Head neck injuries evaluation and transport.pdf

injuries

1. BY,
DR.MANJUNATH.S.T
PG.ANAESTHESIA
MVJMC&RH
BANGALORE

2. Introduction
—60% of patients with severe head & neck trauma have
multisystem trauma and the potential for airway
compromise.
—Head and neck injuries result from either blunt or
penetrating trauma.

3. —20-50% concurrent brain injury.
—1-4% cervical spine injuries.
—Blindness occurs in 0.5-3%.

4. —The management of a severely injured patient is one of
the biggest challenges in prehospitalcare.
—Significant pressure exists to minimize on-scene and
transport times, based on the “golden hour” and
“platinum 10 minutes” concept.
—EMS team must perform a quick but thorough scan of
the entire accident scene and triage all victims. The
overriding goal of the initial patient assessment on the
scene is to identify life-threatening injuries.

5. —The challenges for EMS providers responding to
major trauma begin with assessment of safety at
the scene, scene assessment (number of injured
patients, mechanism of injury, injury severity,
difficult weather and lighting conditions), and
coordination with other first-responder services
(police, fire department).

6. Triage definition
—A process for sorting injured people into groups based
on their need for or likely benefit from immediate
medical treatment. Triage is used in hospital
emergency rooms, on battlefields, and at disaster sites
when limited medical resources must be allocated.

7. TRIAGE CATEGORIES
—EMERGENT
—URGENT
—NON-URGENT
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8. EMERGENT
—CONDITION IS LIFE-THREATENING
—CARE MUST BE INITIATED IMMEDIATELY
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9. URGENT
—Condition is severe but not life-threatening. It
requires medical intervention within two hours
but not immediate care.
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10. NON-URGENT
—Condition is non-acute or minor
—Care can be delayed for hours
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11. Triage Criteria for Major Trauma
—Mechanism of Injury
—Physiologic Criteria Systolic blood pressure <90 mm
Hg
Respiratory rate <10 or >29 breaths/min
Glasgow Coma Scale score <14
Pregnancy
—Anatomic Criteria

13. TRANSPORT
—Transporting patients has risk.
—It requires good communication, Planning &
appropriate staffing.
1.Planning and Preparation include consideration of:
—Type of transport (car, Landover, boat etc)
—The personnel to accompany patient
—The equipment & supplies required enroutefor
routine & emergency treatment
—Potential complications
—The monitoring & final packaging of patient.

14. Patients are transported in neutral position
Logrolledonto spinal boards
Properly immobilized(inline immobilisation,stiffneck collar
or sandbags)
Spinal Boards

15. Cervical Spine Immobilization Using
Cervical Collar, Head Tape and Sand Bags

16. Examination
—Inspection of the face for asymmetry.
—Inspect open wounds for foreign bodies.
—Palpate the entire body.
—Check visual acuity.
—Check pupils for roundness and reactivity.
—Inspect for hematoma, CSF or blood.
—Palpate for crepitus, deformity and subcutaneous air.

17. Airway management
—Chin lift.
—Jaw thrust.
—Oropharyngealsuctioning.
—Manually move the tongue forward.
—Maintain cervical immobilization.

18. Manual inline stabilization of cervical spine

19. —Avoid nasotrachealintubation:
Nasocranialintubation
Nasal hemorrhage
—Avoid Rapid Sequence Intubation:
Failure to intubate or ventilate.
—Consider an awake intubation.
—Sedate with short acting benzodiazepines.

20. —Consider fiberopticintubation if available.
—Alternatives include percutaneous transtracheal
ventilation and retrograde intubation.
—Be prepared for emergency cricothyroidotomyand
tracheostomy.

21. —Maxillofacial bleeding: Anterior and posterior
packing.
—Nasal bleeding: Direct pressure.
—Pharyngeal bleeding:
Packing of the pharynx around ET tube.

22. ANAESTHETIC CONSIDERATIONS
General Considerations
If the patient arrives in the operating room already
intubated, correct positioning of the endotracheal
tube must be verified.
If the patient is not intubatedthe same principles of
airway management described above should be
followed in the operating room. If time permits,
hypovolemiashould be at least partially corrected
prior to induction of general anesthesia.
Succinylcholineis reportedly safe during the first 48 hrs
following the injury but is associated with
lifethreateninghyperkalemiaafterward.

23. —Maintain mean arterial pressure (MAP) and perfusion with
a balance of infusion and inotropes.
—Monitor temperature, warm IV fluids, and use a
patient warming device as needed.
—Perform a baseline neurological assessment on any
patient with suspected spinal injury or spinal cord
injury to document the presence of SCI. If neurologic
deficits are consistent with spinal cord injury,
determine a neurological level and the completeness
of injury. Perform serial examinations as indicated to
detect neurological deterioration or improvement.

24. Hypoxia:
—50% of patients with severe head injury have
PaO2 < 80% and mortality is increased by 20%.
Hypotension:
—MAP < 90mmhg –30% increase in mortality.
Metabolic:
—Glucose > 200 –worse outcome
—CSF CK-BB > 200u/L with low GCS-Death
—Aim to keep ICP < 20mmHg

25. Points to Remember
—Ensure adequate oxygenation & ventilation.
—Assess airway,considerC-Spine injury. -MILS
—Avoid inserting airway/NGT/EET through nose-If base of
skull # suspected.
—Attenuate CVS/ICP responses to stimulus.
—Muscle relaxation with succinylcholine/NDMRs.
—Avoid succinylcholineif head injury is > 2-3 days.
—Ensure adequate CCP (>70mmHg), ICP monitor
—Avoid noxious stimuli.
—Avoid Cerebral vasodilators (Volatile anaesthetics,N2o).
—Base anaesthesiaon
opiods,barbiturates,propofol,lidocaine,musclerelxants.
—Never transport C-Spine injured patient in sitting or prone
position.

26. THANK YOU