Chapter 4: Head, Neurologic, Orthopaedic and Spinal Trauma
Learning objectives for this chapter
By the end of this chapter, we would like you:
-To explain how to rapidly and accurately assess a variety of traumatic head and neurologic injuries, orthopaedic injuries and spinal injuries in the emergency care setting.
-To describe the common mechanisms of injury and presentation of traumatic head and neurologic injuries, orthopaedic injuries and spinal injuries in the emergency care setting.
-To explain how to effectively manage a variety of traumatic head and neurologic injuries, orthopaedic injuries and spinal injuries in the emergency care setting.
Head and neurologic trauma
In patients with head trauma in emergency care settings, missed injuries - including secondary neurologic injuries - are common. This is because the complications of neurologic injuries often develop slowly, sometimes hours or even days after the initial trauma was sustained, and with subtle and non-specific signs. Therefore, patients who present to an emergency care setting after having sustained head trauma must undergo careful, repeated neurological assessment. In emergency care settings, there are two fundamental goals for neurological assessment: (1) to identify any obvious signs of head trauma and underlying neurological injury, and (2) to provide baseline data which can be used to identify a developing neurological injury.
Generally, the neurological assessment of a patient with suspected or actual head trauma will include:
- An assessment of level of consciousness (LOC). Assessment tools such as the Glasgow Coma Scale (GCS) assess the functioning of a patient's central nervous system via their response to verbal and / or painful stimuli. When assessing a patient's level of consciousness using a tool such as the GCS, it is important to remember that substance intoxication can result in an inaccurate score.
- An assessment of pupillary size, equality and reactivity to light, using a pen-torch. Problems with pupillary size, equality and reactivity are often the first signs of increased intracranial pressure (ICP) due to, for example, an intracranial haemorrhage or oedema of the soft tissues of the brain. Increased ICP is a common and significant problem for patients who have experienced a traumatic head injury.
- An assessment of the cranial nerves (CN). These nerves exit the spinal cord around the area of the brainstem, and assessment of their function can provide important information about the functioning of the brainstem. The CNs are rapidly assessed by asking a patient to follow a finger through six directions; disconjugate gaze (deviation of one eye) and ptosis (drooping of the eyelid/s) are common signs of neurologic injury which may be identified during rapid CN assessment.
- An assessment of motor symmetry and strength. For example, a nurse may ask a patient to squeeze their hands or raise their legs off the bed; simultaneous assessment of both sides of the patient's body, where possible, is important. The nurse should be aware of abnormal posturing - particularly flexion and extension, both of which indicate a serious hypoxic brain injury.
- Assessment of the vital signs. Signs of a serious brain injury include hypertension, cardiac dysrhythmia, and hyperthermia. A patient with a severe late brain injury, where there is significant pressure on the brainstem, will often demonstrate signs known as 'Cushing's triad': (1) hypertension, (2) widening pulse pressure, and (3) bradycardia.
- A computed tomography (CT) scan of the head. A CT scan produces a series of X-ray images, which are combined to build a detailed picture of the bones, blood vessels and soft tissue structures - and any damage to them.
During assessment, a nurse may identify one or more of a variety of injuries related to head and neurologic trauma. The most common injuries, and their management in the emergency care setting, are described following:
- Skull fractures - these may be linear, or depressed. Linear skull fractures usually only require supportive care, however depressed skull fractures often require surgical repair, including plating.
- Contusion - this term may be used to describe a bruise on the scalp or on the surface of the brain. When acceleration-deceleration forces are involved in the injury, two contusions on the surface of the brain may result. Most contusions only require supportive care; however, severe contusions may require surgical evacuation, and the removal of a flap of bone to relieve ICP whilst the brain issue heals.
- Subdural or epidural haematoma - this describes bleeding beneath or between the skull and one of the layers of the tissue surrounding the brain. Small haematomas usually only require supportive care, though larger ones may require surgical evacuation.
- Concussion - this is a mild traumatic brain injury that involves a loss of consciousness with associated disruptions to neurological functioning. Care for a patient who has experienced a concussion involves regular observation to identify more serious brain injury, and symptomatic management.
- Diffuse axonal injury (DAI) - this is a severe traumatic brain injury that results in shearing of axons. The management of a patient with DAI involves supportive care; however, the prognosis is often poor, with patients rarely returning to their full pre-injury neurologic function.
Patients presenting with a severe traumatic head injury are at significant risk of increased ICP. Remember: the skull is a closed box with a defined volume, comprising brain tissue, blood and cerebrospinal fluid. Injuries or medical conditions which result in cerebral oedema and increases in cerebral blood flow in particular can result in increases in ICP. Patients with ICP will present with a decreased LOC, changes in vital signs, pupillary dilatation, decreases in motor function, a severe headache and / or nausea / vomiting. Where ICP is very high, pressure on the brainstem may result in 'brain death', where brain function completely and irreversibly ceases. The management of increased ICP involves managing its underlying cause, as described above; medication and surgical therapy may also be used.
When providing care to a person with injuries resulting from head and / or neurological trauma, there are a number of key points to consider. It is important to focus on treating the greatest threat to life first. Additionally, the patient's pain should be effectively managed using small but frequent doses of intravenous opioid; pain can contribute to an increase in intracranial pressure and, as you have seen, this is a common and potentially severe problem associated with a range of traumatic injuries to the head and brain.
Orthopaedic injuries typically require urgent (rather than immediate) care; however, some orthopaedic injuries - including those involving the long bones, which may result in haemorrhage, shock and severe pain - may require immediate care.
