Central nervous

system injury
CNS trauma involves injury to the brain or spinal cord.
Brain injury:
Traumatic brain injury accounts for approximately half of
prehospital deaths from motor vehicle collisions.
Late survival from brain injury is dependent on avoiding
secondary brain injury due to hypoxia and hypotension.

Physiology.
The skull is non-expandable after closure of
fontanelles. It contains the brain, cerebrospinal
fluid and blood.
The Monro-Kellie doctrine states the intracranial
pressure ICP is proportional to the volume of the
contents of the skull. Consequently, ICP can be
altered only by changing the volume of
intracranial contents.
Resulting perfusion pressure to any organ is the
difference between the driving pressure and the
resisting pressure.
For the brain, cerebral perfusion pressure
equals mean arterial pressure minus ICP.

CPP=MAP-ICP
Cerebral boold flow equals CPP divede by
cerebral vascular resistance.

CBF=CPP/CVR

CBF remains relatively constant, between MAP of 50 to 150

mmHg.
THIS AUTOREGULATION IS ACHIEVED THROUGH LOCAL RELEASE
OF MEDIATORS SUCH AS NITRIC OXIDE AND ENDOTHELINS
WHITH ACUTELY ALTER CVR. Autoregulation is deranged in
severe brain injury and CBF becomes exquisitely sensitive to
changes in MAP and ICP.
Additionally ICP is frequently elevated with brain injury.
Thus incresead MAP may be required to maintain adequate
CPP.

Pathology.
Intracranial abnormalities related
to trauma can be classified
according to involvement of the
brain or potential spaces arround
the brain. Of these lesions, spaceoccupying extra-axial subdural
and epidural haematomas are
most amenable to surgical
therapy.

Glasgow coma scale:

GCS is widely used for early aseement
of the severity of brain injury. A score
of 8 or less is usually referred to as
coma.
These pacients have severe brain
injuries and are at high risk of mortality
and log term disability.

Initial management
Immediate priorities include securing the
airway, supporting ventilation and
oxygenation, and optimising circulation and
organ perfusion.
Pacients with severe brain injury from blunt
trauma often have associated injuries,
particularly of spine and spinal cord.
CT of the brain and spinal cord is useful in
evaluating pacients with suspected head
injury, allowing diagnosis of the intra and
extra-axial pathologies.

Treatment.
Treatment of brain injury hinges upon
avoidance of secondary hypoxic injury.
Important goals are maintaining
adequate CPP(60-70 mmHg) and blood
oxygen contents while striving to
minimise cerebral metabolic
requirements.
CPP may be maintained by increasing
MAP with drugs such as phenylephrine
and noradrenaline or by decreasing ICP.

An ICP can be decreased

- evacuation of space
occupying lesion such as
epidural and subdural
haematomas,
- drainage of CSF with a
ventriculostomy catheter
- removal of a portion of the
skull, osmotic diuresis with
mannitol.

Sedation and neuromuscular

blockade may decrease metabolic
requirements.
Barbiturate or propofol induced coma
may be beneficial in the first 24-48h.
Mild hypothermia 35-36 has shown
promise in several studies, but
remains an experimental intervention.
Maintaining normoglycaemia has
been associadet with improved
neurological outcome.

Spinal cord injury.

Evaluation in the ICU:
Pertinent historical points include
mechanism of injury, time course and
extent of neurological deficits, and
treatment already initiated.
Physical examination should include
an attempt to determine the level of
injury based upon sensory and
motor deficits. A map of
myodermatomes can be helpful.

C-Spine Injuries

Cervical Fracture or Dislocation

Weakness or Paralysis

Cervical Nerve Root Injury

Herniated Disc
Laceration
Cord Shock (Central Cord Syndrome)
Hemorrhage
Contusion
Cervical Stenosis

C3

Spinal Nerves
C1-T1
Cervical Plexus
C1-C4
C4 -Phrenic Nerve - Breathing

Brachial Plexus
C5-T1

C-Spine/Neck Injuries

Cervical Strain
Active motion most painful

Cervical Sprain (Whiplash)

Passive and active motion painful

Torticollis (WryNeck)
Muscle spasm and facet irritation

Brachial Plexus Stretch or Compression

Contusions to Throat

Evaluation Techniques

HOPS
History, Observation, Palpation, Special Tests

Your first priority!

Establish the integrity of the spinal cord and
nerve roots
History and several specific tests provide
information

Cervical Injuries

Fairly uncommon in athletics(6-7%) - but greater

than 90% of all fatalities are cervical related.
Cervical injuries are primarily technique related:
Spearing
Tackling or falling head first.

Must have an emergency plan:

All personnel know roles and equipment use.
All unconscious athletes - suspect head/neck
Always suspect the worse until proven otherwise

Cervical Injuries

Axial Loading
Flexion Force
Hyperextension Force
Flexion-Rotation Force
Hyperextension-Rotation
Lateral Flexion

Neurological Testing
Dermatomes
Reflexes

Babinski
Oppenheim
Biceps
Brachioradialis
Triceps

Myotomes

Classification
Spinal cord injuries are either
complete, with loss of all sensory and
motor function distal to the injury, or
incomplete.
The last ones can be divided either
functionally or pathologically.
Functional scales are based on the
degree of loss of sensory and motor
function.

Initial management
If tracheal intubation is required, in-line stabilization
of the cervical spine must be maintainted. Pacient
with cervical spinal cord injuries are unable to
breathe if the level of the injury is above C3-C5.
Even with lower lesion, respiratory compromise can
be important owing to denervation of the
intercostals muscles and paradoxical chest wall
motion with negative pressure ventilation.

Parental infusion of
corticosteroids should be
initiated as soon as spinal
cord injury is suspected
following the improved
neurological outcomes
demonstradet in the NASCIS
studies.

The recommended regimen is

methylprednisolone 30 mg/kg
over over 1 h within 8h of injury
followed by continuous infusion
of 5,4 mg/kg/h over the next
23h. Recently, the benefit of
routine administration of
corticosteroids has been
questioned.

Complication.
Spinal cord injury can affect many
organ systems. Neurogenic or spinal
shock may occur with high thoracic
lesion where sympathetic outflow is
interrupted. This should be treated with
peripheral vasoconstrictors and
adequate fluid resuscitation. This
problem typically resolves within 72 h
of injury.

Pulmonary and urinary tract

infection are common, the
former because of difficulty
clearing secretion frequent
need for tracheal intubation
and latter secondary to
indwelling urinary catheters
or frequent bladder
catheterization .

Prophylactic administration of
proton pump inhibitors or histamine
receptor blocker may decrease the
occurrence of stress ulcers.
Deep venous thrombosis
andpulmonary embolism are
frequent and potentially lethal
complications of paralysis.

GCS:
Eye opening:
points:
Spontaneous
4
To speech
3
To pain
2
None
1

Verbal
communication
Oriented
5
Confused
4
Inappropriated words
3
Incomprehensible sounds
2
None
1

Motor response
Obeys commands
Localized to pain
Withdraws to pain
Abnormal flexion
Abnormal extension
None

6
5
4
3
2
1

Best score is 15 points;

worst score is 3 points.
increase brain oedema and
supporting ventilation to
maintain Pa Co2 between
35 to 40 mmHG.I