by David Page
gunshot wound may, through different mechanisms, all result in a central brain blood clot.
By the way, you never remove an impaling object from the skull. The neurosurgeon will do so in the operating room where all hell may break loose if more bleeding is unleashed.
Bullet wounds to the skull are frequently wrongly invented in contemporary fiction. Improbable entry and exit locations are often chosen which, in reality, would cause disruption of nerve pathways followed by paralysis, prolonged coma or death. Yet, the character walks and talks.
So it's important to remember the following two bad prognostic signs with penetrating head injuries:
1. "Through and through" (entry and exit wounds visible) wounds are ominous.
2. The lower down on the skull (closer to the vital brain stem functions) the bullet hole, the worse the prognosis.
Also, most bullets leave small entry wounds and blow off the back of the skull (huge exit wound). Hemingway got it right. But regardless of which of these brain injuries is suspected, the doctor will assess each patient in the same fashion. The easiest, most productive method of neurologic evaluation tests the victim's ability to open her eyes, talk, and move.
The Glasgow Coma Scale (GCS) is also part of the revised trauma score and describes the method doctors use to assess the trauma patient's present level of brain function. You now understand how important it is for the paramedic to document this information in the field. If the victim's level of consciousness changes, the trauma surgeon may not be aware of it unless proper documentation in the field was carried out. The basic principle is for the examiner to determine what the best response is at that time:
The best GCS score is 15 while a 3 signifies an overwhelming brain injury. Other grave findings in a head injury victim are seizures, restlessness and severely elevated body temperature.
The sidebar on page 69 gives you a sketch of what steps the surgeon takes to triage a head-injured victim.
Scalp Injury
Scalp lacerations vary from trivial but bloody cuts all the way to what doctors refer to as degloving injuries—a literal ripping of the scalp from its bony cranial attachments like stripping off a glove. In the Old Wfest, it was called scalping.
The scalp is the thickest skin in the body; more cushion for the squash. Because scalp arteries run in dense connective tissue and are "held open" by this fibrous net, scalp lacerations bleed like swamps, especially in children. You may recall someone in your childhood, blood dripping into her eyebrows, hair matted, wailing in fear. Scalps can bleed a lot. Use this fact to create drama, uncertainty about prognosis or a major life-threatening hemorrhage.
How the doctor treats a scalp laceration
■ Washes (irrigates) wound with lots of normal saline
■ Clamps massively bleeding blood vessels and ties them off
■ Examines the wound with gloved finger looking for a skull fracture; orders skull x-rays as needed (maybe a CT scan with prolonged coma)
■ If uncomplicated by a fracture, sutures scalp closed
■ If complicated, calls neurosurgeon
Master Injury List For the Head II
Injuries not involving the brain and skull Scalp Wounds
■ Minor: Bleeding may be impressive; lacerations small, require only sutures
■ Major: Most of scalp ripped from skull; needs careful assessment of skull before closure
Facial Fractures
■ Orbital (eye) fractures
■ Nasal fractures
■ Cheekbone fractures Jaw Fractures
■ Lower jaw (mandible): Various patterns
■ Upper jaw (maxilla): LeFort I, II and III
You can remember the layers of the scalp from the outside in by using the mnemonic SCALP. See Figure 8 on page 73.
Facial Injuries
The three types of fractures of the face and cheeks are fractures of the lower jaw, upper jaw and the zygoma or cheekbone. Any fracture of the bones forming the orbit (the bony circle about the eye) must be referred to a plastic surgeon for immediate repair. This is also true for cheekbone breaks. The zygomatic bones, which give the cheek its loft, are immediately beneath the skin and get smashed with some regularity. These injuries also require the skill of a plastic surgeon to elevate the fragments and wire them back into proper alignment. Fixing a broken nose is optional. Fractured nasal bones may need to be pried back into position; undisplaced breaks are left to heal by themselves.
The upper jaw fractures may also involve other facial bones and reflect extensive facial trauma. Called LeFort fractures, they occur with major facial smashes (Figure 9, page 74) and are Types I, II and III.
Lower Jaw Injuries
Bruising of the chin as well as sore jaw joints result from being struck in the jaw. More serious is a fracture of the jaw, as shown in Figure 9.
Jaw fractures are treated by stabilizing the jaw using the teeth to hold the fracture together with bars, wires and rubber bands. Your "wired" character will spend several weeks eating through a straw.
