HEAD INJURIES

• BY DR MOHAMMED HANEEF

• Common major trauma• 4 million people experience head trauma

annually• Severe head injury is most frequent cause of trauma death

• GSW to cranium: 75-80% mortality

• At Risk population• Males 15-24• Infants• Young Children• Elderly

Head Injuries

Introduction

The head is very vulnerable to injury, often with severe consequences. It is particularly susceptible to acceleration/deceleration and rotational forces because it is heavy in relation to its size (3-6 kg, avg 4.5 kg or 10 lb), is freely mobile in 3 dimensions and occupies a relatively unstable position, being secured only by the neck muscles and ligaments.

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Initial clinical evaluationRapid assessment of patients neurological disability can be made on 4 point AVPU SCALE

1. Responds appropriately-Awake2. Responds to Verbal stimuli3. Responds to Painful stimuli4. Does not respond -Unconscious

Coupled with an assessment of pupil reaction allows rapid assessment of degree of head injury

Head Injuries• ABC (PRIMARY SURVEY)• C – consciousness• R – respiration• A - Trauma• N – Neck

• Cervical/Carotid Injury• E- Eyes

• Pupils• Extra ocular muscles• Corneal reflexes• Occulovestibular and occulocephalic reflexes

• A - Airway• Gag relex

• L- Limbs• Motor examination• Reflexes• Sensation

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Conscious level

• Glasgow coma scale• Adelaide coma scale• Blantyre coma scale for children• Edinburgh coma scale• Pittsburg brainstem score (PBSS)

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Glasgow coma scale

• Developed by Teasdale & Jennet• Most widely used coma scale• Eye opening -measure of arousal &

alertness• Motor response -measure of brain

stem injury

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GLASGOW COMA SCALE=E+M+V

The score is determined by the sum of the score in each of the 3 categories, with a maximum score of 15 and a minimum score of 3

• For intubated patients –only E+M& suffix T given• In intubated patients, the maximal GCS score is 10T and the

minimum score is 2T. • Mild head injuries –GCS SCORE 13-15 • Moderate head injuries – GCS SCORE 9-12• Severe head injuries-. GCS SCORE 8 or less

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Blantyre coma scale for children• Modification of Glasgow coma scale

Response Findings Score

best motor response

localizes painful stimulus (pressure with blunt end of pencil on sternum or supraorbital ridge)

2

withdraws limb from painful stimulus (pressure with horizontal pencil on nail bed of finger or toe)

1

no response or inappropriate response 0

best verbal response

cries appropriately with painful stimulus, or, if verbal, speaks 2

moan or abnormal cry with painful stimulus 1

no vocal response to painful stimulus 0

eye movement watches or follows (e.g., mother's face) 1

fails to watch or follow 0

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Blantyre coma scale == (best motor response score) + (best

verbal response score) + (eye movement score)

Interpretation:• minimum score: 0 (poor)• maximum score: 5 (good)• abnormal: score <= 4

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Edinburgh coma scale• Developed in Japan

•Edinburgh-2 Coma Scale (1978)•Set of Questions:•(1) What month is it?•(2) What is your age?•Set of Commands:•(1) Close and open your hand.•(2) Close and open your eyes.

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Stimulation Best Response Score

2 set of question answers both correctly 0

answers either correctly 1

answers neither correctly 2

2 sets of commands obeys both correctly 3

obeys either correctly 4

obeys neither correctly 5

response to strong pain localizing 6

flexion 7

extension 8

no response 9

Interpretation of Edinburgh-2 Coma Scale:• The lower the value the better the prognosis

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Pittsburg brainstem score (PBSS) reflex Present (either side) absent

Lash reflex 2 1Corneal reflex 2 1Doll’s eye 2 1Rt pupil reaction to light 2 1Lt pupil reaction to light 2 1Gag reflex 2 1

Pittsburg brainstem score=sum of all reflexesMinimum score =6Maximum score=12Higher the score the better

