Emergency treatment of head injuries in the accident dispensary

EMERGENCY TREATMENT OF HEAD INJURIES IN THE ACCIDENT DISPENSARY* MICHAEL SCOTT, Assistant

F.A.C.S.

Professor of Neurosurgeyv

PHILADELPHIA,

PENNSYLVANIA

T

HE increase in head injuries caused by automobile accidents has placed a definite responsibility upon the shouIders of the intern in the accident dispensary. He sees the patients when they are at their worst. They are often in shock and the cerebral symptoms are comphcated and masked by injuries elsewhere or by alcoholism. The intern’s judgment and treatment frequently decide the fate of the individua1. If careless, he may permit the premature discharge of a subdura1 or epidura1 hemorrhage suspect. Broken bones, especiaIIy fractures of the spine and internal injuries, may be missed in the unconscious patient if they are not thought of and Iooked for. The stuporous patient having an aIcohoIic odor may be errodrunk” and so neousIy IabeIed “another indicted on the chart from a medica and IegaI sense, when he may actuaJIy have a skuI1 fracture and perhaps may have had onIy an innocuous gIass of beer. In a teaching institution or a hospital where a resident staff is present, the intern has the advantage of an immediate consuItation with the residents in the various specialties if problems in diagnosis or treatment occur. However, in the majority of hospitaIs in this country the intern must handle the emergency himseIf, at Ieast for the first hour or two unti1 his chief arrives. The folIowing plan of emergency treatment of head injuries is taught by Professor Temple Fay and associates to the senior students of TempIe University SchooI of Medicine and is folIowed by the interns on duty in the accident dispensary of the hospita1. In addition, the intern is required to fiIJ in a brief but pertinent form which is a valuable record for the intern who * From Temple

M.D.,

receives the case. This form becomes part of the hospita1 record or the dispensary record if the patient is not admitted.

University 678

OUTLINE

FOR

OF HEAD

EMERGENCY

INJURIES

IN THE

TKEATMES

1’

.-\CCIDEN’I’

DlSPENSAliY

A.

Treut Shock First. I. Patient flat. Do not lower head. 2. Apply beat until rectal tempern-

ture is 99 degrees or above. Carqful of’ burns. 3. If hemorrhage from scalp ~.ound is present, control it temporarily b> packing wound with dichloraminc “T” I per cent or alcohol pack and fairly tight bandage. ArteriaI bIeeding ‘is controIIed by hemostats and the vessets ligated after patient reactsfrom shock. 4. Give ad&s 50 cc. of 50 per cenl glucose intravenousry stat.

ChiJdren are given one-half to one-third this dose. If volume of puIse is poor and rate is 120 or over and there is no marked improvement kvithin I o minutes injection, give after glucose normal saline slowly intravrnously (60 drops per minute and

about eight ounces or 240 c’c. every hour) until puIse rate drops below 120 and systolic, blood pressure rises to go 01 above and diastoIic pressure to above 60. May repeat gIucase in one-haIf hour if no improvement. 5. If excessive perspiration is present, prevent further depIetion of bIood volume by subcutaneous inSchool of \Lledicinc.

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jection

of I5 minims of surgical every one-half hour and &opine sulfate gr. xoo subcutaneousIy every hour until bIood pressure has reached IeveI as given above in (4). 6. If Ioss of blood is excessive, have patient and avaiIable donors typed and crossed whiIe infusion is given and transfuse iJ necessary. 7. Make sure that patient has an adequate airway, that the tongue does not fal1 back and that no foreign bodies or denta plates are Ieft in the mouth. Be careful when applying metal mouth gags. A broken or Ioosened tooth may be aspirated into the Iungs. 8. If the patient is unconscious, IO per cent carbon dioxide in 90 per cent oxygen may be given intranasally by two smaI1 catheters attached to a gIass “Y” tube. pituitrin

B.

