Determining True Coma/Level of Consciousness
Is the patient unconscious? Hysteria, psychological disease, drugs, or alcohol may all make patients seem unconscious when they are not. The following are simple, rapid methods to test for the level of wakefulness in these patients:
- Sternal rub: Use your knuckles and progressively increase pressure as you rub.
- Ammonia capsules: Break three or four and cup them in your hand. Place your cupped hand firmly over the patient's mouth and nose.
- Supraorbital nerve pressure: Similar to a sternal rub; be careful that your finger doesn't slip and injure the eye.
- Jaw pull: Place your second and third fingers behind the ascending ramus of the mandible and pull the patient's jaw forward.
- Nose-hair tickle: Use cotton strands (e.g., from a cotton swab) and gently stimulate the hair inside the nares.
- Rectal exam: Part of the normal full exam for unconscious patients, this procedure may arouse the hysteric. When done in unconscious patients who are about to be chemically paralyzed for intubation, the absence of tone means they are paralyzed from a spinal injury.
- Foley catheter (especially males): This stimulation will usually awaken any male who can be awakened by external stimuli.
The simplest way to transmit information about the level of head injury is by using the Glasgow Coma Score (GCS; also known as the Glasgow Coma Scale). An alternative is the AVPU scale widely used in prehospital care: A = alert; V = responsive to verbal stimuli; P = responsive to painful stimuli; and U = unresponsive. Neurological consultants will want to know this critical information, especially when you ask for their advice or when you want to transfer head-injured patients to them.
Do not rely on the ophthalmoscopic exam to show evidence of acute rises in intracranial pressure. These changes appear only in chronic conditions, but retinal hemorrhages can be seen in infants with head injuries from child abuse.
In the midst of turmoil, be careful not to let easily salvageable head-injured patients die because (a) you confused a bad scalp laceration with an open skull fracture or (b) you did not control significant scalp bleeding. Control scalp hemorrhage by simply wrapping a tourniquet-type bandage around the head above the eye line. (Remember that all vessels to the scalp travel up from the neck.) When the bleeding slows, quickly use scalp clips, staples, or big sutures to stop the bleeding; then remove the tourniquet. Do a better closure later, if necessary.
Unsalvageable Head Injuries
Knowing which patients will not survive is the key to maximizing the use of limited resources to treat hordes of multiple and severely injured patients. As the US military recognizes, "the prognosis of brain injuries is good in patients who respond to simple commands, are not deeply unconscious, and do not deteriorate. The prognosis is grave in patients who are rendered immediately comatose (particularly those sustaining penetrating injury) and remain unconscious for a long period of time."15
Similarly, Dr. Husum and colleagues, in their book, War Surgery, write about patients who are "beyond salvation," saying that "bilateral dilated pupils that do not improve after a few hours in a comatose [head-injured] patient are a sign of major brain injury which normally will not respond to treatment. Operation in such cases is wasted."16 In a similar vein, the US military writes that "a GCS ≤ 5 indicates a dismal prognosis despite aggressive comprehensive treatment, and the casualty should be considered expectant [comfort care provided, but not treatment]."17
Head Injury Decision Rules
In austere situations where computed tomographic (CT) scans are not readily available, it may be an extremely weighty and costly decision to send patients for a CT scan. The question is: How much chance of making an error is reasonable in your situation?
In resource-poor environments, the best option may be to use the Canadian Rules (Adult and Child), since these will detect more patients who actually need neurosurgical intervention.