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Rationale of Coma scales

• Rationale for developing & using coma scales is :

1. Need for sequential follow up to assess potential worsening

2. Need for a standardized baseline measure for comparison with later measures to determine prognosis

3. Development of coma scale is facilitated by simple neurological examination which can be performed on stuporous patient

4. Critical neurological parameters include state of conciousness, pupil & eye movement, best motor response,& nature of respiratory effort

5. Quantification of some or all of these parameters into an easily codable system is a coma scale

HEAD INJURIES

• These may include injuries of the scalp, skull, brain, and blood vessels.

• Scalp Injuries• 1. Laceration of the scalp may be associated with significant

bleeding. Control with deep sutures and compression dressing. Prophylactic antibiotics for Scalp infections as they may spread intracranially via the emissary veins.

• 2. Skull fractures are described according to shape, displacement, site and integrity of the overlying skin. Thus we have, for example, linear, stellate, comminuted, depressed, compound, and basilar fractures.• A fracture can be diagnosed by digital exploration of the wound,

radiographically or clinically. The diagnosis of basilar fractures is often clinical:• CSF leaking from the nose or ear. • Periorbital ecchymosis (raccoon eyes).• Ecchymosis behind the ear (Battle's sign).

Management of Scalp injuries• Scalp lacertations:Copius irrigation to cleanse the wound, carefull

debridement. Closure in layers• Scalp avulsions: copius irrigation, trimming of edges. Primary closure

if avulsion is small. Large area to be covered with suitable flap or left with external dressing for secondary healing.

Skull fractures• Skull fractures are described according to shape, displacement, site and

integrity of the overlying skin. Thus we have, for example, linear, stellate, comminuted, depressed, compound, and basilar fractures.

• A fracture can be diagnosed by digital exploration of the wound, radiographically or clinically. The diagnosis of basilar fractures is often clinical:• CSF leaking from the nose or ear. • Periorbital ecchymosis (raccoon eyes).• Ecchymosis behind the ear (Battle's sign).

• Skull fracture predispose a conscious to about 400 times the possibility of cranial haematoma and about 20 times in a comatose patient

• Classified as:• Closed/open• Linear/stellate/communited• Depressed / non depressed

• Types of skull fracture:• Linear- from the point of impact along lines of anatomical weakness (eg

diastasis of suture fusion lines). frontal fracture (eg head-on RTA) often radiates into anterior cranial fossatemporal fracture (eg blow to side of head) often radiates into middle cranial fossaoccipital fracture (eg backwards fall) often radiates into posterior cranial fossa

• Radiating- outwards from the point of impact • Spider's web- radiating lines connected by concentric fracture rings• Depressed- where fragments are driven inwards• Hinge- passing across the base of the skull (motor cyclist or blow to chin)• Ring- encircling the hole through which the spinal cord passes downwards

(foramen magnum). Due to a fall onto the feet or onto the top of the head • Contre-coup- a backwards fall, striking the back of the head (coup) may

also cause fracture of the thin layer of bone over the roof of the orbits opposite the point of impact (contre-coup) due to suction forces transmitted through the brain tissue.

Management• Closed non depressed fractures:- observation and monitoring

and medical line of treatment for associated intracranial parenchymal injury

• Open non depressed fractures:- close observation, surgical intervation if intracranial bleed is suspected/anticipated

• Depressed skull fractures:- observation, if no untoward neurological sign exists than the operation may be delayed and elevation of the fractured segment is done

Basal skull fractures• Associated tear of the dura and arachnoid at the base of the

skull/ middle or anterior cranial fossa• Battles sign is suggestive of basal skull fracture• A CSF fistula occurs in 70 % patients with in 48 hours of

trauma• 98% of fistulae occur with in 3 months• Post traumatic fistulae heal spontaneously with in week, and