While above Treatment Is Progressing, Examine Patient for I. Fractured bones (suspect a frac-

ture of spine, especiaIIy in cervicaI region unti1 proven otherwise). 2. Injury to ribs (subcutaneous emphysema, hemo- and pneumothorax). 3. Abdominal, renaI and peIvic injury or hemorrhage. 4. Do not during shock.

move

or

turn

patient

(a) If long bone is fractured, appIy temporary spIint without manipuIation. If compounded, caII resident or chief. (b) If chest, abdomina1 or peIvic injury is suspected, caII resident or chief immediateIy. (c) If cervica1 fracture is suspected, support head and neck with sand bags on either side. CaIi resident or chief. C. When Patient Reacts from Shock (usuaIIy 15 minutes to one hour after onset of treatment). Recta1 temperature rises to 9g degrees or above;

Injuries

American

Journal

of Surgery

systoIic pressure to 90 or above, diastoIic to 60 or above.

679

and

I. Do a careful neurologic examination :

(a) Inspect ears, nose, mouth and throat for evidence of bleeding or cerebrospina1 Ieak and the scIera for subconjunctivia1 hemorrhage (basilar fracture?). (b) Decide whether patient is aphasic or unconscious by strong pressure over supraorbita nerves. If patient endeavors to remove examiner’s hands from painfu1 area, he is not unconscious. FaciaI muscles wiII grimace on side of painfu1 stimuIus if patient is not unconscious. (c) Note size and shape of pupiIs and reaction light. A fixed, diIated pupi or a progressiveIy diIating pupil on one side suggests an expanding epior subdura1 cIot, fluid or edema on that side. (d) Examine crania1 nerves (see b). (e) Test patient’s ability to use extremities. Check for weakness or paraIysis. ExternaI rotation of the entire lower extremity when not voIuntary is caused by a fracture of the femur or paraIysis of the extremity. If raise patient is unconscious, both upper extremities above the head and permit them to drop to bedside. The paretic or paraIyzed extremity drops in a flaccid “rag doI1” manner. (f) Test the deep tendon reflexes and for the Hoffman and Babinski sign. (g) Note the reaction of the patient to painfu1 stimuli appIied to each side of the body. (h) Check patient now for possibIe fracture of spine. Do

680 not move patient from table unti1 satisfied that no obvious fracture of spine, especiaIIy in cervica1 region, is present. If cervica1 fracture is suspected, appIy chin-occiput harness with steady traction before moving. If fracture of other vertebrae are suspected, avoid ffexion and extension movements in transporting patient. Do not move patient unless you have enough heIp to Iift him properly. D. 1J Neurological I. Cerebra1

Examination

Shows

involvement as evidenced by any of the foIIowing: prolonged unconsciousness (one-haIf hour or more since the accident), aphasia, dehnite pupillary changes, psychotic or pecuIiar actions, weakness or paraIysis of the extremities, sensory changes, the patient should be admitted and sent directty to room or ward.

If patient’s genera1 condition is good, Iaceration, if present, can be sutured in accident dispensary. If it is extensive or condition poor, cIeanse, secure hemostasis, pack, deIay suturing and admit patient to house (see treatment of Iaceration). 2.

E. If Patient Has Reacted from Shock, Is Conscious, and Neurologic and Physical Findings Are Negative and There Is Still Doubt as to Cerebral Injury I. Do Iumbar puncture (see tech-

nique and contraindications beIow). Record pressure and take off I to 3 cc. of fluid to determine whether cIear or bIoody. If spina fluid is pink or cherry red in coIor and homothroughout, subarachnoid geneous hemorrhage is present and is evidence of Iaceration of the pia and a probabIe skuII fracture.* Patient should be admitted. * Routine spin4 punctures were done on every patient in over 600 cases of head trauma treated on the Neurological-NeurosurgicaI service. Seventy-five per cent of patients having bIoody spina ffuid subsequently had a proven skull fracture.

2. If spinal lluict is clear and pressure is above 12 mm. of mercur!, or 160 mm. of water under correct technic, patient shouId be admitted to dispensary bed and observed for possibIe subdura1 or epidura1 clot. 3. If spinal fluid is clear and pres12 mm. of mercury, sure below laceration of scaIp should be sutured if present. Patient shouId then be kept in accident ward for observation for at least two hours and then discharged if feeling well, with instructions to report to family- physician or if clinic patient to report to accident dispensary- if severe headache, vomiting or any unusual symptoms occur. Patient shouId not be discharged from dispensary, unIess ;rccompanied by friend, reIative OI poIice, who can escort patient home where he can be watched for an> untoward symptoms.

