Chapter 4: Head, Neurologic, Orthopaedic and Spinal Trauma

Introduction

Head, neurologic, orthopaedic and spinal injuries are the most common types of traumatic injuries encountered in emergency care settings in the United Kingdom (UK). It is therefore essential that nurses working in emergency settings are able to assess and manage these conditions. This chapter introduces 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 also considers the most common mechanisms of injury, and typical emergency presentation, of a variety of traumatic head and neurologic injuries, orthopaedic injuries and spinal injuries. The aim of this chapter is to begin to prepare you to provide quality emergency nursing care to patients affected by traumatic injury.

Important note

This chapter assumes a basic knowledge of human anatomy and physiology. If you feel you need to revise these concepts, you are encouraged to consult a quality nursing textbook.

Head and neurologic trauma

Head trauma is a leading cause of disability and death in emergency care settings in the UK; indeed, up to 1.4 million people attend an A&E Department in the UK with a recent traumatic head injury each year. Head trauma can involve a variety of mechanisms of injury, however in emergency care settings in the UK patients with head trauma most often present after involvement in a road traffic accident or a fall from height. The most common forces involved in head trauma are:

• Blunt acceleration forces (e.g. when the head is struck with an object).
• Deceleration forces (e.g. when the head is moving and strikes a stationary object).
• Penetrating forces (e.g. when an object enters the head).

Important note

"It is estimated that 25-30% of children aged under 2 years who are hospitalised with head injury [in the UK] have an abusive head injury".

(NICE, 2014)

Recognising the signs of, and responding appropriately to, suspected child abuse is a key role for emergency nurses.

In patients with head trauma in emergency care settings, missed injuries - including secondary neurologic injuries (i.e. injuries to the brain and brainstem) - 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. Consider the following example:

Nurses working in emergency care settings must be familiar with their organisation's policies and procedures for neurological assessment, and work within these. However, generally, the neurological assessment of a patient with suspected or actual head trauma will include:

• An assessment of level of consciousness (LOC) (e.g. using the Glasgow Coma Scale [GCS]). Assessment tools such as the GCS assess the functioning of a patient's central nervous system via their response to verbal and / or painful stimuli. The GCS is used in a variety of clinical settings; if you are unfamiliar with this tool, you are encouraged read further about it (e.g. at http://www.glasgowcomascale.org/). 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, etc. As you will see in a later section of this chapter, increased ICP is a common and significant problem for patients who have experienced a traumatic head injury.
• An assessment of the cranial nerves (CN), and particularly CN III (oculomotor), CN IV (trochlear) and CN VI (abducens) nerves. 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 (if the patient is conscious). For example, a nurse may ask a patient to squeeze their hands or raise their legs off the bed, etc.; simultaneous assessment of both sides of the patient's body, where possible, is important. The nurse should be aware of abnormal posturing - particularly flexion (where the patient's arms are drawn rigidly up against their chest) and extension (where the patient's arms turn rigidly outwards against the sides of their body), both of which indicate a serious hypoxic brain injury.
• Assessment of the vital signs. Signs of a serious brain injury include hypertension (a compensatory mechanism to maintain cerebral blood flow), cardiac dysrhythmia (due to brainstem dysfunction), and hyperthermia (as cerebral dysfunction and metabolism increases). 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 (i.e. increasing distance between systolic and diastolic blood pressures), 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. The National Institute of Health and Clinical Excellence's Head Injury: Assessment and Early Management (CG176) guideline recommends that a CT scan be undertaken if a patient has a GCS of 13 on initial presentation or a GCS of <15 2 hours after the injury, a suspected skull fracture, a post-traumatic seizure, any focal neurological deficit, or more than 1 episode of vomiting (NICE, 2014), all of which indicate neurologic injury.

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:

• Scalp lacerations - the scalp is highly vascularised and scalp lacerations often bleed profusely; therefore, they are typically managed by direct pressure to control initial haemorrhage, and subsequent wound repair using sutures, staples or clips.
• Skull fractures - these may be linear (e.g. where the fracture is non-displaced, and there is no or minor neurological damage), or depressed (i.e. where one side of the fracture displaces below the other, and there is moderate to severe neurological damage). The signs of a suspected skull fracture include haemotympanum (i.e. leakage of blood from the ears), 'panda' or 'raccoon' eyes (i.e. circular bruising around the eyes), leakage of cerebrospinal fluid from the ear / nose, and Battle's sign (i.e. bruising behind the ears). Linear skull fractures usually only require supportive care (e.g. rest, pain management, etc.), 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 (i.e. one at the initial site of impact [called the coup], and one on the opposite side of the brain [called the contrecoup], as the brain rebounds inside the skull). Patients with contusion typically present with an altered LOC, nausea and / or vomiting, visual disturbances, weakness and / or difficulties with their speech. 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 (usually, the dura mater or arachnoid mater). Patients with haematoma often present with severe headache, pupillary dilatation on the same side of the body to that which they sustained the traumatic injury, and hemiparesis (i.e. one-sided weakness) on the opposite side. 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. Often, people presenting to an emergency care setting with concussion will display mild, transient neurological symptoms such as nausea / vomiting, temporary amnesia, minor confusion and disorientation, headache, dizziness, drowsiness, irritability and / or visual disturbances. Care for a patient who has experienced a concussion involves regular observation to identify more serious brain injury, and symptomatic management (e.g. non-narcotic analgesia, anti-emetics, fluid therapy, etc.). 
• Diffuse axonal injury (DAI) - this is a severe traumatic brain injury that results in shearing of axons, key structures within the white matter of the brain. Patients with DAI typically present with extended loss of consciousness, flexion or extension posturing, and dysfunction of the autonomic nervous system. 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 (i.e. swelling of the brain tissues) and increases in cerebral blood flow (e.g. haemorrhage, acute hypertension, etc.) in particular can result in increases in ICP. Patients with ICP will present with a decreased LOC, changes in vital signs (including Cushing's triad, described earlier in this chapter), 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. 

It is important to note that many patients presenting with a significant head injury will also have injuries to their cervical spine. Patients with a suspected or actual head injury who are attended by paramedics will have routine cervical spine immobilisation in place when they arrive in the emergency care setting. The assessment and management of spinal injuries, actual and suspected, will be described in the following section of this chapter.

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; for example, the management of airway, breathing and circulation should take priority. 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 trauma

Along with head and neurological injuries, orthopaedic injuries are the most common trauma-related injuries seen in UK emergency care settings. The term 'orthopaedic' refers to the bones, surrounding soft tissue, and associated neurovascular structures (i.e. the nerves and blood vessels). Orthopaedic injuries are caused by a variety of mechanisms - including, most commonly, road traffic accidents, falls from height, assaults, sports and recreation accidents, and general accidents at work or in the home. 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.

As with all assessment, the assessment of traumatic orthopaedic injuries begins with an assessment of the patient's airway, breathing and circulation. Assessment of the musculoskeletal system can then be undertaken. Usually, this 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:

• Strains and sprains - these involve minor damage to a muscle, usually at its point of attachment to a tendon. Although painful, strains and sprains do not require urgent care. Patients should be encouraged to support, ice and elevate the affected limb, manage their pain using oral analgesia (e.g. paracetamol, ibuprofen, etc.), and avoid weight-bearing for 24 to 72 hours.
• Fractures - this term is used to describe any disruption or break in the bone. Fractures may be described as closed (i.e. where the bone is broken but the skin is intact), or open compound (i.e. where the bone is open and protrudes through the skin). Patients usually present with obvious deformity (confirmed by X-ray), pain (which may be severe), swelling, bruising and ecchymosis in the affected region. 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, etc.

In the emergency care setting, the management of fractures focuses on the immobilisation of the fracture. For example, the NICE guidelines (2016) recommend a traction splint or an adjacent leg splint for fractures of the femur, or a vacuum splint for all other long bone fractures, and temporary casts may also be used. Minor fractures may be reduced (i.e. realigned) and fixed in the emergency care setting, however more severe fractures require some type of surgical intervention.

• 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. The shoulder, elbow, finger, hip, knee / patella, ankle and toe are all common points of dislocation. Patients usually present with obvious deformity (confirmed by X-ray), pain (which may be severe), swelling and ecchymosis in the affected region. 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 (e.g. foot, hand, ear, nose, etc.). 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 (muscles in the shoulder) and meniscus (fibrocartilage in the knee). 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 (e.g. paracetamol, ibuprofen, etc.), 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' (e.g. myoglobinuria [i.e. myoglobin, a muscle breakdown product, in the urine], acidosis, renal failure and cardiac disruption, etc.). 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 (i.e. lack of blood and oxygen) 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.

Remember: key to the emergency management of the traumatic orthopaedic injuries described above is the management of a patient's pain. Pain is typically managed using oral analgesia (e.g. paracetamol, ibuprofen, etc.) and / or intravenous or intranasal analgesia (e.g. opioids). Immobilisation, as described earlier in this chapter, is another strategy used to manage the pain associated with orthopaedic injuries. 

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 (e.g. surgery, physiotherapy, etc.) will be provided at a later time. Patients are often discharged from emergency care with casts, crutches, walkers, wheelchairs and other equipment to support their mobility. It is important that you are familiar with the use of this equipment, and also your organisation's policies and procedures in relation to its use by patients.

