repeat exam repeat exam

Figure 85-3. Head injuries diag nostic algorithm. CT, computed tomography; DC, discharge; GCS, Glasgow Coma

Scale; ICU, intensive care unit; TBI, traumatic brain injury.

rapid sequence intubation while following head trauma

precautions (see Chapter 1 1). Systemic hypotension can

significantly impair adequate cerebral perfusion, and

patients require aggressive volume resuscitation to maintain

a MAP >90 mmHg and suitable CPP. Address any uncontrolled scalp hemorrhage, as blood loss can be significant.

Patients with evidence of increased ICP and impending

herniation require immediate medical intervention pending

definitive neurosurgical care. Mild hyperventilation to a

goal PaC02 between 30 and 35 mmHg can temporarily

reduce the ICP by decreasing cerebral blood flow.

Hyperosmotic agents such as IV mannitol (0.25-2 g/kg) can

reduce intracerebral edema and thereby decrease the ICP.

Elevating the head of the bed to 30 degrees can reduce the

ICP by simple gravity. All of these interventions should be

considered temporizing measures while awaiting operative

decompression or bedside extraventricular drain placement.

Posttraumatic seizures can be devastating, as they significantly exacerbate secondary brain injury. Antiepileptic

drug loading (eg, phenytoin 18 mg/kg) should be pursued

in all patients without known contraindications. Treat

patients who are actively seizing with aggressive doses of IV

benzodiazepines (eg, lorazepam 0.05 mg/kg) until their

convulsions are controlled.

Patients with traumatic SAH are at an elevated risk of

ischemic complications secondary to cerebral vasospasm.

The careful use of peripheral arteriolar vasodilators ( eg,

nimodipine 60 mg orally) may limit this phenomenon in

hemodynamically stable patients, although recent data

suggests minimal utility at best. Finally, patients with

fractures that either involve a maxillofacial sinus or are

open to the environment warrant antibiotic prophylaxis to

limit secondary infection and tetanus vaccination. Those

with skull fractures whose margins are depressed beyond

the inner table of the adjacent skull warrant neurosurgical

consultation for operative elevation.

DISPOSITION

..... Admission

Admit all patients with severe TBI ( GCS :=;s) or documented injury on CT imaging to an intensive care unit

setting with neurosurgical consultation, as they will require

continuous ICP monitoring. Patients with a persistent

GCS < 1 5, evidence of basilar skull fracture, open or

depressed fractures, and those with linear fractures that

cross an arterial groove or dural sinus require admission

for observation and serial neurologic exams.

..... Discharge

Low-risk patients with a normal GCS and neurologic exam

can be safely discharged from the ED. If a CT scan was not

indicated at the time of the initial visit, discharge the

patient with instructions to return for any changes in mental status, vomiting, or worsening headaches. Ideally, a

responsible adult will be present to monitor the patient at

home over the next 24 hours. If a CT scan is performed

HEAD I NJURI ES

and is negative, it is unlikely the patient will require any

neurosurgical intervention in the future. These patients

can also be discharged assuming normal GCS and neurologic exam. They should receive similar head injury pre ­

cautions.

Patients diagnosed with a concussion should avoid

any contact sports until all symptoms have completely

resolved and they have been cleared by a trained physician.

Postconcussive syndromes including headaches and problems concentrating or sleeping are fairly common and may

persist for several weeks to months after the injury.

SUGGESTED READING

Guidelines for the management of severe traumatic brain injury.

J Neurotrauma. 2007;24(suppl l ):S l.

Jagoda AS, Bazarian JJ, Bruns JJ, et al. Clinical policy: neuroimaging and decision making in adult mild brain injury in the

acute setting. Ann Emerg Med. 20080;52:714.

Nigrovic LE, Lee LK, Hoyle J, et al. Prevalence of clinically

important traumatic brain injuries in children with minor

blunt head trauma and isolated severe injury mechanisms.

Arch Pediatr Adolesc Med. 2012;1 66:356-361.

Wright DW, Merk LH. Head trauma in adults and children. In:

Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka RK,

Meckler GD. Tintinalli's Emergency Medicine: A Comprehensive

Study Guide. 7th Ed. New York, NY: McGraw-Hill, 201 1.

Zink BJ. Traumatic brain injury outcome: Concepts for emer ­

gency care. Ann Emerg Med. 200 1 ;37:3 1 8-332.

Cervical S pine Inj u ries

E. Pa ul DeKoning, MD

Key Points

• Use the N EXUS criteria and/or Canadian C-Spine rules

to determine which patients req u ire rad iographic

imaging.