80% heal with in 6 months.• Spontaneous reoccurance may be there after initial cessation• Otoroheas almost always resolves spontaneously and delayed

otorrhea is rare• Chronic fistulae are indicated for surgical repair

BASE OF SKULLFRACTURE

C/F• Headache• Decreased hearing• Salty taste in mouth• Pneumocephalus present in 30% of the patients

DiagnosisBed side: ring test

tram lineLab test: glucose >30mg/dl

protein < 2/lpresence of b2 transferrin

Management• There may be presence of meningitis - Prophylactic

antimicrobials (3rd generation cephalosporins)• Head elevated to 30 degrees, cautioned againts blowing nose,

forcefull coughing• If leak persists for more than 72 hours, lumbar puncture is

indicated to reduce ICP• Fewer than 5% patients require repair. Immediate surgical

intervention is indicated only open communited fractures with CSF leak

• Delayed surgical repair is indiacted in • Persistent or increased CSF leakage over 1 or 2 weeks• Presence of unresolving pneumocephalus for more than a week• meningitis

Physical Examination

• 1. Assess level of consciousness. Use the Glasgow Coma Scale. The minimum score is 3 and the maximum score is 15. An intubated patient has a maximum GCS 11T. A \score of 8 or less signifies severe brain damage and the prognosis is guarded.

• 2. Check pupils (size, reaction to light).• 3. Check ears and nose for bleeding or CSF leakage.• 4. Check for ecchymosis around the eyes or behind the ears (basilar

fracture).• 5. Check cranial nerves.• 6. Exclude neck injury (neck pain, stiffness, tenderness, or paralysis are

suspicious signs).• 7. Limbs (strength, tone, reflexes)• 8. Vital signs (blood pressure, pulse, respiration, temperature)• 9. Associated injuries

Brain Injuries• As defined by the National Head Injury Foundation

• “a traumatic insult to the brain capable of producing physical, intellectual, emotional, social and vocational changes.”

• 1. Concussion: No gross pathology. Transient loss of consciousness. CT scan is normal.

• 2. Contusion: Bruising of the brain surface underneath a fracture or at the under-surface of the frontal and temporal lobes, due to shearing forces. Diagnosed on CT scan.

• 3. Laceration: Tearing of the brain substance. Diagnosed by CT scan.

• 4. Brain edema: This is localized in the glial cells, myelin sheaths, and intercellular spaces. It causes increased intracranial pressure, which may impair brain circulation, or result in brain herniation. It may be missed in early CT scans. Later CT scans or MRI show edema more reliably.

• Altered Mental Status• Altered orientation• Alteration in personality• Amnesia

• Retrograde• Antegrade

• Cushing’s Reflex• Increased BP• Bradycardia• Erratic respirations

Signs & Symptoms of Brain Injury

Vomiting Without nausea Projectile

Body temperature changesChanges in pupil reactivityDecorticate posturing

Vomiting Without nausea Projectile

Body temperature changesChanges in pupil reactivityDecorticate posturing

• Pathophysiology of Changes• Frontal Lobe Injury

• Alterations in personality• Occipital Lobe Injury

• Visual disturbances• Cortical Disruption

• Reduce mental status or Amnesia• Retrograde

• Unable to recall events before injury• Antegrade

• Unable to recall events after trauma• “Repetitive Questioning”

• Focal Deficits• Hemiplegia, Weakness or Seizures

Signs & Symptoms of Brain Injury

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Cerebral concussion• A concussion is defined as physiologic injury

to the brain without any evidence of structural alteration

• Concussions are graded on a scale of I-V• Grade I : A grade I concussion is one in which a person is

confused temporarily but does not display any memory changes.

• Grade II: In a grade II concussion, brief disorientation and anterograde amnesia of less than 5 minutes' duration are present

• Grade III: In a grade III concussion, retrograde amnesia & loss of consciousness for less than 5 minutes are present, in addition to the 2 criteria for a grade II concussion.

