LO: CNS Trauma

Question 1

Acute management of trauma pt

Answer 1

ABCDE:
Airway
Breathing
Circulation
Disability (basic neuro evaluation)
Exposure (undress pt, looking for injury; control environment)

Question 2

Focused trauma neuro exam includes…

Answer 2

GCS
Pupil size & reactivity
Gross motor
Sensation 
Lateralizing signs
If spinal cord injury: spinal level (sensory)

Question 3

How to clear a C-spine

Answer 3

1. Any high risk factor that mandates radiography?
   if no, then:
2. Any low-risk factor that allows safe assessment of ROM?
   if yes, then:
3. Able to actively rotate neck? (45 degrees L and R)
   If yes: cleared! No imaging needed.
   If any criterion above is not met: proceed to imaging (don’t need to assess all criteria)
   REMEMBER: you cannot clear a c-spine on someone who is drunk!

Question 4

C spine: high risk factors (3)

Answer 4

• 65 or older
• dangerous mechanism
• paresthesias in extremities

Question 5

C spine: dangerous mechanisms

Answer 5

• fall from elevation ≥ 3 ft/5 stairs
• axial load to head, eg diving
• MVC high speed (>100km/h), rollover, ejection
• motorized recreational vehicles
• bicycle struck or collision

Question 6

C-spine: low-risk factors that allow safe assessment of ROM:

Answer 6

• simple rear-end MVC (not: hit by high speed, rollover, hit by bus or large truck, pushed into oncoming traffic)
• sitting position in ED
• Ambulatory at any time
• Delayed onset of neck pain (ie not immediate)
• absence of midline C-spine tenderness

Question 7

TBI definition

Answer 7

non-specific term describing blunt, penetrating, or blast injuries to the brain.
- can be classified as mild, moderate, or severe, typically based on the GCS and/or neurobehavioural deficits after the injury.

Question 8

Neurotrauma focused history

Answer 8

• period of LOC
• post-traumatic amnesia
• loss of bowel/bladder control
• loss of sensation
• weakness
• type of injury/accident

Bonus (from BMJ): seizure, confusion, deterioration in mental status, vomiting, headache, drug or alcohol (current: assoc w/ intracranial injury on CT; chronic: thought to increase BV shear –> bleed), current meds (esp anticoagulants), age (older–> poorer prognosis)

Question 9

Neurotrauma physical exam

Answer 9

• GCS
• head & neck (lacerations, bruises, basal skull # Sx, facial #, foreign bodies)
• spine (palpable deformity, midline pain/tenderness)
• eyes (pupil size & reactivity)
• brainstem (breathing pattern, CN palsies)
• CN
• motor exam, sensory exam (if GCS=15), reflexes
• sphincter tone, saddle sensation
  Record & repeat at regular intervals (BMJ recommends GCS q15min)

Question 10

Neurotrauma investigations

Answer 10

• • continue C-spine precautions until cleared **
• C, T, L spine XR (AP, lateral, & odontoid for C; or, CT)
• CT head for #, loss of mastoid or sinus air spaces, blood in cisterns, pneumocephalus
• ABG, CBC, blood type and cross, drug screen
• CXR, pelvic XR as indicated

Question 11

All patients with head injury have ___ until proven otherwise.

Answer 11

C-spine injury!

Question 12

Spine imaging assessment (mnemonic)

Answer 12

ABCDS
Alignment
Bone (vertebral bodies, facets, spinous processes)
Cartilage
Disc
Soft tissues

Question 13

Canadian CT Head Rule

Answer 13

CT Head only required for pt with minor head injuries if:

High risk:

• GCS<15 2h post-injury
• Suspected open or depressed skull fracture
• Any sign of basal skull fracture
• vomit ≥ 2x
• Age ≥ 65y

Med risk

• amnesia after impact >30min
• dangerous mechanism (same as C-spine)

Question 14

Signs of basal skull fracture

Answer 14

• raccoon eyes, battle sign
• CSF oto/rhinorrhea
• hemotympanum

Question 15

Minor head injury

Answer 15

• witnessed LOC
• definite amnesia
• witnessed disorientation in pt with GCS of 13-15

Question 16

Minor head injury: dangerous mechanism

Answer 16

• pedestrian struck by motor vehicle
• occupant ejected from motor vehicle
• fall from elevation ≥ 3 ft/5 stairs