Canadian Adult Rule (≥16 Years Old; GCS 13 to 15)
- GCS <15 within 2 hours after injury
- Suspected open or depressed skull fracture
- Any sign of basilar skull fracture (hemotympanum, raccoon eyes, otorrhea, rhinorrhea, Battle's sign)
- ≥ 2 episodes of emesis
- >65 years old
- Moderate risk of brain injury on CT scan
- Retrograde amnesia ≥ 30 minutes
- Dangerous injury mechanism (pedestrian struck by motor vehicle, ejection from motor vehicle, fall from 3 feet/1 meter or ≥ 5 stairs)
The Canadian Adult Rule has a sensitivity of 100% and a specificity of 38% for detecting any lesion requiring neurosurgical intervention, and a sensitivity of 87% and a specificity of 39% for detecting any clinically important CT abnormality.18
- Age <2 years
- GCS <15
- Mental status change
- Sensory deficit
- Palpable skull defect
- Any sign of basilar skull fracture (hemotympanum, raccoon eyes, otorrhea, rhinorrhea, Battle's sign)
The Canadian Child Rule has >95% sensitivity and ~49% specificity, with a negative predictive value of >99% and a positive predictive value of >11%.19
Head Injury Treatment in Austere Situations
Skull radiographs are still valuable in head injury management if other imaging is not available. Radiopaque foreign bodies, usually bullets, can be located using both postero-anterior (P-A) and lateral or stereoscopic films (see Chapter 18, Radiology/Imaging). Also, finding a skull fracture is useful because: (a) a patient with a simple skull fracture and no abnormal signs has a 1:30 chance of developing an intracranial hematoma; (b) if there are abnormal signs with the fracture, the risk rises to 1:4; and (c) an intracranial hematoma nearly always will be on the side of, and at the site of, the fracture.20
Patients with facial injuries or who are not fully conscious should, as previously mentioned, be placed in the lateral decubitus or "recovery" position to preserve their airway. If a spinal injury is suspected, the method of rolling them into the recovery position, and the recovery position itself, should be slightly altered.
The HAINES (High Arm IN Endangered Spine) modified recovery position (see Fig. 8-1) has the patient's dependent arm (the one nearest the ground) extended above his head before he is rolled into the lateral decubitus position. When on his side, his head rests on that arm. This reduces lateral neck flexion to less than half of what it is when the dependent arm extends away from the body and the head droops down, as is normally the case. For patients in the HAINES position, flex their legs so the patients are supported on their side.21
In remote or dangerous locations or in disaster settings when resources are minimal, decisions must be made about whether to follow standard field guidelines, that is, to immobilize the spine of anyone with a possible spinal injury.
As the National Association of Emergency Medical Services Physicians wrote, "Full-spine immobilization, if it is not required, can be unnecessarily difficult, impractical, impossible, and even dangerous during prolonged evacuation, especially in severe environments or when using improvised equipment."22 That is not to say that you shouldn't make a reasonable effort to protect the patient's spine, but other factors may take precedence. Using the cervical spine decision rule as described under "C-Spine Decision Rule," later in this chapter, may help, but a situational assessment must accompany its use. Note that even after a decision about immobilization is made, it is necessary to reassess the patient over time, as the clinical picture may change.
While only bilateral sandbags held together with tape over the forehead has been proven to immobilize the spine in the prehospital and emergency department setting,23 in emergency situations, cervical immobilization collars can be fashioned from a sleeping pad; a padded hip belt from a pack; any cloth, padding, or clothing; a tarp; or a tent flap. They may also be made from cotton and gauze and bandages (Schanz collar), newspapers, cardboard, blankets, plaster of Paris, or polyvinyl chloride (PVC) pipe, as described below.
To make a Schanz collar, wind a 5-inch-wide strip of cotton around the patient's neck several times. Over this, apply gauze to compress the cotton. Add additional layers of cotton and gauze, winding the gauze tighter as the collar's thickness increases. To get the desired effect, this collar should fill the entire submental space. As the collar loosens over time, apply additional cotton under the edges, with a tighter gauze bandage over it.24 Although similar to a commercial "soft collar," a Schanz collar provides considerably more support.
To fashion a useable c-collar from newspaper and socks, stack 10 open sheets of newspaper. Fold the stack in half along its longest dimension. Then fold it in thirds. The width should be appropriate for an adult. For a child, use seven sheets and fold them in half until the correct width for that child is found. Then slip a heavy sock over each end, pass the collar around the patient's neck, and secure it with tape, a scarf, a necktie, or bandage material.