• Grade IV: Grade IV concussion is similar to grade III concussion except that in a grade IV concussion, the duration of loss of consciousness is 5-10 minutes.

• Grade V: In Grade V concussion, retrograde amnesia & the loss of consciousness is longer than 10 minutes.

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• Brain damage is classified into:• 1. Primary brain damage. It occurs at the time of injury

and is irreversible (i.e. lacerations, contusions, axonal injuries of the white matter due to shearing forces).

• 2. Secondary brain damage. It occurs at a later stage due to tissue hypoperfusion and may be preventable and reversible. Conditions that may cause secondary brain damage:• Extracranial causes: shock, hypoxia, and electrolyte

abnormalities. • Intracranial causes: hematoma, brain edema, infection, and

hydrocephalus • A minimum CPP of 70 mm Hg (or >50 mmHg in young

children) (CPP = mean arterial pressure (MAP) – intracranial)

Intracranial Bleeding• 1. Epidural hematoma: Usually due to laceration of the middle

meningial artery or venous sinuses. Commonly located in the temporal or parietal region, often with associated fractures. On CT scan it appears as a hyperdense, biconvex-shape lesion.

• 2. Subdural hematoma: • a. Acute subdural: It manifests within the first few hours of injury. It is due to

bleeding from injured brain tissue or from the veins, which bridge the cortex with the cavernous sinus. On CT scan it appears as a crescentshape, hyperdense lesion.

• b. Chronic subdural: It may appear many days, weeks or months after the injury. More common in elderly patients. On CT scan it shows as a crescent-shape, hypodense lesion.

• 3. Intracerebral hematoma: Usually beneath a cortical contusion.• 4. Subarachnoid hemorrhage: It often gives symptoms and signs of Meningial

irritation: headache, photophobia, neck stiffness, fever. The mental status may vary from confusion to coma. On CT scan it appears as linear, highdensity areas following the sulci, often in the Sylvian fissure. The blood is usually absorbed by the CSF. It may cause late hydrocephalus because of obstruction of the CSF circulation.

• A catastrophic complication in patients with intracranial hematomas is herniation of the temporal lobe through the tentorium and compression of the brain stem. Symptoms and signs:• 1. Dilatation of the ipsilateral pupil, due to compression of the third nerve. In the

early stages there may be transient constriction due to stimulation of the nerve.• 2. Depressed level of consciousness, due to compression of the reticular formation• 3. Contralateral hemiparesis, due to compression of the cerebral peduncle• 4. Bradycardia• 5. Elevated blood pressure• 6. Irregular respiration

Ocular function• Reaction of pupils to light• Extraocular muscle function• Oculovestibular and oculocephalic reflexes• Corneal reflex• Gag reflex

Cranial nerve examination• Olfactory nerve• Optic nerve• Occlumotar• Trochlear• Abducent • Trigeminal nerve• Facial nerve• Vestibular nerve• Glossopharyngeal nerve• Spinal accesory nerve• Hypoglossal nerve

Upper motor lesion Vs lower Motor lesion• Mucle groups• Rigid• Slight wastine• Flexor spams• Brisks jerks• Plantars extensor• Normal electrical

reaction

• Individiual• Flaccid• Marked wasting• Fasciculation• Deep jerks absent• Flexor plantars• No or little reaction

Motor nerve examination• Grade 0 – no motor activity• Grade 1 – papable muscle contraction• Grade 2 – complete range of motion with gravity eliminated• Grade 3 – complete range of motion against gravity• Grade 4 - complete range of motion against gravity with

resistance• Grade 5 – complete range of motion against gravity with

complete resistanceGait

• Casual , heal to toe and tandem walking to be examined• Cerebellar dysfunction can cause ataxia of gait• Unilateral cerebellar lesion will produce staggering toward the affected side

( typicall walk with the legs apart)

