HEAD TRAUMA

Background

•  Leading cause of traumatic death in pts <25

•  80% mild (GCS 14–15), 10% mod (GCS 9–13), 10% severe (GCS <9) injuries

•  CPP = MAP − ICP, poor outcome if CPP <70 mmHg, CPP constant when MAP b/w 50 & 160

•  1° brain injury: Mechanical, irreversible damage caused by mechanical cell damage

•  2° brain injury: Alteration in cerebral blood flow → cerebral ischemia, membrane disruption, cerebral edema, free radical generation

Approach

•  Careful hx: Associated sxs (photophobia, vomiting, visual changes, ocular pain), focal neurologic sxs

•  Assess for head or neck trauma, medications, substance abuse

•  Check finger-stick blood sugar to r/o hypoglycemia as cause for AMS

•  Warning signs for neuroimaging: Severe HA, vomiting, worsening over days, aggravated by exertion or Valsalva, neck stiffness, AMS, abnl neuro exam, peri- or retro-orbital pain

Skull Fractures

History

•  Direct blow to the head, pt c/o pain

Findings

•  Skull depression

•  Basilar skull fx: Periorbital ecchymosis (raccoon eyes), retroauricular hematoma (Battle sign), otorrhea & rhinorrhea (CSF leak), 7th nerve palsy, hemotympanum

Evaluation

•  Noncontrast head CT. CBC, Chem, coags, T&C, tox screen; plain films not indicated

•  CTA to eval for vascular injury if basilar skull fx present

Treatment and Disposition

•  Airway management; management guided by underlying brain injury

•  Linear skull fx: If not other IC injury may be observed for 6 h & discharged

•  Depressed skull fx: Admit to NSGY, surgical elevation if depressed skull fx > thickness of skull, update tetanus, consider ppx abx & anticonvulsants

•  Basilar skull fx: Admit to NSGY

Pearl

•  GCS more indicative of underlying brain injury or hemorrhage

Scalp Laceration

History

•  Direct blow to the head, direct bleeding from scalp

Findings

•  Often blood has clotted upon ED arrival; has potential for large blood loss

•  Blood loss may not be evident in ED, eval for blood loss in field

Evaluation

•  Noncontrast head CT if indicated. CBC, Chem, coags, T&C, tox screen if significant blood loss

•  Thoroughly evaluate & explore skull for depressions & large lacerations

Treatment

•  Hemostasis & irrigation: Wounds often contaminated despite rich blood supply, direct venous drainage into the venous sinuses can cause significant CNS infections

•  Staples can be used if galea not involved

•  Interrupted or vertical mattress sutures w/ 3–0 nylon or Prolene

•  Galea must be repaired w/ absorbable sutures if lacerated; continued bleeding → subgaleal hematoma that often becomes infected

Disposition

•  If no other injuries, can d/c. O/w admission & observation.

Pearl

•  Abx not indicated for properly managed head wound unless gross contamination

Postconcussive Syndrome

History

•  Closed head injury, ± LOC (brief). HA, memory problems, dizziness, etc. may last 6 wk.

Findings

•  nl neurologic exam, wide spectrum of mild neuro complaints

Evaluation

•  Noncontrast CT shows no bleed but clinically insignificant SAH may have occurred

Treatment

•  Symptomatic HA control

Disposition

•  D/c w/ careful head injury instructions

•  May return to sport only after 2 wk of complete resolution of concussive sxs

Pearls

•  Thought to be secondary to stretching of white matter fibers at time of injury

•  2nd head injury more dangerous than 1st

Intracerebral/Intraparenchymal Hemorrhage

History

•  Depends on size & location of bleed

Findings

•  Pts commonly c/o HA, n/v

Evaluation

•  Noncontrast head CT. CBC, Chem, coags, T&C.

Treatment

•  Airway management

•  Emergent neurosurgical eval although most pts are managed nonoperatively; ICP monitor if significant bleed present

•  Mannitol for ↑ ICP, antiseizure medication to all pts

•  Reverse coagulopathy emergently w/ Vit K 5–10 mg IV × 1 ± FFP &/or factor conc.

