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Toronto Notes 2019 Neurotrauma
Neurological Exam
• GCS
• headandneck(lacerations,bruises,basalskullfracturesigns,facialfractures,foreignbodies) • spine(palpabledeformity,midlinepain/tenderness)
• eyes(pupillarysizeandreactivity)
• brainstem(breathingpattern,CNpalsies)
• cranialnerveexam
• motorexam,sensoryexam(onlyifGCSis15),reflexes
• sphinctertone,saddlesensation
• recordandrepeatneurologicalexamatregularintervals
Investigations
• spinalinjuryprecautions(cervicalcollar)arecontinueduntilC-spineiscleared
• C,T,L-spinex-rays
■ AP, lateral, odontoid views for C-spine (must see from C1 to T1; swimmer’s view if necessary) or CT
■ rarely done: oblique views looking for pars interarticularis fracture (“Scottie dog” sign)
• CTheadandupperC-spine(wholeC-spineifpatientunconscious)lookforfractures,lossofmastoidor
sinus air spaces, blood in cisterns, pneumocephalus
• crossandtype,ABG,CBC,drugscreen(especiallyalcohol)
• chestandpelvicx-rayasindicated
TREATMENT
Treatment for Minor Head Injury (GCS 13-15)
• observationover24-48h
• wakeeveryhour
• judicioususeofsedativesorpainkillersduringmonitoringperiod
• outpatient:advisepatientstoundergostepwiseapproachtoreturntoplayandreturntoschool(for
latest recommendations, refer to Ontario Neurotrauma Foundation guidelines)
Treatment for Moderate (GCS 9-12) and Severe Head Injury (GCS ≤8) • clearairwayandensurebreathing;intubateifnecessary
• secureC-spine
• maintainadequateBP
• monitorforclinicaldeterioration
• monitorandmanageincreasedICPifpresent(seeHerniationSyndromes,NS7)
Admission required if:
• skullfracture(indirectsignsofbasalskullfracture,seeHeadInjury) • confusion,impairedconsciousness,concussionwith>5minamnesia • focalneurologicalsigns,extremeH/A,vomiting,seizures
• unstablespine
• useofalcohol
• poorsocialsupport
Head Injury
Epidemiology
• M:F=2-3:1
Pathogenesis
• acceleration/deceleration:contusions,subduralhematoma,axonandvesselshearing/mesencephalic hematoma
• impact:skullfracture,concussion,epiduralhematoma
• penetrating: worse with high velocity and/or high missile mass
■ low velocity: highest damage to structures on entry/exit path ■ high velocity: highest damage away from missile tract
Scalp Injury
• richbloodsupply
• considerablebloodloss(vesselscontractpoorlywhenruptured) • minimalriskofinfectionduetorichvascularity
Skull Fractures
• depressedfractures:doubledensityonskullx-ray(outertableofdepressedsegmentbelowinnertableof skull), CT with bone window is gold standard
• simplefractures(closedinjury):noneedforantibiotics,nosurgery
• compoundfractures(openinjury):increasedriskofinfection,surgicaldebridementwithin24his
necessary
■ internal fractures into sinus may lead to meningitis, pneumocephalus ■ risk of operative bleed may limit treatment to antibiotics
Neurosurgery NS31
• Never do lumbar puncture in head injury unless increased ICP has been ruled out
• All patients with head injury have C-spine injury until proven otherwise
• Suspect hematoma in alcoholic-related injuries
• Low BP after head injury means injury elsewhere
• Must clear spine both radiologically AND clinically
Assessment of Spine CT/X-Ray (Parasagittal View)
ABCDS
Alignment (columns: anterior vertebral line, posterior vertebral line, spinolaminar line, posterior spinous line)
Bone (vertebral bodies, facets, spinous processes)
Cartilage
Disc (disc space and interspinous space) Soft tissues
Comparative Effectiveness of Using Computed Tomography Alone to Exclude Cervical Spine Injuries in Obtunded or Intubated Patients: Meta- Analysis of 14,327 Patients with Blunt Trauma
J Neurosurg 2011;115:541-549
Purpose: To determine the effectiveness of helical CT alone (vs. CT and adjuvant imaging such as MR) to diagnose acute unstable cervical spine injury following blunt trauma.
Results: 17 studies with 14,327 patients total. Sensitivity and specificity for modern CT were both >99.9% (95% CI 0.99 -1.00 for both). The negative predictive value of a normal CT scan was 100% (95% CI 0.96-1.00) and accuracy was not affected by the global severity of injury, CT slice thickness, or study quality.
Conclusions: CT alone is sufficient to detect unstable cervical spine injuries in trauma patients and adjuvant imaging is unnecessary with a negative CT scan result. Consequently, if a CT scan is negative for acute injury, the cervical collar may be removed from obtunded or intubated trauma patients.
The Canadian CT Head Rule for Patients with Minor Head Injury
Lancet 2001;357:1391-1396
CT Head is only required for patients with minor head injuries with any one of the following: High Risk (for neurological intervention)
• GCSscore<15at2hafterinjury
• Suspectedopenordepressedskullfracture
• Any sign of basal skull fracture (hemotympanum,
“raccoon” eyes, cerebrospinal fluid otorrhea/
rhinorrhoea, Battle’s sign)
• Vomiting≥2episodes
• Age≥65yr
Medium Risk (for brain injury on CT)
• Amnesiaafterimpact>30min.
• Dangerousmechanism(pedestrianstruckby
motor vehicle, occupant ejected from motor
vehicle, fall from height >3 feet or five stairs). Minor Head Injury is defined as witnessed loss of consciousness, definite amnesia, or witnessed disorientation in a patient with a GCS score of 13-15.