Head, Neck, and Spinal Cord Trauma

last authored: April 2012, David LaPierre
last reviewed:

 

 

Introduction

In all acute care settings, healthcare providers will encounter trauma patients. Some of the most common causes of trauma are motor vehicle collisions (MVC), falls, and sports-related injuries (1,2). Trauma is the leading cause of death of people between the ages of 1 and 44 years old in the developed world, and a major cause of death worldwide for all ages (1, 3).

 

Every year, about 700 teenagers in Canada lose their lives to preventable injuries; this is more than all other causes of death (1). In Canada in 2004, injuries resulted in 13 677 deaths and 67 500 people with permanent disabilities, 5,000 of those classified as total disability (1). Many of these deaths and disabilities are the result of cervical spine (C-spine) injuries (2). Each year more than 4 million patients with potential C-spine injury are seen in emergency departments in Canada and the United States (4). The incidence of C-spine injuries associated with these head injuries and trauma cases is 3-6% in adults and 0.5% in children (<18 years old) (5,6). Up to 10% of unconscious MVC victims will have a C-spine injury (7). C-spine injuries result in a wide range of problems from the fairly benign (ex. neck pain) to the very serious (ex. tetraplegia) to death.

 

Many of the neurologic injuries occur at the time of the trauma, however, up to 25% of the injuries occur after the trauma during transit to the hospital, care in hospital, or after discharge with a missed diagnosis (5). These statistics show the importance of accurate diagnosis, and subsequent management, of C-spine fractures in the emergency department.

 

 

 

The Case of...

add case illustrating clinical presentation, investigations, and differential diagnosis

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Causes and Risk Factors

Causes of trauma include:

 

Risk factors include:

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Pathophysiology

 

Scalp and skull injury

Layers of scalp spell SCALP:

 

Brain injury

As mass expands, the CSF is shunted down the spinal cord. As a hematoma continues to grow, venous blood is compressed out, followed by arterial blood.

brain is about 1800 cc - 80% brain, 10% blood, and 10% CSF

Neurologic damage can be caused by the initial force, developing hematoma, and increased intracranial pressure.

Acute epidural hematoma classically occurs following trauma in which the middle meningeal artery is ruptured. It is almost always associated with a skull fracture.

and causes unconsciousness, an awake, alert patient, gradial re-loss of consciousness, a fixed dilated pupil, and contralateral hemiperesis with decerebrate posture.

Acute subdural hematoma is caused by more substantial trauma in which the branches of the superior saggital sinus shear off and spill venous blood across the brain.

Cerebral contusions can be associated with other injuries. Their effects can appear days later, requiring close monitoring following injury.

 

Spinal cord injury

spinal shock

Other injuries include:

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Clinical Evaluation

Stay focused on the basics: ABCs, neurological exam, immobilization

  • history
  • primary survery
  • secondary survey

History

As with all trauma, history largely depends on mechanism of injury

Ask about

  • any loss of consciousness
  • nausea/vomiting
  • headache
  • post-traumatic amnesia
  • loss os sensation or function

Endeavour to understand the mechanism of injury:

  • timing
  • objects
  • force
  • velocity

  • blunt or penetrating
  • velocity
  • safety devices (seatbelts, helmets, airbags, etc)

Also important are past medical history, medications, allergies, alcohol or drug use, last meal, and previous surgeries.

Power of attorney should be identified in case of incapacity of the patient.

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Investigations

  • lab investigations
  • diagnostic imaging

Lab Investigations

Bloodwork investigations in the trauma setting are described here.

 

NEVER do a lumbar puncture.

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Management

As in all emergency situations, management of the ABCDEs is of primary importance. These are discussed here.

 

Minor injury

If nothing more than concussion is suspected, observe for 24-48 hours, waking every hour. Use sedatives or analgesics selectively while monitoring.

 

 

Severe injury

For major head injury (GSC<12), rapid transport to neurosurgery is of critical importance.

 

Wounds

Irrigate wounds and remove foreign bodies. Debride noviable tissue.

Drain septal hematoma and pack if epistaxis is present.

Provide teanus prophylaxis and antibiotics as warranted.

 

 

Increased intracranial pressure

Manage increased ICP if present; ideally by neurosurgery, or in consultation with them as required

pharmacotherapy:

 

Basal skull fractures

Basal skull fractures are managed expactantly following CT of C-spine and head. Antibiotics are not normally needed.

 

 

Facial fractures

 

Spine fractures

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Consequences and Course

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Resources and References

Trauma Coma Data Bank, Journal Neurosurgery, 1991.

Nova Scotia Head Injury Guideline

 

Stiell I. et al. 2001. The Canadian Cervical Spine Radiography Rule for alert and stable trauma patients. Journal of the American Medical Association. 286:1841-1848.

 

Stiell I. et al. 2003. The Canadian C-spine Rule versus the NEXUS low-risk criteria in patients with trauma. New Engand Journal of Medicine. 349:2510-2518.

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Topic Development

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