Objectives:   Define and recognize common symptoms and treatments of head and neck injuries Become more familiar and comfortable with the history and physical exam techniques of common head and neck injuries Know when to seek a higher level of care for certain common head and neck injurie

Bires, MD, Greta

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Thomas Jefferson University Jefferson Digital Commons Department of Family & Community Medicine Presentations and Grand Rounds Department of Family & Community Medicine 8-13-2020 Head and Neck Injuries for the PCP Greta Bires, MD Thomas Jefferson University Follow this and additional works at: https://jdc.jefferson.edu/fmlectures  Part of the Family Medicine Commons, and the Primary Care Commons Let us know how access to this document benefits you Recommended Citation Bires, MD, Greta, "Head and Neck Injuries for the PCP" (2020). Department of Family & Community Medicine Presentations and Grand Rounds. Paper 437. https://jdc.jefferson.edu/fmlectures/437 This Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of Thomas Jefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarly publications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers and interested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion in Department of Family & Community Medicine Presentations and Grand Rounds by an authorized administrator of the Jefferson Digital Commons. For more information, please contact: JeffersonDigitalCommons@jefferson.edu. Head and Neck Injuries for the PCPGreta Bires, MDPGY2DisclosuresNoneObjectivesDefine and recognize common symptoms and treatments of head and neck injuriesBecome more familiar and comfortable with the history and physical exam techniques of common head and neck injuriesKnow when to seek a higher level of care for certain common head and neck injuriesHead and Neck InjuriesOften occur simultaneously 70% mortality20% permanent disabilityCase 1You’re an intern on service when you get a call from a nurse.  Mr. B was in the chair when he decided to get up on his own to go to the bathroom.  He slipped and fell, hitting his head on the side of the bed.  He is currently lying on the ground. The nurse is asking you to come evaluate. What are your next steps of action?Evaluation of the Head and NeckTime of InjuryAssess LOC, ABCsPeripheral Strength and Sensation w/o moving head or neckPalpate neck for spasm or tendernessIsometric strength without moving neck or spineActive ROM of neckSpurlingNeuro examRecent memory and postural instabilityAsk about symptomsGCS in AdultsBest score 153 categories - Eye opening- Motor response- Verbal responseWorst score 3Mild TBI/Concussion scores 13-15GCSEye opening - Spontaneous (4)- Verbal commands (3)- To pain (2)- None (1)Best motor response- Follows verbal commands (6)- Localizes pain (5)- Normal Flexion to painful stim (4)- Abnormal flexion to painful stim (3)- Decerebrate posturing to pain (2)- None (1)Best verbal response- Oriented to conversation (5)- Disoriented conversation (4)- Inappropriate words (3)- Incomprehensible words (3)- Incomprehensible sounds (2)- None (1)Red Flag Symptoms- Altered consciousness- Behaves unusually or seems confused and irritable- Cannot recognize familiar people or disoriented to place- Double vision- Progressively declining neuro eval- Pupillary asymmetry- Repeated vomiting- Seizures- Slurred speech- Unsteady on feet- Weakness or numbness in arms or legs- Worsening headacheImaging requirementsNexus C-Spine Criteria         Canadian C-Spine RuleFocal neuro deficit presentMidline spinal tendernessAltered level of consciousnessIntoxicationDistracting injuryAge >=65 years oldExtremity paresthesiasDangerous mechanism- Fall from >3 feet/5 stairs- Axial load injury- High speed MVC/rollover/ejection- Bicycle collision- Motorized recreational vehicleCanadian CT Head Injury/Trauma RuleExclusion Criteria: age <16 yo, on blood thinners, seizure after injuryhttps://www.mdcalc.com/canadian-ct-head-injury-trauma-rulePECARN Pediatric Head Injury/Trauma Algorithmhttps://www.mdcalc.com/pecarn-pediatric-head-injury-trauma-algorithmJefferson Fall GuidelinesAssessment done on all patients Nursing to immobilize in hard cervical collar and on long backboard if cervical tendernessPost Fall Assessment order set- STAT head CT scan, STAT cervical spine x-ray, STAT cervical spine CT scan, q1H neuro checks x4, then q2 hour neuro checks x2, consult trauma and neurosurgeryCase 230 year old male with no significant PMH presents with a headache.  He reports that he was out Saturday night, 2 days prior to presentation, and was going down the stairs when he hit his head on the ceiling.  He woke up with a headache the next day, but thought nothing of it.  The headache has persisted and today he was having some trouble concentrating at work so he decided to come in for further evaluation.  