Head and Spinal Cord Trauma

Definition/Etiology:

Head and spinal cord trauma is just that, a traumatic injury. These can be caused by anything from falls to assaults, to motor vehicle collisions, to penetrating knife or gun injuries. The etiology of traumatic injuries goes on and on. If someone can smack their head against something, they risk injuring it.

Pathophysiology:

Any traumatic injury can cause severe damage to the underlying structures. Injuries to the skull will many times cause injury to the underlying brain. While external severity may not coincide with internal severity, the mechanism of injury can paint a pretty good picture.

Clinical Presentation:

When it comes to head injuries, we are going to discuss the skull. Brain injuries and ICP are discussed in other units in this series, which i encourage all of you to go check out.
With skull fractures, you can have linear, depressed, open or closed, and basilar skull fractures. Linear fractures are usually benign. Depressed skull fractures are very much not benign! The clinical symptoms in a depressed skull fx depend on the area that is affected. The most common sign of a worsening problem is a change in the LOC. There are also some signs to watch for with head trauma:

• Battle’s Sign: Bruising behind the ear that is indicative of a basilar skull fracture
• Racoon eyes: Also known as periorbital ecchymosis, is a sign of a severe skull injury
• Look for any other signs of bruising, bleeding or any other external injuries.

With spinal cord injuries, again, we have to do good neuro checks. We want to check motor and sensory function in all 4 extremities. It’s not enough just to ask if they can move a limb, we have to check their sensation as well. You can use a pin (if you can find one), or like I do, the tip of an angiocath.

Collaborative Management:

Need radiology on board. With head injuries, we are probably going to skip X-ray and head right to CT. Same goes with the suspected spinal cord trauma. We will probably do some lab work making sure to get that CBC (and maybe draw a type and cross here as well). If you notice CSF leaking from the ears or nose, DO NOT PACK THE AREA. If we have not received results from CT, try to avoid nasal intubation or NGT. (Let’s be real here, how many of us have ever seen a nasal intubation?)

Not a bad idea to read up on your cranial nerves. CEN always likes to throw a question about them on here. I can’t be specific but have a general idea what they do. You can always use one of the handy mnemonics to help. There are 2 I like. The popular one is On Old Olympus’s Towering Tops, A Finn and German Viewed Some Hops. Now that one is good by my favorite is, Only Owls Observe Them Traveling and Finding Voldemort Guarding Very Secret Horcruxes.

• Elevate the head of the bed 30 degrees. This does not require an order and can help facilitate venous drainage by gravity.

• Make sure to maintain oxygenation. CO2 retention and cerebral vasodilation can cause increased ICP and maintaining that O2 can help to minimize this.

• CEN likes to ask questions about C-spine injury locations and what they can affect. For example, Injuries between T4 and T12 can have bowel and bladder incontinence, paraplegia of the lower body and loss of motor function in the legs. T11-L2 can cause bowel and bladder retention, C3-C5 can cause respiratory paralysis. So, yea, keep in mind the type of injury and the location.

Evaluation | Patient Monitoring | Education:

LOC is most important. Continuous neuro checks for both head and spinal cord injuries are important. With head injuries, obviously a change in LOC will be visible. With the spinal cord, we have to do our motor and sensory checks to make sure there is no worsening of the injury. Also pay close attention to urine output with the SCI. If there is an injury above C5, always be wary of possible airway issues. We should also anticipate vomiting with any of these patients so have our suction ready to go.

Linchpins: (Key Points)

• LOC is KEY
• Location, location, location
• Continued repeated monitoring