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Toronto Notes 2019 Traumatology Mild Traumatic Brain Injury
Epidemiology
• TBIresultsin1.7milliondeaths,hospitalizations,andEDvisitseachyear(US)
• 75%areestimatedtobemildTBI;remainderaremoderateorsevere(seeNeurosurgery,NS31) • highestratesinchildren0-4yr,adolescents15-19yr,andelderly>65yr
Clinical Features
• somatic:headache,sleepdisturbance,N/V,blurredvision
• cognitivedysfunction:attentionalimpairment,reducedprocessingspeed,drowsiness,amnesia • emotionandbehaviour:impulsivity,irritability,depression
• severeconcussion:mayprecipitateseizure,bradycardia,hypotension,sluggishpupils
Etiology
• falls,MVC,struckbyanobject,assault,sports
Investigations
• neurologicalexam
• concussionrecognitiontool(seethinkfirst.ca)
• imaging–CTasperCanadianCTHeadRules,orMRIifworseningsymptomsdespitenormalCT
Treatment
• closeobservationandfollow-up;forpatientsatriskofintracranialcomplications,giveappropriate discharge instructions to patient and family; watch for changes to clinical features above, and if change, return to ED
• hospitalizationwithnormalCT(GCS<15,seizures,bleedingdiathesis),orwithabnormalCT
• earlyrehabilitationtomaximizeoutcomes
• pharmacologicalmanagementofpain,depression,headache
• follow Return to Play guidelines
Prognosis
• mostrecoverwithminimaltreatment
■ athletes with previous concussion are at increased risk of cumulative brain injury
• repeatTBIcanleadtolife-threateningcerebraledemaorpermanentimpairment
Spine and Spinal Cord Trauma
• assumecordinjurywithsignificantfalls(>12ft),decelerationinjuries,blunttraumatohead,neck,or back
• spinalimmobilization(cervicalcollar,spineboardduringpatienttransportonly)mustbemaintained until spinal injury has been ruled out (see Figure 3)
• vertebralinjuriesmaybepresentwithoutspinalcordinjury;normalneurologicexamdoesnotexclude spinal injury
• cordmaybeinjureddespitenormalC-spinex-ray(spinalcordinjurywithoutradiologicabnormality)
• injuriescaninclude:complete/incompletetransection,cordedema,spinalshock
History
• mechanismofinjury,previousdeficits,SAMPLE • neckpain,paralysis/weakness,paresthesia
Physical Exam
• ABCs
• abdominal: ecchymosis, tenderness
• neurological: complete exam, including mental status
• spine: maintain neutral position, palpate C-spine; log roll, then palpate T-spine and L-spine, assess
rectal tone
■ when palpating, assess for tenderness, muscle spasm, bony deformities, step-off, and spinous
process malalignment
• extremities: check capillary refill, suspect thoracolumbar injury with calcaneal fractures
Investigations
• bloodwork:CBC,electrolytes,Cr,glucose,coagulationprofile,crossandtype,toxicologyscreen • imaging
■ full C-spine x-ray series for trauma (AP, lateral, odontoid) • thoracolumbarx-rays
■ AP and lateral views
Emergency Medicine ER9
Extent of retrograde amnesia correlates with severity of injury
Every Patient with One or More of the Following Signs or Symptoms should be Placed in a C-Spine Collar
• Midline tenderness
• Neurological symptoms or signs • Significant distracting injuries
• HI
• Intoxication
• Dangerous mechanism • History of altered LOC
Of the investigations, the lateral C-spine x-ray is the single most important film; 95% of radiologically visible abnormalities are found on this film
Cauda Equina Syndrome can occur with
any spinal cord injury below T10 vertebrae. Look for incontinence, anterior thigh pain, quadriceps weakness, abnormal sacral sensation, decreased rectal tone, and variable reflexes
The Canadian C-Spine Rule vs. the NEXUS Low- Risk Criteria in Patients with Trauma
NEJM 2003;349:2510-18
Purpose: To compare the clinical performance of the Canadian C-Spine Rule (CCR) and the National Emergency X-Radiography Utilization Study (NEXUS) Low-Risk Criteria (NLC).
Study: Trauma patients (n=8,283) in stable condition were prospectively evaluated by both the CCR and NLC by 394 physicians before radiography. 2% of these patients had a C-spine injury.
Results: Compared to the NLC, the CCR was
more sensitive (99.4 vs. 90.7%) and more specific (45.1 vs. 36.8%) after exclusion of indeterminate cases. The number of missed patients would be
1 for the CCR and 16 for the NLC. The ROM was not evaluated in some CCR cases likely because physicians were not comfortable with the procedure and this may slightly lower the sensitivity or specificity of the CCR in practice.
Summary: The CCR is superior to the NLC in alert and stable patients with trauma. The use of the CCR can result in lower radiography rates.