Head Spine trauma assesment and managementATLS Final.pptx

Head and spine trauma

1. Head and Spine Trauma: Assessment and Management

2. ATLS Principles in Trauma Care Rapid assessment and resuscitation ABCDE approach Prevent secondary injury Golden Hour concept Team-based trauma management

3. Global Burden of Trauma Head trauma is a leading cause of death Common in young adults Road traffic accidents and falls High socioeconomic impact Major cause of disability

4. Mechanisms of Head Injury Contact forces: skull/brain impact Inertial forces: acceleration-deceleration Diffuse Axonal Injury (DAI) from shearing Patterns vary with mechanism High-energy trauma = worse outcome

5. Primary vs Secondary Brain Injury Primary = immediate structural damage Secondary = develops hours to days later Causes: hypoxia, hypotension, edema Seizures, metabolic derangements Target for therapy

6. Cellular Response in TBI Calcium influx and free radicals Mitochondrial dysfunction Cytoskeletal disruption Apoptosis and necrosis Inflammatory response prolongs damage

7. Raised ICP & Herniation Normal ICP = 5–15 mmHg Cushing’s triad = late warning Uncal herniation: dilated pupil Central herniation: bilateral signs Tonsillar herniation: brainstem compromise

8. Skull Fractures – Overview Vault vs base fractures Linear, stellate, open or closed Basilar: CT bone windows Signs: raccoon eyes, Battle’s sign, CSF leak CN VII/VIII palsy possible

9. Skull Fractures – Clinical Importance Suspect with CSF leak or CN palsy Carotid canal fractures → vascular injury CTA or angiogram if suspected Open/compound = infection risk Linear fracture ↑ hematoma risk 400x

10. Diffuse Brain Injuries Mild concussion = transient, CT normal Severe diffuse = hypoxic-ischemic injury Diffuse swelling, loss of gray-white distinction Shearing at gray-white junction DAI = punctate bleeds, poor prognosis

11. Epidural Hematoma (EDH) Uncommon (~0.5% TBI, 9% comatose TBI) CT: biconvex/lenticular Temporal region common Middle meningeal artery tear Lucid interval followed by deterioration

12. Subdural Hematoma (SDH) More common (~30% severe TBI) Due to bridging vein rupture CT: crescent shape Often with parenchymal injury Worse prognosis than EDH

13. Contusions & Intracerebral Hematomas 20–30% of severe TBI Frontal & temporal lobes common Can evolve into large ICH 20% need urgent surgery Repeat CT in 24h essential

14. Primary Survey in Head Trauma Airway with cervical spine protection Breathing and oxygenation Circulation and hemorrhage control Disability: GCS, pupils, motor exam Exposure and prevent hypothermia

15. Airway Management in TBI Inline stabilization required Jaw thrust preferred RSI with relaxants to limit ICP rise ETT = definitive airway Surgical airway if intubation fails

16. Breathing & Circulation Maintain SpO₂ > 94% PaCO₂ 35–40 mmHg Avoid hypotension (SBP <100) Use isotonic crystalloids Blood products if shock

17. Neurological Assessment AVPU scale Detailed GCS scoring Pupil exam Motor/sensory assessment Trend monitoring

18. ATLS Management of TBI (Overview) 13–15 Mild TBI 9–12 Moderate TBI 3–8 Severe TBI AMPLE history, neuro exam Discharge if safe Admit if CT abnormal, fracture, CSF leak GCS not back to 15 in 2h Primary survey + resuscitation Neurosurgery eval or transfer Secondary survey Primary survey + resuscitation Urgent neurosurgery consult Airway + ventilation Treat hypotension CT per rules Toxicology screens CT in all cases Check other injuries Crossmatch, coagulation studies CT in all cases Check other injuries Crossmatch, coagulation studies

19. ATLS Management of TBI (Secondary + Disposition) 13–15 Mild TBI 9–12 Moderate TBI 3–8 Severe TBI Serial exams until GCS 15 Follow-up CT if abnormal/deteriorating Serial exams Follow-up CT in 12–18h Frequent neuro exams PaCO₂ 35–40 mmHg Mannitol, hyperventilation if herniation Address lesions Discharge with warning sheet Follow-up arranged Repeat CT if deterioration Transfer to trauma center Transfer urgently to neurosurgery

20. Glasgow Coma Scale (Revised) Original Scale Revised Scale Score Spontaneous / To speech / To pain / None Spontaneous / To sound / To pressure / None / NT 4–1 Oriented / Confused / Inappropriate words / Incomprehensible / None Oriented / Confused / Words / Sounds / None / NT 5–1 Obeys / Localizes / Flexion withdrawal / Abnormal flexion / Extension / None Obeys / Localizing / Normal flexion / Abnormal flexion / Extension / None / NT 6–1