What more do you want to know?Evaluation of the Head and NeckTime of InjuryAssess LOC, ABCsPeripheral Strength and Sensation w/o moving head or neckPalpate neck for spasm or tendernessIsometric strength without moving neck or spineActive ROM of neckSpurlingNeuro ExamRecent memory and postural instabilityAsk about symptomsTBI and ConcussionApproximately 1.7 million TBI annually 75% mild TBIMen > WomenPathophysiologySudden release of excitatory neurotransmittersSudden release of Potassium into extracellular spaceInflux of calcium into cellTransient hypermetabolic glycolytic state and production of free radicalsClinical FeaturesClinical FeaturesLOCRetrograde or anterograde amnesiaHeadacheNauseaTinnitusPhotophobiaVertigoFeeling in fogDifficulty concentratingDecreased reaction timeLabilityDepressed mood AnxietyFatigueDizzinessGait instabilitySomnolenceDrowsinessinsomniaSCAT5 and Child SCAT5https://bjsm.bmj.com/content/bjsports/early/2017/04/26/bjsports-2017-097506SCAT5.full.pdfWhat instructions do you give him?TreatmentInitial RestEarly EducationManage Specific SymptomsTransition back to school/work and return to playSlow reintegration, avoid standardized testing, monitor 2-3 months for difficultiesStart return after rest and resolution of symptomsSteps of return to play- Symptom limited activity (normal activities of daily living)- Non Impact aerobic exercise- Sport-specific exercise (non-impact drills)- Non-contact training drills- Full contact practice- Return to normal playFollow upPatient comes back to you one month later.  He has persistent headache and still feels like he isn’t completely out of a fog. What are your next steps?Persistent Postconcussion syndrome> 1 month Education and reassuranceCBTExercise, vestibular, and cognitive rehab programsReferCTEAttention, memory and psych symptomsRegional deposition of tau proteinsAssoc with alzheimer disease, parkinson disease, depression, suicideCase 343 year old female with history of HTN presents after fender bender complaining of neck pain.  She reports she got rear-ended by another vehicle.  She estimates the other car was going around 20 mph.  She did not hit her head, but felt jolted.  No real pain at that time, but within 30 minutes she started to feel very sore and couldn’t move her neck to the L.  She had no numbness, tingling or weakness. She tried tylenol without relief. Cervical Spine Anatomyhttp://journalofprolotherapy.com/cervical-spine-injuries-literature-reviews/https://musculoskeletalkey.com/posterior-cervical-approach/Whiplash InjuryAcceleration-deceleration mechanism causing sudden neck extension and flexionSx: neck pain and stiffness immediately after injury, shoulder or back pain, dizziness, paresthesias, fatigueDx: clinical presentation and clinical findingsTreatment: early mobilization, early return to normal activityCervical strain/sprainNo injury to nerves or bonesSx: cervical pain without radiation or neuro symptomsExam: limited cervical ROM and muscular spasm or tendernessInitial treat: NSAIDs/tylenol, modalities (heat, etc)Postural SyndromesSx: periscapular or posterior neck pain exacerbated by prolonged static posturePE: thoracic kyphosis, rounded shoulders, tight pectoral muscles, restricted shoulder movements, protruding chinTreat: retraining, workplace modifications, physical therapyCase 4AJ is 8 years old and was playing basketball with his dad.  His dad threw him the ball and it came a little faster than he expected and ended up hitting him in the face.  He immediately felt pain and his nose started to bleed.  His dad reports they applied pressure for about 30 minutes, but his nose was still bleeding a little so they decided to come in for further evaluation.  He denies any headache, LOC, nausea, dizziness, or blurry vision.  He does not take any medications regularly and has no PMH.  No prior injury to the nose. What’s on your differential?Nose Anatomy-https://www.aafp.org/afp/2004/1001/p1315.htmlNasal FracturesMCC: fights, sports injuries, falls, vehicle crashesKey History: mechanism, direction, strength of force, timing, extent of bleedingPE: adequate airspace, eval for other head or neck injuries, palpateRed flags: clear rhinorrhea, subcut emphysema, mental status change, limited EOMTreatment: pain medications, rest, ice, maintain head elevation, delayed reductionEpistaxis60% general population, 6% (1 in 10) seek medical attentionPeak distribution children <10 yo, adults 70-79 yoHistory: side of bleeding, previous episodes, treatments, comorbid conditions, med usePhysical: vitals, mental status, airway patencyVascular supply  https://www.aafp.org/afp/2018/0815/p240.pdfHow would you treat?Anterior EpistaxisCompressive therapyOxymetazoline nasal spray, topical epiDirect nasal cautery - silver nitrateTopical therapy and Nasal PackingPosterior EpistaxisIV access and fluid resuscitationChemical cautery not possibleStabilize with posterior packingOften requires hospitalization - refer to ENT or EDAAFP Photo Quiz CaseA 25-year-old man presented with complaints of midfacial pain, fever, and general malaise of about 48 hours' duration. He denied having a cough, rhinorrhea, or