F. IMethod of Examining and Repairing Laceration of Scalp. I. Cut and then shave a11 hair

within a radius of at least two inches from any point of the Iaceration. In a woman so arrange the hair and comb it so that later the uncut part can be combed over the cut area. 2. CIeanse shaved area thoroughly with soap and water, avoiding the laceration or its edges at this stage. 3. AppIy three and one-haIf per cent iodine to cIeansed area and remove with aIcoho1. 4. Put on steriIe gIoves and completely surround periphera1 border of shaved area with a one per cent novocaine bIock so that the novoCaine ring is one inch internal to the hair border. (Fig. I.) 3. The Iaceration wiI1 now be anesthetic and can be cIeaned, inspected and sutured without pain to the patient. 6. Inspect wound for foreign bodies. AI1 dirt and grease shouId be removed from margins or depth of

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wound by cotton applicators soaked in benzine. The Iaceration is then gentIy irrigated and sponged with ether folIowed by three and one-haIf per cent tincture of iodine. (Caution: Protect patient’s eyes against irrigating soIutions.) 7. Change gIoves and proceed to inspect wound for injury to bone, herniations of brain tissue, cerebrospina Ieak. Use steriIe gIoved finger to paIpate carefuIIy and gentIy for depressions. Use no probes (these may introduce infection to deeper IeveIs). If inspection or paIpation or both suggest a compound fracture of the skull, gentIy pack Iaceration with dressing of one per cent dichloramine “T” or aIcoho1 and admit patient to the hospital. Never suture a Iaceration in a suspected compound fracture of the skuI1 except in an operating room where the set-up wiI1 permit handIing of any d&uIties or compIications that may occur when bone fragments are manipuIated or the brain exposed. 8. If there is no evidence that the periosteum has been torn and the bone injured or exposed (in other words if there is no compound fracture), the Iaceration shouId besutured with siIk or wire. AI1 traumatized and necrotic tissue shouId be debrided carefuIIy, saving as much normal tissue as possibIe. Venous and capillary ooze wiI1 be controIIed by pressure on edges of Iaceration and when the sutures are tied. If the gaIea is cut, this Iayer should be approximated with interrupted sutures pIaced about one-fourth to one-haIf inch apart and tied firmly with just enough pressure to approximate the edges without strangIing them. The skin and subcutaneous Iayer down to the aponeurosis can then be sutured as a separateIayer. The sutures shouId be pIaced about one-haIf inch apart, shouId enter and

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681

emerge from the skin at Ieast onefourth inch on each side of the Iacerated edge. They shouId be tied

FIG. I. Preparation of scaIp before repair. The scaIp is shaved and cIeansed with soap and water; followed by application of three and one-haIf per cent iodine which is removed with alcohol. The Iaceration is not touched. The wound is then surrounded by a ring of one per cent novocaine which is placed about one inch interna to the periphery of the shaven area. The laceration and its edges are now anesthetic and can be cleansed, inspected and sutured without pain.

just firmly enough to approximate the edges and shouId Iie Aat without puckering or creasing the skin. It is not necessary to drain if the wound has been cleansed thoroughIy and appeared cIean initiaIIy. If the wound was dirty or if a great deal of tissue was contused, insert a rubber dam drain from one-fourth to onehalf inch in width in one angle of the Iaceration before the sutures are tied, so that the inserted end wiI1 be under the aponeurotic Iayer if it was cut, or down to the aponeurosis if onIy the skin and subcutaneous tissues were invoIved. The sutures may then be tied. An aIcoho1 dressing shouId then be appIied to the sutured area and kept in pIace by a head dressing. (Be

