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It’s a no brainer

It’s a no brainer . By Christopher I’Anson SJA Advanced Student Doctor Training Officer Leeds LINKS (2012-13) . Topics. Head and neck injuries C-spine Concussion Compression Cerebrovascular accidents TIAs Strokes Meningitis Seizures Examination H-test Pupillary light reflexes

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It’s a no brainer

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  1. It’s a no brainer By Christopher I’Anson SJA Advanced Student Doctor Training Officer Leeds LINKS (2012-13)

  2. Topics • Head and neck injuries • C-spine • Concussion • Compression • Cerebrovascular accidents • TIAs • Strokes • Meningitis • Seizures • Examination • H-test • Pupillary light reflexes • Peripheral grip strength

  3. Anatomy • The brain is enclosed in several layers • Meninges (brain covering) • Contain blood vessels • Cushion brain • Skull (hard rigid box unlike meninges) • Skin • Cerebrospinal fluid • Fluid surrounding the brain • Supports and cushions

  4. Anatomy • There are 7 cervical vertebra • Each has a nerve exiting near it • Each protects the spinal cord • Aids movement and support of head • Spinal Nerves C3,4,5 are important • Supply the diaphragm • Cause breathing • “C3,4,5 keep the diaphragm alive!”

  5. C-spine injuries • The 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)

  6. C-spine injuries • Clinical features: • Mid-line tenderness • Pain in neck • Numbness or tingling in extremities • Peripheral weakness or paralysis • Deformity in the neck • Significant MOI • GCS<15

  7. C-spine injuries • Assessment: • Maintain immobilisation until you are happy • Feel down the back of the neck for lumps or bumps • Ask patient to wiggle toes and/ or squeeze fingers

  8. C-spine injures • Management: • Manual In-line immobilisation • Collar and board (if ETA) • 3 point immobilisation • 999

  9. NICE guidelines • Indications for Spinal Immobilisation: • GCS <15 • Neck pain or tenderness • “Focal neurological deficits” (weakness and sensory changes in English) • Numbness and tingling in extremities • Clinical suspicion (MOI, head injuries etc)

  10. Head injuries • Does not include minor face lacerations* • Every year about 1.4 million people attend A&E with one • 50% are children • 1,500 have severe brain damage • 5,000 die each year due to these * Remain suspicious

  11. Head injuries • Common causes: • RTC • Falls • Assaults • Sports/leisure • Workplace • Others • 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

  12. Head injuries • Either: • Primary (direct local or diffuse injury) • e.g Contra-coup • Secondary

  13. Head injuries: Concussion • This is where the brain shacks inside the skull • Not usually associated with long term damage • This causes: • Nausea +/- vomiting • Headache • Dizziness • Disorientation

  14. Head injuries: Concussion • Management: • ABCDE! • Observations • Especially AVPU or GCS • Give head injury advice card • Advice to go to hospital • NO MEDICATIONS!

  15. 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

  16. Head injuries: Compression • It 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 BSF • 999 • Protect airway • No pain killers

  17. 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

  18. CVA: TIA and Strokes • Clinical Features: • FAST! • Facial weakness • Arm weakness (can not hold them up) • Speech (is slurred) • Time to call 999

  19. CVA • Other features • Unconsciousness or collapse (rare) • Sensory disturbance (e.g. Vision) • Generalised weakness • Legs  unable to walk • Arms  unable to hold self up

  20. Meningitis • Inflammation of the lining of the brain • Clinical Features: • Nausea and Vomiting • Fever • Muscle ache or pain • Aggression or drowsy • Coma • Seizures • ?Rash

  21. Meningitis • Management: • 999 • No medications! • Manage symptoms as best as possible

  22. Seizures • These are the same as fits • There are many types and causes (inc Epilepsy and febrile convulsions) • Management: • Remove dangerous/ harmful objects • DO NOT restrain the patient • TIME the fit • If first fit or >5mins call 999 • Recovery position after the fit has subsided • Cover the patient with a blanket in case the wet themselves (DIGNITY)

  23. Examinations • After ABCDE • Not for people that need immobilisation! • Pupil response • H-test • Grip strength

  24. ANY QUESTIONS!

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