nasal congestion. The patient reported being hit in the nose about 10 days earlier and had received no interval treatment. The patient's temperature was 100.6° F (38.1° C) orally and he had no frontal or maxillary sinus tenderness. Nasal examination revealed bilateral midline nasal swelling. The rest of the physical examination was unremarkable.https://www.aafp.org/afp/2006/0501/p1617.htmlBased on the history and physical exam what is the most likely diagnosis?a. Sinusitisb. Septal hematomac. Nasal polypsd. Foreign bodye. Viral syndromehttps://www.aafp.org/afp/2006/0501/p1617.htmlSeptal hematomaCollection between nasal mucosa and cartilaginous septumOften bilaterally following nasal traumaEasily infectedPE: slightly white or purple area of fluctuance on one or both sides of nasal septumImmediate referralComplications: saddle nose deformityObjectivesDefine and recognize common symptoms and treatments of head and neck injuriesBecome more familiar and comfortable with common history and physical exam techniques of common head and neck injuriesKnow when to seek a higher level of care for certain common head and neck injuriesEvaluation of the Head and NeckNote exact time injuryAssess LOC, ABCsPeripheral strength and sensation without moving head or neckPalpate neck for asymmetric spasm or tendernessIsometric strength without moving neck or spineAssess active ROM of neckProvocative testNeuro ExamAssess memory and postural instabilityAsk about symptomsThank you. ReferencesStiell I. Canadian C-Spine Rule. MDCalc. Accessed August 10, 2020. https://www.mdcalc.com/canadian-c-spine-ruleStiell I. Canadian CT Head Injury/Trauma Rule. MDCalc. Accessed August 10, 2020. https://www.mdcalc.com/canadian-ct-head-injury-trauma-ruleFerry B, DeCastro A. Concussion. In: StatPearls. StatPearls Publishing; 2020. Accessed August 10, 2020. http://www.ncbi.nlm.nih.gov/books/NBK537017/Yue JK, Upadhyayula PS, Avalos LN, Phelps RRL, Suen CG, Cage TA. Concussion and Mild-Traumatic Brain Injury in Rural Settings: Epidemiology and Specific Health Care Considerations. J Neurosci Rural Pract. 2020;11(1):23-33. doi:10.1055/s-0039-3402581DeMatteo C, Randall S, Falla K, et al. Concussion Management for Children Has Changed: New Pediatric Protocols Using the Latest Evidence: Clinical Pediatrics. Published online October 18, 2019. doi:10.1177/0009922819879457Thank you. ReferencesWomack J, Stabile M, Kropa J. Epistaxis: Outpatient Management. American Family Physician. 2018;94(4):240-245.Isaac Z, Kelly H. Evaluation of the adult patient with neck pain - UpToDate. Accessed August 10, 2020. https://www.uptodate.com/contents/evaluation-of-the-adult-patient-with-neck-pain?search=common%20neck%20injuries&source=search_result&selectedTitle=9~150&usage_type=default&display_rank=9#H474720179Kucik CJ, Clenney TL, Phelan J. Management of Acute Nasal Fractures. AFP. 2004;70(7):1315-1320.Silverberg ND, Iaccarino MA, Panenka WJ, et al. Management of Concussion and Mild Traumatic Brain Injury: A Synthesis of Practice Guidelines. Archives of Physical Medicine and Rehabilitation. 2020;101(2):382-393. doi:10.1016/j.apmr.2019.10.179Binder A. Neck Pain. AFP. 2005;71(1):117.Childress M, Stuek S. Neck Pain: Initial Evaluation and Management - American Family Physician. AAFP. Accessed August 10, 2020. https://www.aafp.org/afp/2020/0801/p150.htmlThank you. ReferencesHoffman J. NEXUS Criteria for C-Spine Imaging. MDCalc. Accessed August 10, 2020. https://www.mdcalc.com/nexus-criteria-c-spine-imagingNosebleed (Epistaxis). Accessed August 10, 2020. https://www.aafp.org/patient-care/clinical-recommendations/all/nosebleed.htmlGhiselli G, Schaadt G, McAllister DR. On-the-field evaluation of an athlete with a head or neck injury. Clinics in Sports Medicine. 2003;22(3):445-465. doi:10.1016/S0278-5919(02)00109-6Patient education: Whiplash (The Basics) - UpToDate. Accessed August 10, 2020. https://www.uptodate.com/contents/whiplash-the-basics?search=whiplash&source=search_result&selectedTitle=2~29&usage_type=default&display_rank=2#H11943796Kuppermann N. PECARN Pediatric Head Injury/Trauma Algorithm. MDCalc. Accessed August 10, 2020. https://www.mdcalc.com/pecarn-pediatric-head-injury-trauma-algorithmThank you. ReferencesMisch MR, Raukar NP. Sports Medicine Update: Concussion. Emergency Medicine Clinics of North America. 2020;38(1):207-222. doi:10.1016/j.emc.2019.09.010Junnila J. Swollen Masses in the Nose. AFP. 2006;73(9):1617.Graham R, Rivara FP, Ford MA, et al. Treatment and Management of Prolonged Symptoms and Post-Concussion Syndrome. National Academies Press (US); 2014. Accessed August 10, 2020. https://www.ncbi.nlm.nih.gov/books/NBK185342/Eck JC, Hodges SD, Humphreys SC. Whiplash: a review of a commonly misunderstood injury. The American Journal of Medicine. 2001;110(8):651-656. doi:10.1016/S0002-9343(01)00680-5

Head and Neck Injuries for the PCP

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Head and Neck Injuries for the PCP

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