The framework for this c-collar is made either from a corrugated cardboard box, such as that in which stores receive merchandise, or by cutting off the top of a plastic bucket. Cut an 18- × 6-inch piece and cut an indentation in the middle of one long edge to accommodate the chin; cut two shallower pieces from the sides where the collar passes over the shoulders. Finally, cut a shallow indentation on the upper (chin) side at each end of the piece to accommodate the occiput.
If using cardboard, bend it at multiple sites along its length so that it will easily encircle the neck. Next, wrap the cardboard with cotton, socks, or other soft padding materials. Then slip it into a stockinet or long sock, or wrap it with a tight elastic or gauze bandage (Fig. 26-3). Secure it around the neck with additional bandaging, tape, a belt, or a similar tie. The tightness of these ties determines how much stability the collar will have.24
Cervical collar from wrapped cardboard.
Blanket rolls can be made and easily stored for use as cervical collars for patients who are supine, who are prone, or who must be kept on their sides. Blankets can also be used to make a collar for a seated patient. First, fold a heavy blanket lengthwise once. Then tightly roll it toward the middle from both ends. When the two rolls meet, tape the entire package together for storage. Experience shows that it needs two layers of tape. When a collar is needed, the tape can be cut and the rolls opened as far as necessary.
For a cervical collar (patient supine, prone, or on his side), open the two rolls wide enough to accommodate the patient's head and position the back of the roll behind the head (Fig. 26-4). Then put tape around the package. This is often easiest if the patient is on a backboard. For a seated patient, unroll the package, but keep the blanket folded. Roll it tightly lengthwise and wrap it around the patient's neck, with the ends overlapping across his chest. Tightly tape the two ends of the blanket together (Fig. 26-5).25
Blanket roll as c-spine stabilizer for supine patient.
Blanket roll stabilizing c-spine in seated patient.
Plaster of Paris has long been used as a c-collar. It can be placed over virtually any type of padding as a primary collar, or can be used to hold other materials (such as clothing being used as a c-collar) in place.26 A c-collar made totally of plaster is heavy, so it is not generally used in ambulatory patients.
The cast must extend the entire length of the c-spine. It must have a broad weight-bearing base over the shoulders and support the jaw and occiput. Unless the patient is already in cervical traction, someone must maintain traction while the plaster is applied and until it sets. To apply it, put thick padding over the shoulders, jaw, and occiput. Next apply two broad plaster slabs—one anteriorly and the other posteriorly. Then apply the plaster around the neck to secure these slabs.27 The problem with this collar is that once applied, it is difficult to adjust. "After the first day, or two, a certain amount of play will develop from compression of the padding material."24
More durable cervical collars can be made from pieces of a large plastic (PVC) drain pipe. Although these collars take some time to make, PVC pipe is ubiquitous and the collars last a long time.
Use a piece of pipe that has an internal diameter of the neck(s) you want to stabilize, and saw the piece in half. Drill 0.25- to 0.5-inch holes in it so air can pass through to the neck for comfort. Drill smaller holes along the edges that fit together and use lacing to close the two halves around the neck (Fig. 26-6). Making multiple rows of holes for lacing material allows this collar to be used on various sized patients.
Shape the collar so that it will fit better around the neck, chin, and occiput by placing it in boiling water or by using a welding torch or other low-intensity flame to soften it. If a flame is used, take care not to burn the plastic.28 (See Chapter 27, Ophthalmology, for more information on making medical equipment using PVC pipe.)
Thoracic and Lumbar Spine
A number of makeshift litters are described in Chapter 20, Patient Transport/Evacuation. However, many are not rigid enough to provide optimal support for suspected thoracic or lumbosacral spine injuries. Ideally, patients with a suspected thoracic spine injury should be immobilized from head to pelvis, with their hips adjusted for comfort. Patients with potential lumbar-pelvic injuries should have their thoracic spine, pelvis, and hips (in a position of comfort) splinted. This generally requires using a backboard, which can be made from a flat door, a piece of wood or metal (usually too heavy), or another strong flat object.
