SPINE AND HEAD TRAUMA
| SPINE TRAUMA —Kenneth C. Jackimczyk, MD, Attending Physician, Department of Emergency Medicine, Maricopa
Medical Center, Phoenix
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| Introduction: when is prehospital immobilization necessary? which emergency department (ED) patients need cervical
spine films? are there other imaging studies besides plain films that are useful?
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| Spine immobilization: 5 million immobilized patients annually; costs ≈$15/patient ($75 million annually), added
time at scene, patient discomfort (100% uncomfortable after 30 min); majority of immobilizations not helpful; direct
and indirect costs of finding abnormal film in nontender patient; one study showed patients who were not immobilized
had slightly better outcomes
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 | Fresno algorithm: 5-yr retrospective study; immobilized only those patients with pain or tenderness, multiple system
trauma, head/facial trauma, extremity numbness, loss of consciousness, or altered mental status; of 500 patients
with spinal injury, 3 missed; concluded selective immobilization may be safely applied in prehospital setting; mechanism
of injury not considered
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| Domeier criteria: used altered mental status, neurologic deficit, spinal pain or tenderness, intoxication, and extremity
fracture to determine need for immobilization; enrolled ≈9000 patients, almost 300 of whom had spinal injuries; of
15 injuries missed, only 2 unstable
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| Conclusion: research going forward with protocols and looking at objective criteria for immobilization
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| National Emergency X-Radiography Utilization Study (NEXUS): criteria for low probability for injury—no midline
cervical tenderness; no focal neurologic deficit; normal alertness; no intoxication; no painful distracting injuries;
mechanism of injury not included in criteria; study—34,000 patients; 800 had spinal cord injury; missed 8
fractures, of which 2 clinically significant (one patient treated with soft collar, one had transient loss of consciousness
and paraspinous muscle tenderness [probably failure to apply rules correctly]); NEXUS—very sensitive;
avoids ≈1 in 8 radiographs; speaker uses criteria to justify not getting x-rays in patients who do not need them
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| Canadian cervical spine rules: 10 Canadian centers involved in study; 20 criteria; 9000 patients enrolled; clinically
cleared one third; 151 patients had injuries
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| High risk: older patients; dangerous mechanism; paresthesias in extremities; obtain films on these patients
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| Low risk: do not need films
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| Moderate risk: obtain films in patients who do not fall under high or low risk; range neck side to side to check for
neck tenderness
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| Conclusion: more difficult to remember than NEXUS criteria but more sensitive and specific and have better inter-
rater reliability
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| Key point: whichever rules used, must know them well
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| Three-view cervical series: review of NEXUS data shows about one third of 3-view plain films inadequate when patients
had cervical fractures
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| Flexion-extension films: traditionally used in patients who have neck tenderness despite normal appearance on 3 views;
problem with getting adequate films in patients experiencing neck tenderness; number of studies show no neurologic
sequelae from neck movement; one third of films inconclusive; significant minority of films inadequate
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| Computed tomography (CT): moving up on algorithm; best for bone; shows more than plain films
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| Indications: patients with normal plain films who are in severe pain; abnormal neurologic examination; inadequate
visualization; abnormal plain films; obtunded patients
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| Reasons for screening CT: high-velocity accident; distracting injuries; patient >50 yr of age; efficiency (if head CT
indicated, request neck CT at same time)
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| Magnetic resonance imaging (MRI): good for soft tissues and ligaments; starting to be used for grading injuries; indicated
for patients with neurologic findings or persistent neck pain on follow-up
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| Steroids: many criticisms of National Acute Spinal Cord Injury Studies (NASCIS), eg, question whether “significant
improvements” clinically relevant, placebo subgroups dissimilar; did not focus on preplanned primary outcome measures;
difficult to prove results because placebo-controlled studies no longer allowed in United States; speaker passes
decision on steroid use to consultant