21. ICP Monitoring Indicated if GCS ≤8 with abnormal CT EVD = gold standard Intraparenchymal probes alternative Target ICP <20 mmHg CPP goal 60–70 mmHg

22. ICP Management Head elevation 30° Avoid hypoxia & hypercarbia Hyperventilation temporarily Mannitol IV bolus Hypertonic saline alternative

23. Fluid Therapy in TBI Use isotonic crystalloids Avoid hypotonic solutions Maintain SBP >100–110 mmHg Avoid over-resuscitation Balance CPP goals

24. Sedation & Analgesia Adequate analgesia lowers ICP surges Propofol, midazolam used Avoid long paralytics Barbiturates for refractory ICP Secure airway first

25. Seizure Prophylaxis Early seizures common (<7 days) Phenytoin/levetiracetam recommended Not effective for late seizures Monitor drug levels Prevents secondary neuronal injury

26. Definitive Neurosurgical Management EDH: urgent craniotomy SDH: evacuation if mass effect Decompressive craniectomy in refractory ICP Repair depressed fractures Post-op ICU care critical

27. Complications of Head Trauma Seizures Hydrocephalus Chronic subdural hematoma Infections (meningitis, abscess) Psychiatric sequelae

28. Rehabilitation in Head Trauma Physiotherapy Cognitive rehab Psychological support Occupational therapy Long-term recovery

29. Spinal Column Anatomy 7 cervical, 12 thoracic, 5 lumbar Sacrum and coccyx Facet joints allow motion Discs cushion Ligaments stabilize

30. Spinal Cord Anatomy Extends medulla to L1–L2 Gray and white matter Cervical & lumbar enlargements Cauda equina Motor and sensory tracts

31. Dermatomes C5 = lateral arm T4 = nipple line T10 = umbilicus L4 = medial leg S1 = lateral foot

32. Myotomes C5 = elbow flexion C6 = wrist extension C7 = elbow extension L4 = ankle dorsiflexion S1 = plantarflexion

33. Spinal Cord Syndromes Central cord: arms > legs Anterior cord: motor + pain/temp loss Brown-Séquard: ipsilateral motor, contralateral sensory loss Posterior cord: proprioception loss Cauda equina: incontinence, flaccid paralysis

34. Neurogenic vs Spinal Shock Neurogenic: hypotension + bradycardia Loss of sympathetic tone Spinal shock = areflexia Differentiate clinically ATLS emphasizes recognition

35. Systemic Effects of SCI Respiratory failure in high lesions Hypotension from autonomic loss Bradycardia common in C-spine Bladder/bowel dysfunction Pressure sores risk

36. Radiographic Evaluation CT cervical spine preferred MRI for cord/ligament injury X-rays if CT unavailable Follow ATLS rules Clinical clearance in stable patients

37. Cervical Spine Imaging CT superior to X-ray Odontoid fractures Hangman’s fracture Jefferson fracture MRI if neuro deficit

38. Thoracic & Lumbar Imaging CT for burst/compression fractures MRI for cord involvement Thoracolumbar junction high-risk Plain films screening Document morphology

39. Documentation of SCI Specify injury level Severity: ASIA grading Morphology: compression/burst/dislocation Syndrome type Complete vs incomplete

40. Cervical Spine Fractures Odontoid fracture Hangman’s fracture Jefferson fracture Teardrop fracture High mortality if unstable

41. Thoracic Spine Fractures High-energy trauma Compression fracture Burst fracture Associated rib fractures Cord injury risk

42. Thoracolumbar Junction Injuries Common at T11–L1 Compression/burst patterns Chance fracture (flexion-distraction) Paraplegia possible Fixation if unstable

43. Lumbar Fractures Compression fractures Burst fractures Lower risk of cord injury Stable vs unstable classification Surgical fixation if unstable

44. Penetrating Spinal Injuries Bullets, knives High infection risk Cord transection possible Surgical decompression if needed Broad-spectrum antibiotics

45. Blunt Carotid & Vertebral Artery Injuries Associated with cervical fractures Can cause stroke CT angiography diagnostic Anticoagulation/antiplatelets Endovascular treatment

46. General Management of Spine Trauma Spinal motion restriction Steroids not recommended (ATLS) Maintain MAP 85–90 mmHg Urgent decompression if compression Stabilization surgery/braces

47. Transfer & Teamwork Early transfer to trauma center Maintain immobilization during transfer Multidisciplinary approach Clear documentation Communication essential

48. Key Take-Home Messages Head & spine trauma emergencies ABCDE + ATLS principles save lives Prevent secondary injury Timely surgery improves outcomes Rehabilitation completes recovery