Assessment of the musculoskeletal system usually begins with the trauma site/s being examined for obvious signs of injury - such as obvious deformity, contusions / abrasions / lacerations, oedema and pain. Where any of these signs are identified, a focused neurovascular assessment is undertaken; this involves a structured assessment of the colour, temperature, pulses, sensation and motor function in the affected limb/s.
During assessment, a nurse may identify one or more of a variety of injuries related to orthopaedic trauma. The most common injuries, and their management in the emergency care setting, are described following:
- Fractures - this term is used to describe any disruption or break in the bone. Fractures may be described as closed, or open compound. It is important to note that fractures may be associated with significant complications; for example, broken bones may lacerate vital organs / arteries / nerves, and fractures of the large bones may result in haemorrhage.
- Dislocations - this occurs when a joint exceeds its normal range of motion, and the joint surfaces become disconnected. A dislocation may be described as a subluxation if there is only partial or incomplete displacement of the joint surfaces. Minor dislocations may be corrected in the emergency care setting, however - as with fractures - more severe dislocations require surgical intervention.
- Traumatic amputation - this involves the removal of all or part of a digit, limb or other body structure. Resuscitation, as described in the previous chapter of this module, is usually required for larger amputations involving haemorrhage. Preservation of the stump - for example, by irrigating with normal saline to remove gross contamination, moist dressing, elevation and prophylactic antibiotic administration - should be the focus of care in the emergency setting. In some cases, the amputated part may be reattached using complex surgery; however, it is important to highlight that this is not successful in all cases.
- Muscle injuries - including injuries to the rotator cuff and meniscus. Although painful, these injuries do not require urgent care, though they may be corrected with surgery at a later date. Patients should be encouraged to support and ice the affected area, manage their pain using oral analgesia, and avoid use for 24 to 72 hours.
- Crush injury - this occurs when part of the body, typically a digit or limb, is crushed for a prolonged period. A patient may present with necrosis of the crushed body part and the symptoms of 'systemic crush syndrome'. Many crush injuries only require supportive care; however, severe crush injuries may require intensive medical and surgical intervention.
Patients who experience a traumatic orthopaedic injury are at significant risk of developing compartment syndrome. This occurs when damage to bones, soft tissue and / or neurovascular structures causes the pressure within a muscle compartment to rise, resulting in severe ischaemia in the affected muscle. The death of the muscle may result. Compartment syndrome usually develops between 6 and 8 hours after the primary injury. Patients present with unrelieved pain, passive flexion and decreased mobility, paraesthesia, coolness and pallor in the affected region. Although compartment management is usually managed via supportive care, surgical intervention is sometimes required.
Often, patients with minor to moderate orthopaedic trauma are discharged directly from the emergency care setting, because they are stable and either: (1) they require no further intervention, or (2) the intervention they do require will be provided at a later time.
Even though, in comparison to head / neurologic and orthopaedic trauma, spinal trauma is uncommon, it may result in injuries which are devastating and life-threatening. The spinal cord, protected inside the body vertebrae of the spine, is a key part of the central nervous system (CNS) and controls all the body's function. Damage to the spinal cord, depending on the location of the injury, may result in partial or complete paralysis, loss of motor ability, loss of conscious function of body processes, and life-threatening CNS dysfunction.
Assessment of the spine and CNS usually begins with the inspection and palpation of the spine, and patients are asked about pain and altered sensation in various regions of the body. Strategies to assess the patient's CNS function are then used; these often involve assessing a patient's conscious motor function and their reflexes. Imaging, including X-rays and CT scans, may be used to visualise suspected injuries.
Spinal injuries are associated with a number of significant complications, which nurses working in emergency care settings should be aware of:
- Incomplete spinal cord injury - this occurs when a spinal cord injury results in only partial severing of the spinal cord. Typically, a patient with an incomplete spinal cord injury will experience impairments in, rather than the complete cessation of, sensation and motor function below the level of the injury.
- Neurogenic shock - this occurs when a spinal cord injury is complete, and all sensation and motor function below the level of the injury immediately ceases. Neurogenic shock is, generally, irreversible; however, patients must be carefully managed using spinal immobilisation techniques to prevent further injury to the unstable cord in the immediate post-injury period. If the injury to the spinal cord is high, neurogenic shock may result in problems with the patient's ability to breathe, maintain their circulation and thermoregulate; these problems all require emergency intervention.
- Autonomic dysreflexia - this is a complication of spinal cord injury which occurs above the level of the T6 vertebrae. It occurs when impairments in the functioning of the sympathetic nervous system lead to a massive, uncontrolled cardiovascular response. Often, autonomic dysreflexia is triggered by simple causes such as a full bladder or bowel, and it can occur any time after the onset of a spinal injury. Management of the patient's airways, breathing and circulation, and correction of the underlying cause/s, are crucial.
- Secondary injuries to the spinal cord - including haemorrhage / oedema / hypoperfusion of the spinal cord, and endogenous biochemical responses. This occurs particularly if the injury to the spinal cord involves a vertebral fracture. Secondary spinal cord injuries may develop over hours following the initial injury to the spinal cord; therefore, ongoing assessment and monitoring of the patient is crucial.
In the emergency care setting, the management of all spinal injuries focuses on the immobilisation of the injury before surgery or other interventions can be used to correct the injury. The immobilisation of spinal injuries is crucial in ensuring further damage to the spinal cord does not occur during the transport, assessment and emergency management of the patient.
This chapter has introduced the knowledge and skills required to accurately and rapidly assess, and effectively manage, a variety of traumatic head and neurologic injuries, orthopaedic injuries and spinal injuries in the emergency care setting. This chapter has also considered the most common mechanisms of injury, and typical emergency presentation, of a variety of traumatic head and neurologic injuries, orthopaedic injuries and spinal injuries.
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