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| Trends: less immobilization in field; physicians becoming more selective in ordering cervical spine films; CT use increasing
(must consider benefits and risks; one CT gives same radiation as 350 chest x-rays); use of MRI gradually increasing;
use of methylprednisolone gradually decreasing
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| PEDIATRIC HEAD TRAUMA —Jeffrey R. Avner, MD, Professor of Clinical Pediatrics, Albert Einstein College of
Medicine, and Chief, Children’s Emergency Service, Children’s Hospital at Montefiore, Bronx, New York
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| Pathophysiology of head injury: primary injury—happens at scene and can cause brain damage directly; can lead
to reactive lesions in central nervous system (CNS), eg, cerebral swelling, autoregulatory dysfunction in brain that can
cause secondary injury that may result in brain damage; severe systemic injury (eg, bleeding, hypotension) can also
cause secondary injury leading to brain damage; prevention of secondary injury goal of emergency management
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| Case 1: 8-yr-old boy unrestrained front seat passenger in motor vehicle accident (car hit light post); child’s head struck
windshield; windshield intact; child dizzy but oriented at scene; pulse 110 beats/min, respiratory rate 24 breaths/min,
blood pressure (BP) 110/70 mm Hg; 30 min after event, child presents to ED oriented times 3, Glasgow Coma Scale
(GCS) score 13; has bruise to upper forehead and no other obvious injuries; neurologic examination nonfocal
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| Discussion: simple bruise to head can involve number of forces to brain, eg, rotational, shearing, pressure
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| Low-risk injuries: most common; patients commonly present completely asymptomatic or have mild headache, may
have vomited once or twice, dizzy at scene but now resolved, normal neurologic examination; vomiting normal mechanism
in young children, even after minor head trauma, as long as it is not progressive and takes place within 6 hr of injury;
can discharge if patient does not decompensate after 2 to 3 hr of observation in ED
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| Moderate-risk injuries: not uncommon in pediatrics; have history of loss of consciousness (difficult to get accurate
duration); progressive headache; vomiting >6 hr after injury; seizures; amnesia; severe associated injuries; drug or alcohol
intoxication; suspected child abuse; evidence of basal skull fracture; observe for 4 to 6 hr; obtain CT if available; consider
neurosurgical consultation; consider admission, depending on nature of injury and ability of parents to follow
patient at home
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| High-risk injuries: depressed level of consciousness; penetrating injury; depressed skull fracture; focal neurologic
examination; positional tachycardia; obtain immediate neurosurgical consultation
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| Initial management: secure airway; immobilize cervical spine; breathing; circulation; disability (check pupils and perform
quick neurologic examination); exposure
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| Case 1 progression: categorized as moderate-risk injury; intravenous (IV) access established and O2 placed; child
sent to CT; upon return to ED, child disoriented, became lethargic; developed irregular respirations; pulse oximetry
dropped to low 90s; heart rate fell from 112 bpm to 80 bpm; blood pressure rising; GCS score <8 (sign of intracranial
hypertension); neurologic examination otherwise nonfocal; edema seen on CT
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| Pathophysiology of case 1
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| Intracerebral buffering system: intracranial vault consists of ≈80% brain, ≈10% blood, ≈10% cerebrospinal fluid (CSF);
as brain swells, buffering of blood and CSF exhausted, resulting in dramatic rise in pressure
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| Cerebral perfusion pressure (CPP): comprised of mean arterial pressure (MAP) minus intracranial pressure (ICP); in
normal brain, cerebral blood flow constant at normal MAP; CPP should be >50 mm Hg
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| Emergency management of increased ICP: place head in neutral position; elevate head of bed to 30°; use euvolemic
dehydration; hyperventilate; goal to maintain MAP between 65 and 70 mm Hg
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| How hyperventilation works: produces hypocapnia, causing constriction of carotids, which reduces ICP by reducing cerebral
blood flow; good for initial management (≈2 hr) because it slows expansion of bleeding and buys time to get child to
neurologic evaluation and possible neurosurgical intervention
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| Intubation: indications include intracranial hypertension, abnormal respiratory rate or pattern, loss of protective airway
reflexes, respiratory muscle dysfunction, or chest wall dysfunction; speaker uses MSOAP, ie, monitor, suction,
oxygen, airway equipment, pharmacy (drugs and personnel); apply suction via nasogastric (NG) tube, preoxygenate