Coordination• Ability to perform finger to nose, heel to shin, and rapid alternative

movements• Hemispheric cerebellar disease usually lateralize, middle vermian lesions

affect bilaterally

Sensory system• Grade 0 – absent• Grade 1 – present• Grade 2 – normal• Grade 3 – normal active• Grade 4 – hyperactive• Grade 5 – hyperactive with Clonus

Jaw jerkBicep jerkSuppinator jerkTricep jerkKnee jerkAngle jerkBabinskis sign

Diagnostic tests• 1. Plain skull x-rays only if CT scan is not available (may show fractures, foreign

bodies, air in the skull, shifting of calcified midline structures). A linear fracture increases the risk of intracranial hematoma by 400 times.

• 2. Cervical spine x-rays and CT scan for all unconscious patients and those with suspicious symptoms (local tenderness, neurological signs).

• 3. CT scan: This is the most important diagnostic tool. • Indications: All patients with history of loss of consciousness, amnesia,

depressed level of consciousness, headache and localizing signs should have a CT scan investigation. Subsequent CT scan may be necessary if there is deterioration of the neurological status.

• 4. Carotid angiogram (limited use). It might be useful in some penetrating injuries, especially with retained knife blades or bullet injuries.

• 5. Intracranial Pressure (ICP) monitoring: It is an essential diagnostic, monitoring, and therapeutic modality in severe head injuries. The CPP (Cerebral Perfusion Pressure) is much more important than ICP absolute values. Maintain a CPP >70 mmHg or >50 mmHg in young children.

SEND FOR NEUROLOGICAL CONSULTATION

Epidural Hematomas

• Blood between inner table of the skull and the dura

• Lens shaped hematomas that do not cross suture lines on CT

Subdural Hematomas

• Blood beneath the dura, overlying the brain and arachnoid, resulting from tears to bridging vessels

• Crescent shaped density that may run length of skull

• Very common in the elderly

Subarachnoid Hemorrhage • Bleeding beneath the arachnoid membrane on the surface of

the brain.

Intracranial Hematoma

• Focal areas of hemorrhage within the parenchyma

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Marshall’s classification• Classifies head injuries according to the

changes demonstrated on CT scan images.

• Diffuse injury 1: Evidence of any significant brain injury is lacking.

• Diffuse injury 2: Either no midline shift or a shift of less than 5 mm is present .

• Diffuse injury 3: A midline shift of less than 5 mm is present, withpartial compression or absence of the basal cisterns.

• • Diffuse injury 4: Defined as midline shift greater than 5

mm with compression or absence of the basal cisterns.

Managemet of Mild Head injuryGCS 14 - 15

• History • Name/Age/Sex• Mechanism of Injur• +/- loss of consciousnes• Level of alertness• Amnesia –

Retrograd/anterograde• Head ache- mild/moderate/sever• +/-seizure

• GPE• Limited

neurological examination

• Cervical spine radiographs

• Blood alcohol• CT scan

• Admit/observe• No CT Scan/Abnormal CT scan• Penetrating Head Injuries• Deteroriting Condition• Moderate/sever head ache• Alcohol intoxification• Skull fracture• CSF leak• Amnesia• H/O unconsciousnes

• Discharge• Schedule follow up

with in 1 week

Management of Moderate head Injury (Flow Chart)

GCS 9-13

Admission CT Scan of Brain

If patient improves discharge if patient detoriates, manage as per severe head injury

Management in Case of Sever head injury

GCS score 3-8

• ABC

• Previous history for allergies, medications, past illness, last meals and events leading to head injury

Neurologic Reevaluation

• Eye opening

• Motor response

• Verbal response

• Pupillary light reaction

• Occulo cephalics reflex

• Occulo vestibular reflex

Therapeutic Agents

• Mannitol

• Moderate hyperventilation

• Anticonvulsants if requireed

• CT scans

• Air Venticulogram

• Angiogram

Cervical Spine Injuries• Only 2% incidence of cervical spine injuries in maxillofacial

trauma patients• Identification of obvious fracture , widening of posterior spina

process interspace• CT scan is choice of diagnostic radiographic tool• Emergency management include:

• ABC• C-Spine stabilization using rigid and semi rigid collars• 30mg/kg predisonolone bolus followed by 5.4g/kg/hr for 24 hours• Definitive management include skeletal traction, with the use of halo

traction with stryker frame with abouts 25 pounds of traction force

Orbital injuries• Opthalmic exatmination:

• Visual accuity• Enoptholmoses/proptosis/diplopia

• Eye movement• Size , level and reaction of pupils• Intra occular examination of choroid, anterior chamber, cornea,iris

• Extra ocular examination• Lid integrity• Nasolacrimal duct injury• Echymosis• Ptosis

Hutchinson’s pupil

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•Seen in case of cerebral compression•Consists of 3 stages

Pupil of the side of injury contract due to irritation of occulomotor nervePupil on other side -normal

pupil of the injured side becomesdilated due to paralysis of occulomotor nervePupil of other side contracts

Pupils of both sides dilated, no reaction to light

Pupillary response inference

Bilaterally reactive pupils that react to both direct & consensual stimuli

Normal pupil

Bilateral small pupils Narcotics, pontine injury, early central herniation on the pons

Bilateral fixed & dilated pupils Inadequate cerebral perfusion,severe elevation of ICP preventing adequate blood flow to brain

Unilateral fixed & dilated pupils. pupil that does not constrict when light is directed at the pupil but constricts when light is directed to contralateral pupil

Traumatic optic nerve injury(Marcus Gun pupil)

A core optic pupil (pupil that appears irregular in shape)

Lack of coordination of contraction of the muscle fibers of the iris and is associated with midbrain injuries

Unilateral dilated pupil that does not respond to either direct or consensual stimulation

Transtentorial Herniation

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Cranial nerve 3,4,6:

- light reflex

- intorsion and extorsion

Vision-threatening injuries (VTI)

• These include:• Retrobulbar haemorrhage;• Traumatic optic neuropathy;• Open and Closed globe injuries;• Loss of eyelid integrity;• Chemical injury.

• Loss of sight following blunt facial trauma may be crudely considered to be due to the following mechanisms.• Direct injury to the globe;• Direct injury to the optic nerve, e.g. bony impingement;• Indirect injury to the optic nerve, e.g. deceleration injury resulting in shearing,

stretching forces;• As a result of a generalised or regional fall in tissue perfusion (anterior ischaemic

optic neuropathy,• retrobulbar haemorrhage, nutrient vessel disruption);• Loss of eyelid integrity

Retrobulbar haemorrhage

• A tense, proptosed globe and a dilated pupil may be the only clues to the presence of a retrobulbar haemorrhage

• A lateral canthotomy, with lateral canthal tendon division, can be performed under local anaesthesia in the emergency setting. Lignocaine 1%, with adrenaline (1 in 200,000), is injected into the lateral canthal area of the affected eye, the lateral canthus incised to the orbital rim and the canthal tendon identified and cut. The lower eyelid is then pulled forward and its lateral attachment to the orbital rim divided.

• This allows the globe to translate forward, partially relieving the pressure by increasing the retrobulbar volume. If necessary, the same procedure can also be applied to the upper eyelid laterally. Formal decompression is then carried out under a general anaesthesia

CHEST INJURIESRib trauma is occurs in aout 56% of poly trauma patients followed by pneumothorax, flail chest, injuty to heart and major vessles• Degree of injury to chest is not indicative of the severity of injury to inner

structures • During the Primary Survey, the following life-threatening conditions from the

chest should be identified and treated:• 1) Tension pneumothorax• 2) Fail chest• 3) Open, blowing chest wound• 4) Massive hemothorax• 5) Cardiac tamponade

• During the Secondary Survey, the following injuries should be identified and treated: • 1) Contained rupture of the aorta• 2) Perforation of the tracheobronchial tree• 3) Perforation of the esophagus• 4) Rupture of the diaphragm/trachea• 5) Myocardial contusion• 6) Pulmonary contusion

• PNEUMOTHORAXDefinition: The presence of free air in the pleural cavity. • Symptoms and signs

• 1. Often asymptomatic.• 2. Dyspnea, tachypnea.• 3. Diminished breath sounds, hyperresonance, poorly

moving hemithorax.