Disposition

•  Follow

Pearl

•  Frontal lobe hematoma may cause disinhibition & personality changes

Subarachnoid Hemorrhage (SAH)

History

•  Pt c/o “worst HA of life”; acute onset & rapid progression, meningismus, vomiting, photophobia; can often pinpoint exact moment of onset

•  Spontaneous (ruptured cerebral aneurysm [∼75%], AVM [∼10%]) or traumatic

Findings

•  HA, n/v, sz, syncope, acute distress

•  Acute AMS is indicative of large bleed, usually requires emergent intervention

Evaluation

•  Noncontrast CT scan of head, ancillary studies (CBC, BMP, coags, T&S)

•  Head CT 95–99% sens for acute SAH (w/i 6–24 h); perform LP if CT neg

•  If concern for ruptured cerebral aneurysm, should also obtain CT angiogram

•  Large # RBC in CSF highly suggestive of SAH

•  RBCs are hemolyzed in CSF, may not be present in large numbers after 12 h or may not be present at all after 2 wk

•  Xanthochromia highly suggestive of bleed b/w 12 h & 2 wk (yellow discoloration due to RBC breakdown)

•  Check finger-stick blood sugar to R/O hypoglycemia as cause for AMS

Treatment

•  Airway management if comatose or not protecting airway, neurosurgical consultation

•  ICP & BP monitoring if bleed is significant; a-line, elevate head of bed to 30°

•  SPB b/w 90 & 140 mmHg, HR b/w 50 & 90 bpm, nicardipine or labetalol

•  Mannitol for significant bleed

•  Nimodipine to decrease vasospasm 60 mg PO q4h × 21 d

•  Sz prophylaxis (phenytoin, Keppra)

Disposition

•  To neurologic ICU

Pearls

•  Outcome directly related to amount of intracranial blood

•  30–50% have “sentinel HA” days to weeks prior to SAH

Subdural Hematoma (SDH)

History

•  Often caused by acceleration/deceleration tearing injury of bridging veins

•  Can be acute (<48 h), subacute (2 d–3 wk) or chronic (>3 wk)

Findings

•  Varied. Range from HA w/ nausea to comatose & flaccid

Evaluation

•  Noncontrast head CT shows crescent-shaped mass. Check CBC, Chem, Coags, T&C.

Treatment

•  Airway management, emergent neurosurgical eval

•  If e/o ↑ ICP or midline shift, mannitol & anticonvulsant

•  Reverse coagulopathy emergently w/ Vit K 5–10 mg IV × 1 ± FFP &/or factor conc.

Disposition

•  Follow

Pearls

•  More common than epidural hematoma

•  Comatose & flaccid pts w/ SDH have an extremely poor prognosis, should discuss w/ family

Epidural Hematoma

History

•  Brief LOC followed by “lucid interval,” then rapidly progressive deterioration

•  Head injury usually in area of temporal bone, causes damage to middle meningeal artery

Findings

•  Ipsilateral pupil deviation, occasionally contralateral hemiparesis, n/v, sz, hyperreflexia, + Babinski

Evaluation

•  Noncontrast CT often shows lenticular biconcave mass, possible fx of temporal bone

•  CBC, Chem, coag panel, T&C

Treatment

•  Airway management, emergent neurosurgical consultation

•  Mannitol & anticonvulsant

•  Reverse coagulopathy emergently w/ Vit K 5–10 mg IV × 1 ± FFP &/or factor conc.