with 100% O2 , apply cricoid pressure, give rapid infusion of sedative and muscle relaxant; make sure patient in full
relaxation before performing laryngoscopy and intubation; use vagolytic (depending on physician style and age of
patient), then use sedative (eg, thiopental or fentanyl), followed by full muscle relaxation (eg, vecuronium 0.2 mg/
kg); lidocaine controversial
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| Managing ICP: many options, most not very effective; mannitol not helpful routinely (causes electrolyte problems, especially
in children); steroids no longer used acutely; barbiturate coma should be reserved for intensive care unit
(ICU); many complications with hypothermia
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| Case conclusion: child had diffuse axonal injury; typical sites of injury include internal capsule, cerebellar peduncle,
and brainstem; perform serial examinations and get child to ICU as soon as possible
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| Case 2: 16-yr-old hockey player checked into boards, hit his head and fell to ground; probable loss of consciousness for
about 1 min; dizzy on awakening, groggy for 10 to 15 min; vomited 3 times shortly after event; in ED 6 hr later, patient
awake, alert, feels fine, and has normal vital signs on examination; no memory of incident; no vomiting within
last 2 hr
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| Indications for CT: penetrating injury; signs of intracranial hypertension; GCS score ≤13; GCS score of 15 with signs
of depressed skull fracture, prolonged (≥5 min) loss of consciousness, distracting injury, short loss of consciousness with
contact seizure
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| Concussion: common injury in children; immediate transient interruption of normal neurologic function (loss of consciousness
means patient had concussion but loss of consciousness not required for concussion); disturbance of vigilance
and heightened distractibility or inability to maintain coherent stream of thought, or inability to carry out
sequence of goal-directed movements; can be graded into categories 1, 2, and 3; recommended that player’s season
over by third concussion
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| Case 3: 9-mo-old child fell off changing table this morning; cried immediately; seemed fine after event; seen by regular
physician 4 hr after event; physical examination normal; child diagnosed with minor head trauma and sent home; 8 hr
after event, child presents to ED crying, irritable, not acting right, tachycardic; has swelling of right parietotemporal
scalp; neurologic examination otherwise nonfocal
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| Epidural hematoma: 4% of children evaluated with CT have epidural hematoma; skull films can show fracture but often
normal (rarely performed now); usually due to interruption of middle meningeal artery; generally presents in 3
ways
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| Classic presentation (“talk and die”): patient has loss of consciousness, followed by lucid interval, followed by lapse
into coma; occurs in 33% of cases; trauma results in concussion and loss of consciousness; patient sustains tear in
middle meningeal artery; child awakens; middle meningeal artery goes into spasm (child can look fine at this point);
spasm stops, blood starts pouring into epidural space, causing compression; surgical emergency (good outcome if
skull decompressed in timely fashion)
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| Loss of consciousness from scene: 33% of cases
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| No loss of consciousness: 33% of cases
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| Subdural hematoma: worse than epidural hematoma because mechanism worse; usually associated with underlying
brain injury; high morbidity and mortality, especially in young children; consider child abuse
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| Case 4: 10-mo-old child presents with boggy right parietal swelling that mother noted this morning; child has been acting
normally; no known recent trauma, except child fell out of stroller 3 days ago, cried, then seemed fine
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| Discussion: boggy scalp mass is subgaleal hematoma overlying linear simple skull fracture
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| Linear skull fracture: accounts for 90% of skull fractures; subgaleal hematoma may occur immediately but often
delayed 3 to 5 days after injury; at speaker’s institution, patients sent for CT to document simple skull fracture; can occur
from minor event; no therapy required
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| Depressed skull fracture: feels like dented ping-pong ball; often associated with dural or cortical laceration; some
underlying brain injury; depth of depression determines need for surgical intervention
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Educational Objectives
| The goal of this program is to educate the listener about spine and head trauma. After hearing and assimilating this program,
the clinician will be better able to:
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| 1. Name and describe 2 prominent algorithms for spine immobilization.