682

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carefu1 not to make head dressing too tight or headache wiI1 deveIop.) Patient should report in twentyfour hours to family physician or clinic for remova of drain or inspection of wound. Sutures are removed on the fifth day. 9. AI1 dirty or punctured wounds or those recejved in tields, farms, or about premises where horses or cattle are present, should receive a prophylactic injection of tetanus and gas gangrene antitoxin. IO. Wounds of forehead are treated like those in hair areas except that the deep and subcutaneous Iayers do not toIerate silk, therefore, No. ooo chromic gut should be used for these deep layers. The skin and subcutaneous Iayer should be sutured with either interrupted or continuous dura1 siIk and a Vaseline gauze dressing appIied. No drains are used. The sutures should be removed on the fourth day if healing occurs. These precautions are used to reduce the size of scars. G. Treatment of Alcoholic with Suspected Head Injury I. Treat the same as any head injury case. 2. Do not give depressant drugs. 3. Do not do Iumbar puncture and drainage unti1 out of shock. 1. If noisy and uncooperative, patient may be given paraldehyde, drams I to 3 by nasa1 tube. H. Pointers in Doing Lumbar Puncture I. Do not flex head but permit it to be kept in natural position. Flexing head may constrict jugular veins and increase intracerebra1 venous and hence cerebra1 spina fluid pressure as much as 20 mm. Hg. and thus give a false high reading. 2. Never do Iumbar puncture in sitting position. Patient to be on his side in horizontal position.

Injuries 3. Never do lumbar puncture without manometer and initial pressure reading. 1. Contraindications to Lumbar Puncture I. Pimples, acne, or infection in or about Iumbar puncture area (third or fourth lumbar interspace). 2. Shock. 3. Uncooperati\,e patient. 4. Irregular respirations or irespirations beIo\v I 6) suggest medullar? compression. Cal1 chief resident otresident on neurosurgery before doing puncture. If fractured spine is suspected, patient is not to be movecl from table until chief resident physician, resident on orthopedics or resident on neurosurgery examines the patient. DISPENSARY

KECORDS

IN

CASES

OF

HEAD

INJURY

Most of the patients have received their injuries in automobile accidents, fights when at work and at times when inebriated. These cases are, therefore, often of medicoIega1 importance. Accurate records in the dispensary- are vita1 to the patient’s interest as well as to others invoIved and certainIS; to the intern on the ward who receives the case. Too often the records sa>’ “drunk” or under the “inIt is the dutv of the fluence of alcohol.” intern to record on the records that there is an odor of alcohol if he definiteI?; smells it. He should not state that the person ih drunk or under the influence of liquor unIess the patient is awake, boisterous, Ioquacious and exhibits the classical actions seen in the acti\.e, acute, alcoholic spree. Since the intern is estremel; bus- in the accident dispensar>-, it is essential that the records he must make be brief and to the point. The foIIowing form was arranged and is used in the Temple University HospitaI Accident Dispensary :

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3

TEMPLE ACCIDENT FILL IN THIS

UNIVERSITY

DISPENSARY

HEAD

FORM AND SEND WITH Color

Name: Date

Injuries

Time:

:

Amrrican

OF Surycry

683

HOSPITAL INJURY

RECORD

PATIENT

IF ADMITTED Sex

Age:

:

Journal

Brought

(I) Admitted to dispensary: Discharged from dispensary: (3) Sent to ward or room:

:

in by:

(2)

History:

(I) Where found and etioIogy

(2)

Condition

of patient

(3) Final TPR

of accident:

on entering

and blood pressure

dispensary

with initiat TPR:

when sent to ward or discharged

from dispensary:

Examination: (1) Location

(2)

and extent

Comparative

(3) Bleeding

size of pupiIs and reaction

or cerebrospinal

(4) Abnormal

neuroIogic

(5) List fractures (6) List suspected (7) List evidence Treatment:

Iight:

ffuid from cavities

of skull:

tindings:

of bones: injury

to chest, abdomen,

kidney, bhrdder or spine:

of aIcohoI odor to breath:

Name and amount

Lumbar

of scalp injury:

puncture

Record treatment

of drugs and antitoxin

done?

of scalp Iaceration

given and record of TPR

and bIood pressure g. W hour:

If so, give (a) InitiaI pressure(b) Amount and color--(c) FinaI pressureif presenti Signed: