be only residual

function


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Effects of Spinal Cord Injury

Neurogenic shock

Spinal shock

Other consequences

Fasciculus cuneatus

Dorsal columnFasciculus gracilis

Lateral corticospinal tract

Spinothalamic


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Cardiovascular phenomenon due toloss of sympathetic tone

Associated with cervical / high thoracicspine injury

Hypotension and slow heart rate

Treatment includes fluid resuscitationand occasional atropine andvasopressors

Neurogenic Shock Direct Effects


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Neurologic, not hemodynamicphenomenon

Occurs shortly after cord injury

Variable duration

Flaccidity and loss of reflexes

Spinal Shock Direct Effects


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Management

How do I manage pat ients w i th spinal cord

in jury and l im i t secondary in jury?


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Management

Ensure adequate ventilation and

oxygenation

Maintain blood pressure

Maintain perfusion of spinal cord

How do I manage pat ients w i th spinal cord

in jury and l im i t secondary in jury?


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Management

Assess for associated bleeding

Consider neurogenic shock

Monitor urinary output

Management of Hypotension

Stop

the

bleeding!


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Management

Unstable fractures

Neurologic deficit

Whom do I trans fer?

Avoid transfer delay!

Caution


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Management

Provide respiratory

support as needed Exclude other life-

threatening injury

Properly immobilize

entire patient

Avoid hypothermia

Management of Patients Requiring Transfer


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Summary

Treat life-threatening injuries first

Properly immobilize entire patient

Obtain appropriate spine films

Document examination

Obtain neurosurgical / orthopaedic consult

Transfer unstable fracture / cord injury


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Musculoskeletal

Trauma


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Case Scenario

A wall collapses on a 44-year-old

male worker

BP: 130/75; Pulse: 110; RR: 22

GCS score: 15

Painful, bruised, deformed right leg

What are your pr io r i t ies?

Is th is l i fe- or l imb-threatening?


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Objectives

Describe the principles for assessing patients

with musculoskeletal injuries.

Identify treatment priorities.

Explain the importance of musculoskeletal

injuries in multiply injured patients.


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Primary Survey

What are my pr ior i t ies and m anagement p r incip les?


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Primary Survey

Stop the bleeding! (pressure / tourniquet)

Splint the extremity

Stabilize the pelvis

During the Primary SurveyThe 3 Ss

What are my pr ior i t ies and m anagement p r incip les?


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Primary Survey

Stabilization


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Secondary Survey

Look

Listen

Feel


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Secondary Survey

Look

Deformity Pain

Tenderness

Wound(s)

Rationale for Splinting

Listen

Dopplersignals

Bruit

Feel

Crepitus Skin flaps

Neurologicdeficit

Pulses


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Secondary Survey

Preinjury status and predisposing factors

Mechanism of injury

Time of injury

Associated factors (eg, environment)

Prehospital observations and care

Key Information


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Secondary Survey

Vascular compromise

Open fractures

Early Concerns


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Secondary Survey

Reduce fracture(s)

Splint fracture(s)

Assess by Doppler

Obtain surgical consult

Time is critical!

Consider angiography

Assess and Manage Vascular Compromise


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Secondary Survey

Apply appropriate splint

Cleanse / debride(now or later)

Consider time factor

Obtain orthopedic consult

Antibiotic / tetanus status

Managing Open Fractures


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Secondary Survey

What x-rays do I need?

Any suspected area One joint above and below

When do I obtain them?

Patient is hemodynamically

normal

X-Ray Studies


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Secondary Survey

When should I delay getting

x-rays?

If life-threatening injuries take

priority

If patient transfer will be

delayed

X-Ray Studies


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Compartment Syndrome

What in jur ies can cause compartment synd rome?


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What in jur ies can cause compartment synd rome?

Tibia and forearm fractures

Vascular and bony injuries

Injuries immobilized in tight

dressings or casts

Severe crush injuries to muscle

Burns


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How do I recogn ize com partment syndrom e?


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Pain

Disproportionate Passive stretch

Tense compartments

Asymmetry

Paresthesia

Tissue pressures > 35 to 45 mm Hg

How do I recogn ize com partment syndrom e?


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Altered sensation

Compartment syndrome

Vascular injury

Crush injuries / myoglobinuria

Occult fractures / soft tissue injuries

Coagulation disorders

Pitfalls

Pitfalls


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Summary

Manage life-threatening injuries first

Stop the bleeding!

Reduce and immobilize fractures and

dislocations

Recognize vascular compromise

Consider compartment syndrome


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02.Sabtu PAGI, Chapter06-08, Continous Presentation.

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Transcript of 02.Sabtu PAGI, Chapter06-08, Continous Presentation.