• Forego plain films and proceed directly to computed to ­

mography imaging of the cervica l spine for all patients

with a moderate to high risk of injury.

INTRODUCTION

There are currently more than 200,000 patients living with

spinal cord injury (SCI) in the United States, and between

12,000 and 20,000 new cases occur on an annual basis. The

majority of patients are between 16 and 30 years of age,

with motor vehicle collisions, falls, violence, and sporting

injuries accounting for the bulk of cases. Fewer than 1% of

patients experience complete neurologic recovery before

hospital discharge, and the associated economical, physical,

and emotional tolls are astronomical.

The cervical spine is composed of 7 cervical vertebrae,

the first 2 of which are unique, whereas the remaining 5

(C3 through C7) are functionally similar. The anatomy of

the axis (C1) is that of a bony ring without a true vertebral

body. It consists of an anterior and posterior arch joined

together by 2 lateral masses that articulate with the

occipital condyles above and C2 below. The Atlas ( C2) has

a unique anterior body that extends superiorly to form the

odontoid process. This structure articulates with the

internal surface of the anterior ring of C1 and is held in

place by the transverse ligament. The unique design of

these 2 vertebrae allow for the increased flexibility and

axial rotation of the upper cervical spine. The remaining

cervical vertebrae are functionally similar and composed

of an anterior body and a posterior arch.

• Consider spinal cord injury without radiologic abnormality in pediatric patients with neurologic findings despite

negative initial imaging.

• The use of high-dose corticosteroids to improve longterm neurologic outcomes in patients with blunt spinal

cord injury is no longer recommended.

The vertebrae are separated by flexible intervertebral

disks and linked together by an intricate system of ligaments

that allows the spine to function as a single unit. Anterior

and posterior longitudinal ligaments run along the entire

length of the vertebral bodies, whereas the posterior rings

are linked together by the ligamentum flavum and

interspinous ligaments (Figure 86-1). This network enables

significant spinal column mobility while still providing

adequate spinal cord protection as it courses within the

spinal canal between the body and arch of each vertebra.

External forces that exceed the normal physiologic range of

motion can result in fractures, dislocations, and spinal cord

injuries. Children and the elderly are especially prone to

injury of the upper cervical spine ( C1 through C3 ), whereas

young and middle-aged adults are more likely to injure the

lower cervical spine (C6 through Tl). Of the cervical

vertebrae, the atlas (C2) is the most frequently fractured.

Delineating between stable and unstable injury is of

supreme clinical importance. The Denis 3-colurnn theory

is very helpful in this regard and divides the spine into 3

functional units. The anterior column is composed of the

anterior portions of the vertebral body and annulus

fibrosis together with the anterior longitudinal ligament.

The middle column includes the posterior vertebral body,

the posterior annulus fibrosis, and the posterior longitudinal ligament. The posterior column is composed of the

368

CERVICAL SPINE I NJURI ES

interspinous

ligament

posterior longit.udinal

l igament

• Figure 86-1 . Bony and ligamentous anatomy of the

spine. Reprinted with permission from Tintina lli JE,

Ke len GD, Stapczynski JS. Tintinolli's Emergency

Medicine: A Comprehensive Study Guide. 6th ed. New

York: McGraw-Hill, 2004.

posterior vertebral arch and the posterior ligamentous

complex including the ligamentum flavum and the

interspinous and supraspinous ligaments. Injuries to �2 of

the columns are considered functionally unstable. In

addition, acute compression fractures involving >25% of

the height of the vertebral bodies of C3-C7 are considered

clinically unstable.

Cervical spine fractures can be further classified by their

mechanism of injury (Table 86- 1). Flexion injuries

compress the anterior column and distract the posterior

column, resulting in anterior body fractures and disruption

of the posterior ligamentous complex. Specific examples

include anterior subluxations, bilateral facet dislocations,

simple wedge fractures, spinous process avulsions (clay

shoveler's fracture), and flexion teardrop fractures. A concurrent rotational mechanism results in unilateral facet

dislocations. Simple wedge fractures, spinous process

avulsions, and unilateral facet dislocations are generally

considered stable, whereas the remainder represent unstable

injuries.

Extension injuries compress the posterior column

and distract the anterior column, resulting in crush

injuries to the posterior elements and disruption of

the anterior longitudinal ligament. Specific examples

include extension teardrop fractures, hangman's fractures

(traumatic spondylolisthesis of C2), laminar fractures, and

hyperextension dislocations. With the exception of simple

laminar fractures, these injuries are generally unstable.