Head, neck injury

Question 1

Basilar skull # signs

Answer 1

through petrous part of temporal bone

1. Racoon eyes - tarsal sparing
2. BATTLEs sign - post auricular echymosis
3. HALO sign - CSF otorrhoea
4. Hemotympanum

Question 2

GCS score

Answer 2

<8 - unconscious

Question 3

Mx of head injury in a rural setting

Answer 3

Consider
1. Stable/unstable
2. GCS score
3. How far/long is the tertiary centre

●<8 GCS, <2hrs away - transfer

●<8 GCS, >2hrs away
If Stable (still risky) - CT **risky
Unstable - Burr hole (for location - site of wound, if going blind, done on temporal area

●>8 GCS - CT

Question 4

Assessing pt with head injury

Answer 4

1. Primary survey, resuscitation
2. Severity - GCS
   15 = mild without r/f
   14-15 = mild with r/f
   9-13 = mod
   3-8 = severe

Question 5

Mechanisms of severe head injury (5)

Answer 5

1. Motor vehicle accident with patient ejection or rollover, death of another passenger
2. Pedestrian or cyclist struck by motor vehicle
3. Falls of ≥1 m (<2 vr)
4. Fall >1.5 m (>2 yr)
5. Head struck by high impact object

Question 6

Mx of head injury with GCS 15 = mild without r/f

Answer 6

1. Secondary survey (other injuries)
2. Discharge

Question 7

MX of head injury with GCS 14-15 = mild with r/f

Answer 7

1. Secondary survey
2. Observe for 4 hrs
3. Add inv if necessary

Question 8

Mx of head injury with GCS 9-13 = mod

Answer 8

1. Consult senior/neurology team
2. Emergency CT head/cervical spine
3. Secondary survey

Question 9

Mx of head injury with GCS 3-8 = severe

Answer 9

1. Trauma call
2. Consider intubation
3. Consult neurosurgical team
4. Urgent CT head +/-cervical spine
5. Complete secondary survey

Question 10

Epidural hematoma

Answer 10

1. Mild - mod injury
2. Unconscious … LUCID INTERVAL (a symptomatic) … Gradually unconscious
3. Fixed dilated pupil
4. C/L hemiparesis with decerebrate posturing
5. CT - LENS/BICONVEX SHAPED
6. Mx- emergency craniotomy

Question 11

Subdural hematoma

Answer 11

1. High force injury (helmet broken etc)
2. NO LUCID INTERVAL, unconscious/asymptomatic
3. CT - CRESCENT SHAPED
4. Bad prognosis

Question 12

How do we avoid increase in ICP post hematoma

Answer 12

1. ICP monitoring
2. Head elevation
3. Modest hyperventilation - in herniation (target PCO2 - 35mmHg)
4. Avoidance of fluid over-load
5. Diuretics such as mannitol/furosemide

Question 13

Zones of neck for evaluating penetrating neck trauma

Answer 13

Zone 1 - Clavicle to Cricoid cartilage
Zone 2 - Cricoid to angle of mandible
Zone 3 - Above angle of mandible

Question 14

Mx of zone 1,3 penetrating neck injury

Answer 14

1. Angiography
2. Esophagogram
3. Esophagoscopy
4. Bronchoscopy

Question 15

Mx of zone 2 penetrating neck injury

Answer 15

1. Unstable - Surgical exploration urgent
2. Stable - Zone 1 investigations

Question 16

Blunt trauma neck, check which structure?

Answer 16

If pt unconscious/pain @cervical region
Cervical spine
CT - neck

Question 17

*NEXUS criteria for cervical spine injury

Answer 17

Cervical spine injury cannot be excluded if
1. Midline cervical pain
2. Focal neurological deficit
3. Altered mental status
4. Drug/alcohol intoxication
5. Injury painful enough to distract from neck pain

CT/MRI imaging done (not xray)

Question 18

Canadian C-spine rule

Answer 18

1. Age >65
2. Dangerous mechanism of injury
3. Focal neurological deficit

Imaging mandatory

Question 19

Mx of C-spine injury

Answer 19

1. High r/f - Imaging (nexus/canadian criteria)
2. Low r/f - neck rotation
   >45degrees - no imaging required
   <45degrees - imaging (CT/MRI)

Question 20

Sub-arachnoid haemorrhage c/f

Answer 20

1. Headache - thunderclap
2. Vomiting
3. Mild neck stiffness
4. Horner syndrome features

CT can be normal … (blood in the fissures)
Do LP … normal …
CT/MR Angio