• Investigations• Chest x-ray, preferably erect and in expiration

• HEMOTHORAXDefinition: Free blood in the pleural cavity.• Symptoms and signs

• 1. Often asymptomatic. • 2. Dyspnea, tachypnea, hypovolemia.• 3. Diminished breath sounds, dullness on

percussion, poorly moving hemithorax

• TENSION PNEUMOTHORAX Definition: Air under pressure in the pleural cavity due to a valve effect. Associated with life-threatening cardiorespiratory compromise due to collapse of the affected lung, compression of the normal lung and decreased venous return. • Symptoms and signs

• Dramatic presentation. Panicky patient. • Dyspnea, cyanosis, tachypnea,• Shock, distended neck veins. • Deviated Trachea to opposite side• Absent breath sounds, hyperresonance on affected side. • Prominent hemithorax with no movement on respiration

Flail Chest• Occur as a result of three or more contigous ribs fracturedd at

two points• Lateral type of flail chest is more common• Anteior type occures when ribs become separated at the

costrochondral junction, with or without associated fracture of sternum.

• The posterior type occurs whe n the posterior ribs are fractured

• Pulmonary contusion, hemothorax and pneumothorax may be associated with flail chest,

• Mechanical ventilation is indicated• Tachyapnea• Shallow rapid breaths• Distended neck veins• hypercapnea

Placement of thoracic tube

Abdominal Injuries• The abdomen is systemically examined by inspection,

palpation and auscullation and percussion• Injury to be suspected in deacceleration injuries, blunt

trauma apart from penatrative injuries• Presence of haematuria in Routine urine examinatio

may indicate a renal/genito urinary trauma• Serum amylase a non specific test in presence of

abdominal pain is significant• LFT should also be advised to check liver injuries• Dignostics include USG, CT Scan PA abdomen and DPL

DPL (diagnostic peritonial Lavage)

• Indicated in patients with + H/O abdominal trauma with abdominal pain /tenderness.

• Objective is to obtain fluid from the pelvic fossa for analysis• Bladder should be emptied to avoid injury during DPL.• Aspiration of fluid is done, if no fluid is obtained tha n 20ml/kg of

RL is infused upto 1 Litre and removed fluid should atleast be in range of 500-700 ml.

• Three methods:• Closed type: catheter blindly inserter below the umblicus in to the

peritoneal cavity. Highest incidence of complication, false negative tests and iatrogenic injury to visecral organs

• Semiopen type: 2-3 cm infraumblical skin incision, blunt dissection. Incision into fascia. Insertion of trocar

• Open technique: insertion of the catheter direct vision. Safest and guarantees intraperitoneal placement

Managemet of abdominal injuries• Physical examination to be repeated every 6 hourly• Management of shock, sepsis• Surgical exploration and intervention when necessary• Monitoring of urine output every hourly• Patient to be NPO• Nutritional support

Urological injuries• Occurs in 10% polytrauma patients• Majority of injuries are non threatning• Evaluation of kidneys, ureter, bladder, urethra and genitila• Excellent healing capibilities of genitourinary tract, if urinary

flow can be maintained without obstruction than healing is likely with just medical intervention

• Kidney is the most common urologic organ to be injured• CT scan is the gold standard for diagnosing renal injuries

Skeletal injuries

Retrograde intubation

Submental intubation