Spinal trauma

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 (e.g. problems with airway, breathing, circulation, etc.). Spinal trauma can involve a variety of mechanisms of injury, however in emergency care settings in the UK patients with spinal trauma most often present after involvement in road traffic accidents, falls from height, assaults, sports and recreation accidents, and general accidents at work or in the home.

As with all assessment, the assessment of traumatic spinal injuries begins with an assessment of the patient's airway, breathing and circulation. Assessment of the spine and CNS can then be undertaken. Usually, this begins with the inspection and palpation of the spine, and patients (if they are conscious) 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 (described later in this chapter) 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. Patients will present with a sudden severe headache, hypertension, bradycardia, anxiety and nausea / vomiting, as well as a combination of profuse sweating above and coolness below the level of the 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. Often, spinal injuries are associated with head and / or neurologic injuries; for this reason, as described in the previous section of this chapter, patients with a suspected or actual head injury who are attended by paramedics will have routine cervical spine immobilisation in place when they arrive in the emergency care setting. Patients with suspected spinal injuries - for example, those who complain of altered sensation in their peripheries - will also be fully immobilised on a spinal board. 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. Although they can be very uncomfortable, immobilisation devices must not be removed until it has been confirmed that the patient has no spinal cord injury, or any spinal cord injury present is determined to be stable.

Although it is a fundamental aspect of nursing care in all settings, the psychosocial care of a patient with a suspected or actual spinal injury is particularly important. Patients and / or their families, carers and significant others will often ask nurses whether a patient with a spinal cord injury will be able to move, walk or 'be the same' again. Although it is important that nurses working in emergency care settings provide patients and others with honest information about outcomes, this should be done in a way which prevents undue worry. Discussions should focus on the investigations and interventions being provided to the patient, and the fact that the patient is in the correct place to ensure the best outcome possible. Consider the following example:

Providing information to the patient and their significant other/s as assessment progresses can help to reduce the shock of the diagnosis of a spinal cord injury, particularly where this injury will result in significant and permanent disability. However, it is important that the information provided is accurate, consistent and sensitive to the complex emotions those involved in the situation will inevitably experience. Note that it is usually the role of the emergency consultant/s to discuss a diagnosis with a patient and their significant other/s, and to answer questions on the longer-term management of this diagnosis.

Conclusion

As you have seen throughout this chapter, head, neurologic, orthopaedic and spinal injuries are the most common types of traumatic injury encountered in emergency care settings in the UK. 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. In completing this chapter, you have begun to prepare to provide quality emergency nursing care to patients affected by traumatic injury. The skills and knowledge you have developed in this chapter will be extended upon in the following chapter of this module.

Reference list

Childs, S.G. (2007). Nursing Management: Musculoskeletal Trauma and Orthopaedic Surgery. In S. Lewis, M.M. Heitkemper, S.R. Dirksen, P.G. O'Brien & L. Bucher (Eds.). Medical-Surgical Nursing: Assessment and Management of Clinical Problems - International Edition. (7th edn.): St Louis: Mosby-Elsevier.

Hendrickson, S.G. (2007). Nursing Assessment: Nervous System. In S. Lewis, M.M. Heitkemper, S.R. Dirksen, P.G. O'Brien & L. Bucher (Eds.). Medical-Surgical Nursing: Assessment and Management of Clinical Problems - International Edition. (7th edn.): St Louis: Mosby-Elsevier.

Howard, P.K. & Steinmann, R.A. (Eds.). (2010). Sheehy's Emergency Nursing: Principles and Practice. Naperville, IL: Mosby Elsevier.

Jones, G., Endacott, R. & Crouch, R. (2007). Emergency Nursing Care: Principles and Practice. Cambridge: Cambridge University Press.

Laskowski-Jones, L. (2007). Nursing Management: Peripheral Nerve and Spinal Cord Problems. In S. Lewis, M.M. Heitkemper, S.R. Dirksen, P.G. O'Brien & L. Bucher (Eds.). Medical-Surgical Nursing: Assessment and Management of Clinical Problems - International Edition. (7th edn.): St Louis: Mosby-Elsevier.

National Institute for Health and Care Excellence. (2014). Head Injury: Assessment and Early Management (CG176). Retrieved from: https://www.nice.org.uk/guidance/cg176/chapter/1-recommendations

National Institute for Health and Care Excellence. (2016a). Fractures (Complex): Assessment and Management (NG38). Retrieved from: https://www.nice.org.uk/guidance/ng37/chapter/recommendations

National Institute for Health and Care Excellence. (2016b). Fractures (Non-Complex): Assessment and Management (NG37). Retrieved from: https://www.nice.org.uk/guidance/ng38/chapter/recommendations

National Institute for Health and Care Excellence. (2016c). Spinal Injury: Assessment and Initial Management (NG41). Retrieved from: https://www.nice.org.uk/guidance/ng41/chapter/recommendations