it’s a no brainer

It’s a no brainer By Christopher I’Anson

SJA Advanced Student DoctorTraining Officer Leeds LINKS (2012-13)

TopicsHead and neck injuries

C-spineConcussionCompression

Cerebrovascular accidents TIAsStrokes

Meningitis SeizuresExamination

H-testPupillary light reflexesPeripheral grip strength

AnatomyThe brain is enclosed in several layers

Meninges (brain covering) Contain blood vessels Cushion brain

Skull (hard rigid box unlike meninges)SkinCerebrospinal fluid

Fluid surrounding the brain Supports and cushions

AnatomyThere are 7 cervical vertebra

Each has a nerve exiting near it Each protects the spinal cordAids movement and support of head

Spinal Nerves C3,4,5 are importantSupply the diaphragm

Cause breathing “C3,4,5 keep the diaphragm alive!”

C-spine injuriesThe head is extremely heavy!

The neck support this weight It can be easily damaged as it is exposed and has a

heavy “bowling ball on top of it” (see DEMO)

C-spine injuriesClinical features:

Mid-line tendernessPain in neckNumbness or tingling in extremitiesPeripheral weakness or paralysisDeformity in the neck

Significant MOIGCS<15

C-spine injuriesAssessment:

Maintain immobilisation until you are happyFeel down the back of the neck for lumps or

bumpsAsk patient to wiggle toes and/ or squeeze

fingers

C-spine injuresManagement:

Manual In-line immobilisationCollar and board (if ETA)3 point immobilisation999

NICE guidelinesIndications for Spinal Immobilisation:

GCS <15Neck pain or tenderness“Focal neurological deficits” (weakness and

sensory changes in English)Numbness and tingling in extremitiesClinical suspicion (MOI, head injuries etc)

Head injuriesDoes not include minor face lacerations*Every year about 1.4 million people attend

A&E with one50% are children1,500 have severe brain damage5,000 die each year due to these

* Remain suspicious

Head injuriesCommon causes:

RTCFallsAssaultsSports/leisureWorkplaceOthers

Factors associated with serious injuries:•High-speed impact•Death of another in the same accident•Entrapment•Intrusion of vehicles •Ejection of the patient from the vehicle •Pedestrian or motorcyclist vs. Motor vehicle •Fall from >5m

Head injuriesEither:

Primary (direct local or diffuse injury) e.g Contra-coup

Secondary

Head injuries: ConcussionThis is where the brain shacks inside the

skullNot usually associated with long term

damageThis causes:

Nausea +/- vomitingHeadacheDizzinessDisorientation

Head injuries: ConcussionManagement:

ABCDE!Observations

Especially AVPU or GCS Give head injury advice card Advice to go to hospital NO MEDICATIONS!

Head injuries: Compression This is where the brain is compressed inside the skull

NB: the skull can not expand causing effects on the brain Can be fluid or blood

CF: Drowsiness or unconsciousness (inc history of LOC) Amnesia (retrograde and/or anterograde) Seizures N+V Posturing (decortate or decerebrate) Sensory disturbance (e.g. Vision) and weakness Headache Personality change May have deformity of Skull due to cause Blood or fluid (CSF) from the nose or ears (BSF)* Battle sign or racoon eyes

*?basal skull fracture

Head injuries: CompressionIt is difficult to diagnose this as you do not

have a CT scanner Use your clinical suspicions or if in doubt treat

as worst case!Management:

ABCDE!Immobilisation in unconscious or previous LOC

or BSF999Protect airwayNo pain killers

Cerebrovascular accident (CVA)This is a posh more PC way of taking about:

Strokes (where symptoms last for >24 hours)Transient ischaemic attacks (TIA) or “mini-

strokes” Symptoms last <24 hours

Clinically in the acute phase there is no difference

CVA: TIA and StrokesClinical Features:

FAST! Facial weakness Arm weakness (can not hold them up) Speech (is slurred) Time to call 999

CVAOther features

Unconsciousness or collapse (rare)Sensory disturbance (e.g. Vision)Generalised weakness

Legs unable to walk Arms unable to hold self up

MeningitisInflammation of the lining of the brainClinical Features:

Nausea and VomitingFeverMuscle ache or painAggression or drowsyComaSeizures?Rash

Meningitis Management:

999No medications!Manage symptoms as best as possible

SeizuresThese are the same as fitsThere are many types and causes (inc Epilepsy

and febrile convulsions) Management:

Remove dangerous/ harmful objectsDO NOT restrain the patientTIME the fit

If first fit or >5mins call 999Recovery position after the fit has subsided Cover the patient with a blanket in case the wet

themselves (DIGNITY)

ExaminationsAfter ABCDE

Not for people that need immobilisation!

Pupil response

H-test

Grip strength

ANY QUESTIONS!