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| 2. Describe and explain the National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian
cervical spine rules for obtaining plain films in patients with suspected spine injuries.
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| 3. Discuss the current status of the use of steroids in spinal injury.
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| 4. Describe low-, moderate-, and high-risk pediatric head trauma.
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| 5. Explain the management of increased intracranial pressure (ICP) in the pediatric patient.
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Discussed on This Program
Fentanyl citrate [Sublimaze]
Lidocaine HCl (many trade names)
Mannitol [Osmitrol, Resectisol]
Methylprednisolone [Medrol]
Thiopental sodium [Pentothal]
Vecuronium bromide [Norcuron]
Programs of Related Interest
Bernstein RM, Bernstein SM: Back problems. Audio-Digest Pediatrics 52:03(Feb 7), 2006; Bovis GK et al:
Spinal trauma. Audio-Digest Orthopaedics 29:01(Jan 1), 2006; Congeni JA: Sports injuries. Audio-Digest Pediatrics
51:14(Jul 21), 2005; Herbert M: Head trauma. Audio-Digest Emergency Medicine 21:05(Mar 7), 2004.
To Order, Contact Subscriber Service (1-800-423-2308)
Suggested Reading
Barry TB et al: Clinical decision rules and cervical spine injury in an elderly patient: a word of caution. J Emerg Med
29:433, 2005; Biasca N et al: Review of typical ice hockey injuries. Survey of the North American NHL and Hockey
Canada versus European leagues. Unfallchirurg 98:283, 1995; Brown LH et al: Can EMS providers adequately assess
trauma patients for cervical spinal injury? Prehosp Emerg Care 2:33, 1998; Cervical spine immobilization before
admission to the hospital. Neurosurgery 50:S7, 2002; Coleman WP et al: A critical appraisal of the reporting of the
National Acute Spinal Cord Injury Studies (II and III) of methylprednisolone in acute spinal cord injury. J Spinal Disord
13:185, 2000; Dias MS: Traumatic brain and spinal cord injury. Pediatr Clin North Am 51:271, 2004; Dickinson G
et al: Retrospective application of the NEXUS low-risk criteria for cervical spine radiography in Canadian emergency
departments. Ann Emerg Med 43:507, 2004; Genuardi FJ et al: Inappropriate discharge instructions for youth athletes
hospitalized for concussion. Pediatrics 95:216, 1995; Hauswald M et al: Confusing extrication with immobilization:
the inappropriate use of hard spine boards for interhospital transfers. Air Med J 19:126, 2000; Hauswald M et
al: Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med 5:214, 1998; Knopp R:
Comparing NEXUS and Canadian C-Spine decision rules for determining the need for cervical spine radiography. Ann
Emerg Med 43:518, 2004; Nesathurai S: Steroids and spinal cord injury: revisiting the NASCIS 2 and NASCIS 3 trials.
J Trauma 45:1088, 1998; Russ SA et al: Patterns and risks in spinal trauma: the emergency transport perspective.
Arch Dis Child 90:985, 2005; Stiell IG et al: The Canadian C-spine rule versus the NEXUS low-risk criteria in patients
with trauma. N Engl J Med 349:2510, 2003; Viccellio P et al: A prospective multicenter study of cervical spine
injury in children. Pediatrics 108:E20, 2001.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty
reported no conflict.
Dr. Jackimczyk was recorded in Scottsdale, Arizona, on April 19, 2005, at Emergency Medicine 2005: Moving Forward,
sponsored by Mayo Clinic College of Medicine at Scottsdale; Dr. Avner, in Lake Buena Vista, Florida, on March
31, 2005, at Pediatric Emergency Medicine 2005: Advances and Controversies for the Clinician, sponsored by The
Nemours Children’s Clinic. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in
the production of this program.
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