The best way to diagnose a broken jaw is to find the tender point and move it. A crunching noise called crepitus tips off your doctor character, who should don gloves for this exam. It's performed with both hands, one inside the mouth, one outside. Will he get bitten by his patient?
We'll finish with a few head odds and ends that can be useful in characterization.
Patterns of Baldness
Baldness coupled with evidence of a hair transplant may help develop character or reflect how one deals with aging. Does the CEO walk into the boardroom with plugs of one-inch hair creating a new hairline
above his bushy eyebrows? Are the surgeon's indelible ink marks still evident at the base of each tuft? Does anyone in the room dare ask?
Eye Signs From Local Trauma
Subconjunctival hemorrhage: Bleeding under the red inside part of the eyelid. Usually heals without treatment but looks terrible for a while.
Scleral hemorrhage: Bleeding beneath the white part of the eye that abates slowly. May suggest other more serious eye injuries.
Orbital cellulitis: Infection of the soft tissue about the eye with swelling, redness and pain in the eye; often must be treated in the hospital with IV antibiotics. This is a good problem to get character out of the way for a few days. A managed care plan may not allow hospitalization. Ruptured orbit: Fluid drains from eyeball, which collapses. Usually from impalement of eye with sharp object; results in blindness if not repaired, and may cause blindness regardless of treatment.
Cut Facial Nerves and Facial Paralysis
Upper facial laceration: A cut lateral to eye on cheek may produce a permanently open eye with drainage—a one-sided vacant stare. Lower facial laceration: If anywhere near jaw margin, this can produce a depression ("droopy") deformity at the corner of the mouth.
Bizarre Things
Stephen King hits the high-water mark for the medically grotesque in the prologue of The Dark Half when he describes a neurosurgeon opening the skull of a patient whose twin was all but absorbed during embryological development. Left on the surface of the brain, the fascinated surgeon discovers, is an eyeball that "looked as if it were trying to wink at them," three fingernails and two teeth. This, from the master of aberration.
Do what you will with the noble head. Create new injuries, bizarre scars. Make your readers remember your friends any way you can.
Witness expert trauma care at an accident scene and you will notice how obsessive paramedics are about protecting the neck in cases of potential cervical spine injury. Not only is head trauma often associated with neck injury, but the neck injury is potentially unstable.
Potentially. That means conflict.
Angular with soft muscular cords framed by brunette locks or massive from the fullback's hairline to his shoulders, the neck conceals a vital tangle of tubes, nerves and blood vessels. These essential structures travel from the head to the chest or arise from the heart and shoot upward in a sprig of branch
es to the head, neck and arms. Size does little to afford the neck protection from injury.
The neck is also a common target for assault. Weapons such as a knife, screwdriver, ice pick, piece of glass, length of wire or gun may be used to slash, stab, garotte or shoot the neck. A maddened, mindless attacker may not use a penetrating weapon. Grabbing anything in sight to bludgeon his victim, or employing his fists, the villain may smash repeatedly at the neck. Blunt trauma in the form of strikes or compressive force by hands, arm, wire or rope produce different injuries from those seen with penetrating trauma. A stranglehold may be used to frighten human prey as well as to kill.
While the spinal cord isn't always at risk, major blood vessels in the neck frequently come under attack. A lot of anatomical structures stand in the path of a neck assault, and most of them don't take kindly to being cut open. Before we get to specific injuries, e.g., those produced by blunt vs. penetrating impact, consider what's at risk regardless of the traumatic agent:
• Larynx (voice box)
• Trachea (windpipe)
• Jugular vein
• Carotid artery
• Esophagus (gullet)
• Spinal cord
• Vertebrae
The neck encompasses an impressive number of vital organs, and the injury of any of these structures, could result in death. Both blunt and penetrating neck trauma cause major injuries, and some are associated with prolonged disability.
As always, it's a matter of degree.
Direct Trauma to the Neck
Penetrating Neck Trauma
The treatment of any neck injury begins with two questions: (1) Is there an actual or potential spinal cord injury? (2) Does the victim have an adequate airway?
Assume for the moment we're dealing with penetrating neck trauma from a knife assault. Most neck injuries result from a stabbing attack. Sharp, penetrating attacks to the neck often come from in front and are aimed at the anterior neck or chest, and frequntly, structures in both anatomic areas become injured with a single assault. Attacks from behind are still directed for the most part at the throat. With a "reach-around" knife assault, the intent is to slash open the major neck blood vessels.