The NEXUS C-Spine Rule (Table 26-2) uses five very subjective criteria. If the patient meets all five criteria, he has a low probability of a clinically significant ("likely to result in any harm to patient") cervical spine injury. The NEXUS C-Spine Rule has a sensitivity of 99% and a negative predictive value of 99.8%.29
Table 26-2 NEXUS C-Spine Rule |Favorite Table|Download (.pdf)
Table 26-2 NEXUS C-Spine Rule
|1. No tenderness at the posterior midline of the cervical spine.*|
|2. No focal neurological deficit.†|
|3. A normal level of alertness.‡|
|4. No evidence of intoxication.§|
|5. Absence of clinically apparent pain that might distract the patient from the pain of a cervical-spine injury.|||
In austere medical situations when the patient cannot be imaged, you will need to make a decision at some point to remove the collar—or to leave it on long term. Remove spinal immobilization (without imaging) if the patient meets the c-spine rules for not applying a collar and the patient (a) is conversant, alert, and not inebriated on any substance; (b) has no spontaneous complaint of neck or back pain; (c) has no major distracting (painful) injury; and (d) has no neurological compromise on exam (i.e., can move all extremities, no tenderness on palpation of spine).
Cervical spine injury with neurological signs indicates the need for cervical traction.30 For unstable c-spines, surgery or braces are generally used rather than traction. However, in austere circumstances, traction may be the only option. The problem is that unless traction is being used only symptomatically for cervical disc pain or to reduce a subluxation, prolonged traction, long-term c-collar use, or surgery may have to follow at some point. Traction used for fractures of subluxations nearly always needs to be followed using radiographs. That is the only way to determine if there is sufficient weight pulling in the correct direction.
Halter or sling traction is the easiest and least-invasive traction method; it can be used not only for unstable c-spines and subluxations, but also for cervical disc pain. If used for disc pain, it can be applied intermittently as an outpatient or used in the patient's home. When using this method, do not exceed 5 kg of weight (which may not be sufficient in spinal injuries). If used for spinal injury, attempt to replace it with a more formal traction method within 24 hours.31
Halter traction equipment can be easily and inexpensively made from local resources. The basic parts of the system are the pulleys, cord, head harness, and weights.32 Pulleys are made from small pipes grooved to allow passage of the cord. These can be taken from orthopedic traction devices and attached to the end of the bed or stretcher. Any cotton or nylon rope is suitable, as long as it is strong enough to hold the weights and fits in the pulley grooves.
The head harness should be well padded with a soft cloth. It can be made from cow leather and sandal buckles. It could also be made from jeans or khaki clothing material, or from canvas (Fig. 26-7). Remember, the hole between the two strips must be wide enough to slip over the head.
Weights can be fashioned from 5-L heavy-plastic bags (irrigation bags), large jars, or plastic bottles. They should be calibrated in kilograms by water weight: add 1 L of water at a time and mark them at each level (1 L water = 1 kg). Hooks can be made from 0.25-inch metal rods shaped into an S.
Cervical Traction Management
These rules apply to most cases where cervical traction is being applied for acute trauma.33,34
Traction is strictly neutral—the patient's neck should be neither in flexion nor in extension.
Apply counter-traction by elevating the head of the bed about 4 cm for each kilogram of weight applied (as with femoral traction).
Traction weight for adults (larger individuals may need more): C1, use 2.5 to 5 kg; C2, 3 to 5 kg; C3, 4 to 7 kg; C4, 5 to 10 kg; C5–6, 7 to 15 kg.
Increase the weight stepwise, adding 2 kg every 4 to 6 hours. Use lateral c-spine radiographs at each step. The spinal deformity will gradually reduce under traction.
Analgesia prevents muscle spasms and makes the traction more effective.
Most c-spine fractures are in the correct position within 24 hours. The traction weights are then gradually reduced under radiographic control.
Displaced neck fractures >1 week old may require several days to reduce.
Displaced neck fractures >3 weeks old may not respond to traction. Stabilize them in a cast or a collar.