Trauma | The Massachusetts General Hospital Handbook of Neurology

Authors: Flaherty, Alice W.; Rost, Natalia S.

Title: Massachusetts General Hospital Handbook of Neurology, The, 2nd Edition

> Table of Contents > Adult Neurology > Trauma

Trauma

A. Indications for head CT

Focal deficit, anticoagulation, significant LOC, drug intoxication. Usually do not need (but highly recommended) to get a CT in pts with very brief LOC and no focal neurological signs.

B. Exam

Note exact time of exam and amount and time of last sedation.

1. General: Vital signs and pattern of respiration. Palpate head for skull fractures, facial fractures. Look for lacerations, raccoon eyes, battle sign (bruise behind ear). Fundi (papilledema, hemorrhage, retinal detachment). Blood in nose/ears; CSF leak (q.v., p. 20). Listen for bruits over eyes, carotids. Look for evidence of spine trauma.
2. Neuro:
- a. Quick: Assess alertness; coma exam (see p. 30), cerebellar exam if cooperative.
3. R/o spine injury:
- a. Rectal: Including anal wink and bulbocavernosus.
- b. Sensory: Pinprick all four limbs and trunk; touch major dermatomes C4, C6-8, T4, T6, T10, L2, L4-S2. Vibration and proprioception for posterior columns.
- c. Motor: In more detail than just noting moving all extremities.

C. Types of head injury

see p. 182 for CT appearance of head trauma.

1. Concussion: Any altered consciousness after minor head injury, including confusion, N/V, dizziness. LOC is not required.

a. Hx: Cause of injury, h/o previous concussions.
b. PE: Orientation, attention, memory, CN, coordination, sensation. Symptoms should not be present even after significant exertion, e.g., sprinting 40 meters.
c. Complications:
- 1) Postconcussive syndrome: Weeks to months of fatigue, HA, attention. Try nortriptyline, load to 75 mg qhs.
- 2) Cerebral edema: Head reinjury before complete symptom resolution can cause life-threatening cerebral swelling. Concussion grade, determined by presence of LOC and length of other symptoms, predicts risk of returning to contact sports:

P.120

Table 33. Contact sport restrictions after concussion.

Concussion	Symptom	Time Until Contact Sports Safe
Grade	Length	1st Concussion?	>1 Concussion?
1	<15 min, no LOC	That day	1 wk
2	>15 min, no LOC	1 wk	2 wk
3	LOC <1 min	1 wk	>4 wk
3	LOC >1 min	2 wk	>4 wk

2. Contusion: Gray matter injury after head trauma.
3. Diffuse axonal injury: AKA shear injury. Seen especially after deceleration injury.
4. Contrecoup injury: Seen when the brain is thrust against the skull opposite from the primary blow.
5. Skull fracture: May not be visible on head CT for several days.
6. Intracranial hemorrhage: Q.v., p. 61.
7. Dissection of carotid or vertebral artery.

D. Rx

Consider neurosurgery consult.

1. Spinal cord trauma:
- a. Methylprednisolone: Must be given within 8 h of injury. 30 mg/kg initial IV bolus over 15 min; then wait 45 min, then 5.4 mg/kg/h for 23 h.
- b. Blood pressure and temperature control: May be very labile.
- c. Nasogastric tube: For paralytic ileus.
- d. Bladder catheter: To avoid bladder distension.
2. Head trauma:
- a. Indications for seizure prophylaxis: Intracranial blood, Glasgow Coma Scale <10, significant alcohol history. Give ACD 1 wk. If pt. needs craniotomy, give 3-6 mo (may discontinue at 3 mo if no h/o seizure).
- b. Indications for mannitol: Evidence of herniation (e.g., dilated pupils) or local mass effect (e.g., hemiparesis) or sudden deterioration. Hypotension is a relative contraindication.
- c. Indications for intubation: Glasgow Coma Scale (GCS) <7, inability to protect airway (e.g., from maxillofacial trauma or when heavy secretions), recurrent seizures, high ICP.
- d. Admission orders for moderate head injury: GCS 9-13.
  - 1) Neuro checks: q 1-2 h.
  - 2) Activity: HOB up 30-45 degrees.
  - 3) Diet: NPO until alert or no risk of surgery; then clear liquids. NS + 20 mEq KCl/L at 75 cc/h.
  - 4) Meds: Mild analgesics and antiemetics. Have naltrexone handy. Avoid phenothiazines, which lower seizure threshold.