1. By Christopher I’Anson SJA Advanced Student Doctor Training Officer Leeds LINKS (2012-13)

2. Topics Head and neck injuries C-spine Concussion Compression Cerebrovascular accidents TIAs Strokes Meningitis Seizures Examination H-test Pupillary light reflexes Peripheral grip strength

3. Anatomy The brain is enclosed in several layers Meninges (brain covering) Contain blood vessels Cushion brain Skull (hard rigid box unlike meninges) Skin Cerebrospinal fluid Fluid surrounding the brain Supports and cushions

4. Anatomy There are 7 cervical vertebra Each has a nerve exiting near it Each protects the spinal cord Aids movement and support of head Spinal Nerves C3,4,5 are important Supply the diaphragm Cause breathing “C3,4,5 keep the diaphragm alive!”

5. C-spine injuries The head is extremely heavy! The neck support this weight It can be easily damaged as it is exposed and has a heavy “bowling ball on top of it” (see DEMO)

6. C-spine injuries Clinical features: Mid-line tenderness Pain in neck Numbness or tingling in extremities Peripheral weakness or paralysis Deformity in the neck Significant MOI GCS<15

7. C-spine injuries Assessment: Maintain immobilisation until you are happy Feel down the back of the neck for lumps or bumps Ask patient to wiggle toes and/ or squeeze fingers

8. C-spine injures Management: Manual In-line immobilisation Collar and board (if ETA) 3 point immobilisation 999

9. NICE guidelines Indications for Spinal Immobilisation: GCS <15 Neck pain or tenderness “Focal neurological deficits” (weakness and sensory changes in English) Numbness and tingling in extremities Clinical suspicion (MOI, head injuries etc)

10. Head injuries Does not include minor face lacerations* Every year about 1.4 million people attend A&E with one 50% are children 1,500 have severe brain damage 5,000 die each year due to these * Remain suspicious

11. Head injuries Common causes: RTC Falls Assaults Sports/leisure Workplace Others Factors associated with serious injuries: High-speed impact Death of another in the same accident Entrapment Intrusion of vehicles Ejection of the patient from the vehicle Pedestrian or motorcyclist vs. Motor vehicle Fall from >5m

12. Head injuries Either: Primary (direct local or diffuse injury) e.g Contra-coup Secondary

13. Head injuries: Concussion This is where the brain shacks inside the skull Not usually associated with long term damage This causes: Nausea +/- vomiting Headache Dizziness Disorientation

14. Head injuries: Concussion Management: ABCDE! Observations Especially AVPU or GCS Give head injury advice card Advice to go to hospital NO MEDICATIONS!

15. Head injuries: Compression This is where the brain is compressed inside the skull NB: the skull can not expand causing effects on the brain Can be fluid or blood CF: Drowsiness or unconsciousness (inc history of LOC) Amnesia (retrograde and/or anterograde) Seizures N+V Posturing (decortate or decerebrate) Sensory disturbance (e.g. Vision) and weakness Headache Personality change May have deformity of Skull due to cause Blood or fluid (CSF) from the nose or ears (BSF)* Battle sign or racoon eyes *?basal skull fracture

16. Head injuries: Compression It is difficult to diagnose this as you do not have a CT scanner  Use your clinical suspicions or if in doubt treat as worst case! Management: ABCDE! Immobilisation in unconscious or previous LOC or BSF 999 Protect airway No pain killers

17. Cerebrovascular accident (CVA) This is a posh more PC way of taking about: Strokes (where symptoms last for >24 hours) Transient ischaemic attacks (TIA) or “mini-strokes” Symptoms last <24 hours Clinically in the acute phase there is no difference

18. CVA: TIA and Strokes Clinical Features: FAST! Facial weakness Arm weakness (can not hold them up) Speech (is slurred) Time to call 999

19. CVA Other features Unconsciousness or collapse (rare) Sensory disturbance (e.g. Vision) Generalised weakness Legs  unable to walk Arms  unable to hold self up

20. Meningitis Inflammation of the lining of the brain Clinical Features: Nausea and Vomiting Fever Muscle ache or pain Aggression or drowsy Coma Seizures ?Rash

21. Meningitis Management: 999 No medications! Manage symptoms as best as possible

22. Seizures These are the same as fits There are many types and causes (inc Epilepsy and febrile convulsions) Management: Remove dangerous/ harmful objects DO NOT restrain the patient TIME the fit If first fit or >5mins call 999 Recovery position after the fit has subsided Cover the patient with a blanket in case the wet themselves (DIGNITY)

23. Examinations After ABCDE Not for people that need immobilisation! Pupil response H-test Grip strength