Disposition

•  Follow

Pearl

•  Bleeding b/w the dura mater & skull

Diffuse Axonal Injury (DAI)

History

•  Result of tremendous shearing forces seen in high-speed MVCs

Findings

•  Pts present in coma; document best neuro response: May have prognostic value

Evaluation

•  Noncontrast CT often nl, must r/o bleed

•  CBC, Chem, coag panel, T&C, tox; look for other etiology for coma

•  MRI (nonemergent) will show changes & can guide prognosis

Treatment

•  Airway management

•  Emergent neurosurgical consultation for ICP monitor to avoid 2° injury from edema

•  Mannitol & phenytoin

Disposition

•  Follow

Pearl

•  Prognosis determined by clinical course & difficult to predict

MAXILLOFACIAL INJURY

Definition

•  Injuries to the soft tissue or bones of the face (50% caused by MVCs)

Approach

Inspection

•  Deformities, enophthalmos (orbital blowout fracture), jaw malocclusion, dentition step-offs, nasal septal/auricular hematomas, rhinorrhea (CSF leak), trigeminal/facial nerve deficits, abnl EOM, diplopia, gross visual acuity

Palpation

•  Facial prominences for tenderness/bony defects/crepitance/false motion, FB

Radiology

•  Panoramic x-ray for mandibular/dental fractures, maxillofacial CT scan for most injuries, CTA in injuries at high risk for vascular trauma

Soft Tissue Injury

Definition

•  Injury to the soft tissue of the face

History

•  MVC/bites/assault

Evaluation

•  CT only if bony injury/FB suspected

Treatment

•  Irrigate/eval for FB/primary closure w/in 24 h, abx (cefazolin, Ampicillin/Sulbactam, amoxicillin/clavulanate) for contaminated wounds (eg, bites), plastic surgery repair for nerve damage/extensive repair

Disposition

•  Home

Septal/Auricular Hematomas

Definition

•  Hematoma of nasal septum/ear

History

•  Direct trauma to the nose (a/w nasal bone fractures)/ear (classically in wrestlers)

Physical Findings

•  Swelling/purple discoloration

Treatment

•  Septal: Apply topical anesthetic, incise/evacuate w/ elliptical incision, pack bilateral nares, abx (amoxicillin/clavulanate) (failure to drain → cartilage necrosis → saddle nose deformity)

•  Auricular: Anesthetize area (lidocaine 1%) or auricular block, needle aspiration (chronic hematomas) or incise along skin folds, evacuate, apply compression dressing (failure to drain/compress → cauliflower ear/infection)

Disposition

•  Home, f/u in 24 h

Nasal Fractures

Definition

•  Fractures of the nasal bone

History

•  Direct trauma to the nose

Physical Findings

•  Swelling/deformity note: Patency of nares & appearance of septum

Evaluation

•  CT only if significant deformity/persistent epistaxis/rhinorrhea

Disposition

•  Isolated nasal fractures → Most home w/ plastic/ENT f/u in 5–7 d for reduction, consider reduction in ED if displaced, (pediatric pts → 3 d, ↑ risk for growth dysplasia)

Pearl

•  Septal hematoma requires immediate I&D to prevent necrosis

Zygomatic Fracture

Definition

•  Fractures of the zygomatic arch or fracture at the zygomaticotemporal suture/zygomaticofrontal suture/infraorbital foramen (tripod fracture)

History

•  Direct trauma to face

Physical Findings

•  Shallow depression over temporal region, trismus, edema, diplopia/vertical dystopia/infraorbital nerve anesthesia (tripod fracture)

Evaluation

•  Maxillofacial CT

Treatment

•  ENT/OMFS/Plastics consult

Disposition

•  Home, ENT/OMFS/plastics f/u for delayed ORIF, sinus precautions

Mandibular Fractures

Definition

•  Fracture of the mandible (>50% multiple fracture sites)

History

•  Direct trauma to mandible (assaults usually = body/angle fractures, MVC usually = symphysis/condylar fractures)

Physical Findings

•  Malocclusion, trismus, associated dental & lingual injury

Evaluation

•  Panorex (isolated mandibular fractures): Can miss condylar fracture, maxillofacial CT (preferred): Condylar fractures/additional facial trauma

Treatment

•  OMFS or plastic surgery consult: Temporary immobilization (wiring of jaw) or delayed ORIF, abx (PCN, clindamycin) if gingival bleeding

Disposition

•  Home

Pearls

•  Pts discharged w/ temporary wiring must be discharged w/ wire cutters

•  Tongue blade test has high sens for mandibular fx

Maxillary Fractures

Definition

•  Fracture of the maxilla, rare in isolation, a/w significant mechanism, greatest risk of airway compromise, traditionally classified by Le Fort system

History

•  Significant mechanism trauma to the face (high-speed MVC)

Physical Findings

•  Midface swelling/mobility, malocclusion of mandible, CSF rhinorrhea

Evaluation

•  Maxillofacial CT

•  CTA in Le Fort II & III should be strongly considered

Treatment

•  Airway management (eval for difficult airway, Le Fort II/III highest risk), hemorrhage control (nasal packing/nasal Foley/elevation of head), abx (ceftriaxone) for CSF communication, ENT/OMFS consult

Disposition

•  Admit

EYE INJURY

Definition

•  Injury to eye caused by trauma

Approach

•  Assess visual acuity (use lid retractors if needed) & Extraocular muscles (EOM), remove contact lenses

Orbital Fracture

Definition

•  Fracture to the wall of the orbit (floor/medial wall most common)

History

•  Blunt trauma to eye by object larger than the orbital rim

Physical Findings

•  Periorbital swelling/crepitance, tenderness/irregularities to bony orbit, vertical diplopia/limited Range of motion (ROM) w/ upward gaze (inferior rectus/inferior oblique entrapment), diplopia/limited ROM w/ lateral gaze (medius rectus entrapment), hypoesthesia of lower lid/cheek (infraorbital nerve entrapment), enophthalmos, ptosis

Evaluation

•  Orbital CT (opacification of maxillary sinus = orbital floor fracture)

Treatment

•  Abx (cover sinus flora), ophthalmology consult (rarely require surgery unless diplopia/entrapment) if any EOM entrapment or visual acuity change, “sinus precautions” (no nose blowing/sneezing, no sucking on straws/smoking)

Disposition

•  Home

Pearls

•  Orbital floor fractures are rare but a/w CNS trauma/infection

•  Pts are at ↑ risk zygomatic tripod fractures/Le Fort II & III fractures

Globe Rupture

Definition

•  Full-thickness defect in the cornea/sclera

History

•  Blunt (most common at muscle insertion sites/corneoscleral junction) or penetrating (more common) trauma, decreased vision, pain

Physical Findings

•  ↓ visual acuity, teardrop-shaped pupil, hyphema, + Seidel test (bright stream of aqueous humor after fluorescein) for corneal perforations, intraocular content extrusion, flattening of anterior chamber, oculocardiac reflex can cause bradycardia

Evaluation

•  Orbital/head CT (for FB/intracranial injury), US–but must be careful to not apply pressure

Treatment

•  Ophthalmology consult (for surgical repair), tetanus, abx (fluoroquinolones, vanc/gent), avoid pressure on eye/topical agents/Valsalva (antiemetics), protective shield

Disposition

•  Admit

Chemical Burns

Definition

•  Burns to sclera/conjunctiva/cornea/lid caused by alkali (oven cleaner, dish soap, detergents, cement, bleach) or acid (less severe)

History

•  Chemical exposure, severe pain, FB sensation, photophobia

Physical Findings

•  ↓ visual acuity, conjunctival injection, corneal edema, lens opacification, limbal blanching

Evaluation

•  pH testing of effluent in fornixes

Treatment

•  Topical anesthetics, irrigation (>2 L NS), use Morgan lens/manual retraction to keep eye open, check pH every 30 min until pH 7.3–7.7 & 10 min later, ↑ IOP treat like glaucoma, cycloplegics (cyclopentolate, tropicamide) if ciliary spasm, antibiotic ointment, ophthalmology consult for corneal haziness/perforation/conjunctival blanching

Disposition

•  Admit for increased IOP/intractable pain, minor burns: F/u in 24 h

Pearls

•  Hydrofluoric acid exposure: Administer 1% calcium gluconate drops during irrigation

•  If no pH paper available can use urine dipstick, for nl pH compare to unaffected eye

Retrobulbar Hematoma

Definition

•  Bleeding in the space surrounding the globe

History

•  Blunt trauma, recent eye surgery, pain, vomiting, ↓ visual acuity

Physical Findings

•  Afferent papillary defect, restricted EOM, ↑ IOP, proptosis, periorbital ecchymosis, subconjunctival hemorrhage

Evaluation

•  Orbital CT

Treatment

•  Immediate ophthalmology consult, treat ↑ IOP (timolol, acetazolamide), decompress w/ lateral canthotomy

Disposition

•  Admit

Retinal Detachment

Definition

•  Detachment of the retina

History

•  Floaters/flashing lights, “mosca volante”—solitary large floater, ↑ IOP, visual loss (macula involvement)

Physical Findings

•  Visual field deficit (curtain being pulled down), dilated retinal exam: Retinal tears/detachment

Evaluation

•  β-scan U/S

Treatment

•  NPO, bed rest, restrict EOM, immediate ophthalmology consult for surgical repair

Disposition

•  Admit

Hyphema

Definition

•  Accumulation of blood in the anterior chamber caused by rupture iris root vessel (trauma) or sickle cell/DM/anticoagulation

History

•  Blunt or penetrating trauma to the globe, dull eye pain, photophobia

Physical Findings

•  Microhyphemas: Visualized w/ slit lamp, larger hyphemas: Visualized w/ tangential pen light, total hyphema (high association w/ globe rupture): ↑ IOP

Evaluation

•  INR if on Coumadin

•  If any FH of hemoglobinopathy pt should be screened

Treatment

•  Immediate ophthalmology consult for >10%/↑ IOP, treat ↑ IOP (timolol, acetazolamide), metal eye shield, cycloplegics (cyclopentolate, tropicamide) if ciliary spasm

•  HOB >45% (upright allows blood to settle in anterior chamber/avoid retinal staining)

•  Topical anesthesia if no globe rupture, PO/IV analgesia

•  Topical steroids may help prevent rebleeding & synechiae

•  Consider tranexamic acid in those at high risk for rebleed

Disposition

•  Admit for >50%, ↑ IOP

•  Urgent ophthalmology f/u

Pearls

•  Sickle cell: Avoid acetazolamide/pilocarpine/hyperosmotic, ↑ risk of rapid ↑ IOP → optic nerve injury

•  Avoid ASA/NSAIDs b/c ↑ rebleed

•  10% rebleed (usually more severe) in 2–5 d

Vitreous Hemorrhage

Definition

•  Blood in the vitreous humor

History

•  Blunt trauma, floaters, blurry vision, vision loss, sickle cell/DM

Physical Findings

•  Loss of light reflex, poorly visualized fundus

Evaluation

•  β-scan U/S: For associated retinal detachment

Treatment

•  Immediate ophthalmology consult, HOB >45%, bed rest

Disposition

•  Admit if retinal tear/unknown cause

Pearl

•  Avoid ASA/NSAIDs b/c ↑ risk rebleed

Subconjunctival Hemorrhage

Definition

•  Hemorrhage b/w the conjunctiva & sclera caused by trauma, Valsalva (coughing/straining/vomiting), HTN, coagulopathy

History

•  Painless red eye

Physical Findings

•  Blood b/w the conjunctiva & sclera

Treatment

•  BP control, avoid Valsalva, avoid ASA/NSAIDs, artificial tears for comfort

Disposition

•  Home, ophthalmology f/u in 1 wk

Pearls

•  Resolution in 2 wk

•  Blood chemosis (large/circumferential) ↑ risk globe rupture

NECK TRAUMA

Definition

•  Injuries soft tissue & structures of the neck

Approach

•  Evaluate 3 main categories: Vascular, pharyngoesophageal, laryngotracheal (do not place NGT if esophageal/laryngeal injury suspected)

Inspection

•  Violation of platysma (↑ incidence of underlying structure injury, may indicate need for surgical exploration) (Trauma 1979;19:391), pulsatile/expanding hematomas

Penetrating Trauma Zones

•  Anterior triangle: Bordered by anterior SCM, midline, mandible. Posterior: Posterior to SCM, anterior to trapezius, superior to clavicle, most significant structures are anterior.

•  Zone I: Below cricoid cartilage (highest mortality), Zone II: B/w cricoid & angle of mandible, Zone III: Above angle of mandible)

Penetrating Neck Trauma

Definition

•  Injury to the neck from GSW, stabbings, projectile objects (shrapnel/glass)

Physical Findings

•  Laryngotracheal injuries may have stridor, respiratory distress, hemoptysis, SQ air, dysphonia

•  Esophageal injuries may have dysphagia, hematemesis, SQ air

•  Vascular injuries may have neuro deficits, expanding/pulsatile hematoma/bleeding, bruit/thrill, hypotension

Evaluation

•  CXR/(ptx/htx), lateral neck x-ray in trauma bay, CT, CTA

•  Trauma labs: CBC, BMP, T/S or C, PTT/PT, ABG

Treatment

•  Airway management (may be difficult airway), surgical consultation if platysma violation, abx (if ↑ risk contamination from aerodigestive perforation)

•  Treat as trauma resuscitation (ABCs, transfusion, etc.)

Disposition

•  Admit if surgical intervention/observation needed

Pearl

•  Arrest due to penetrating neck trauma is indication for ED thoracotomy

Strangulation

Definition

•  Neck trauma due to strangulation (3500 deaths/y)

History

•  Strangulation, voice changes, attempt to obtain “height of drop” from EMS

Physical Findings

•  Dysphonia/dyspnea (indicators serious injury), petechial hemorrhages (Tardieu spots), ligature/finger marks, neuro deficits/coma

Treatment

•  Airway management (may be difficult airway), surgical consultation (if needed), abx (if ↑ risk contamination from aerodigestive perforation)

Disposition

•  Admit if needed

Pearls

•  ↑ incidence of ARDS & long-term neuropsychiatric sequelae (selective vulnerability of hippocampus to anoxic injury)

•  Self-inflicted hanging rarely a/w C-spine injury, see hangman’s fracture (Chapter 18)

CERVICAL SPINE TRAUMA

Definition

•  Injury to the bony/ligamentous structure of the cervical spine (C2 24%, C6 20%, C7 19%)

Approach

•  Maintain C-spine immobilization until cleared clinically w/o imaging (see table) or radiographically

Palpation

•  Midline cervical tenderness, step-offs, neurologic deficits

Radiology

•  Plain c-spine x-rays: 52% sens (limited use), C-spine CT: 98% sens → persistent midline tenderness/obtunded → Flex/ex films: 94% sens for ligamentous injury if adequate ROM (30° flexion/extension), MRI: 98% sens for ligamentous injury (J Trauma 58(5):902) (J Trauma 53(3):426)

C1 Burst Fracture (Jefferson Fracture)

Definition

•  Unstable burst fracture of atlas (C1) causing widening of lateral masses (33% a/w C2 fracture)

History

•  Axial load

Physical Findings

•  C1 tenderness, neurologic deficit rare (wide canal at C1)

Evaluation

•  CT/CTA, MRI for ligamentous injury

Treatment

•  C-spine immobilization, spine consult for operative management

Disposition

•  Admit

C2 Hangman’s Fracture

Definition

•  Unstable fracture of bilateral C2 pedicles (↑ risk of C2 anterior subluxation/C2–C3 disk rupture → high mortality)

History

•  Hyperextension

•  Named due to judicial hangings in which knot is in front of pt & “height of drop” is at least as long as victim

Physical Findings

•  C2 tenderness, high-impact trauma, neurologic deficits

Evaluation

•  CT/CTA, MRI for ligamentous injury

Treatment

•  C-spine immobilization, spine consult for operative management

Disposition

•  Admit

Odontoid Fracture (C2 Dens)

Definition

•  Fracture through the dens w/ variable stability (see table)

History

•  Flexion injury

Physical Findings

•  C2 tenderness

Evaluation

•  CT scan, MRI for ligamentous injury

Treatment

•  C-spine immobilization, spine consult

Disposition

•  Likely admit

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