Thus, as a general statement, muscles, ligaments and vertebrae (including the spinal cord) are seriously injured by indirect neck trauma, while superficial anterior structures are at risk from sharp weapon
Master Injury List For Neck Trauma
Minor Neck Injuries
■ Neck sprain
■ Minor fracture of vertebral process
■ Stable ligament tear
■ Contusion of neck
■ Minor lacerations
■ Temporary spinal cord injury Major Neck Injuries
■ Laceration of the jugular vein
■ Laceration of the carotid artery
■ Perforation of the larynx
■ Perforation of the trachea
■ Perforation of the esophagus
■ Unstable neck fractures
■ Permanent spinal cord injury
assaults. On the other hand, gunshot wounds may rip through any part of the neck.
A discussion of penetrating injuries centers on whom the trauma surgeon should take to surgery in order to explore the neck structures for serious injury. But with neck fractures, the issue is what method of stabilization is most advantageous.
In a study on penetrating neck wounds, those victims explored immediately had a 6 percent mortality rate. Victims of a neck stab injury either not operated on at all or for whom surgery was delayed during initial observation had a 35 percent death rate—almost a sixfold increase.
Quite a difference. And while we don't know how many of the operated patients developed complications after surgery, the number of patients who had a neck operation with no findings of a major injury ranged from 40 to 63 percent. Still, this large negative exploration rate wasn't enough to discourage most trauma surgeons from an aggressive approach to these injuries. And these injuries are not a new problem. The first lacerated carotid artery was tied off by a French surgeon in the 1500s!
Neck and Spinal Cord Injuries: Snapped, Stabbed and Strangled / 79
To resolve the issue of whom to operate on and whom to observe, a system is used that divides the neck into three zones, as shown in Figure 10. Treatment decisions are now determined by the zone involved. Zone I: Root of the neck, from the collarbone to the lower edge of the larynx (Adam's Apple). This is the most dangerous neck zone as serious injuries to the great vessels arising from the heart occur with downward-directed knife assaults. An innocent-looking stab wound above the collarbone may lacerate the aorta in the chest. Beneath the skin in the middle of the neck lies the trachea (windpipe) and just behind it the esophagus (gullet). A knife attack may cut open the esophagus, spilling terrible bacteria into the chest. Immediate or delayed infections can occur if these injuries aren't recognized.
The surgeon may ask for an arteriogram, a special dye study (an x-ray) of the arteries in the region of the wound. This will indicate if there's a blood vessel leak. Other studies include an upper GI series, to examine the gullet for a perforation, and bronchoscopy, a look inside the windpipe with a fiberoptic instrument.
If a major injury is diagnosed, the surgeon will have to "crack" (surgically open) the chest. Midline sternum-splitting incisions as well as horizontal incisions beneath the collarbone are used.
Zone II: From the lower edge of larynx to angle of the jaw. Many of the stab wounds in this area are evaluated in the trauma room where a decision about further surgery depends on a few reliable physical findings. Because most of the vital structures are not deep in this zone, special x-rays are used less often.
Acute physical findings that require emergency surgery include:
• A hematoma (blood clot) that's expanding or growing as it is observed, the implication being that a major blood vessel continues to bleed and the airway may become squeezed
• Major bleeding from the wound not adequately controlled in the trauma room
• Air in the neck tissue (subcutaneous emphysema), which means the larynx or trachea has been perforated
• A major wound that must be debrided (cleaned up) surgically and inspected carefully (Bleeding and poor lighting in the ER mean that not all wounds are properly assessed there).
Zone III: The area above the jaw up to the base of the skull. It's not easy for a surgeon to dig around in the tight spaces of the upper neck and face without inadvertently causing more damage than already exists. If major hemorrhage is the problem, the radiologist will perform an arteriogram and inject material into the small arteries of the facial area to plug the holes and stop the bleeding without surgery. More superficial wounds may be explored directly.
In any of these zones, the wound may not appear to be deep, and careful observation—if local exploration in the trauma room reveals no major injuries—is a reasonable option. At times, a decision is made to observe a patient, only to be reversed hours later. With neck wounds, a healthy dose of suspicion is warranted. Proponents of the two schools of thought—to observe some neck wound victims or operate on everyone— cross swords over whose approach represents the best medicine.
Observation includes performing any number of the following tests at any time during the first few hospital days:
• Barium swallow to evaluate the gullet (esophagus)
• Endoscopy to look directly into the esophagus
• Laryngoscopy to assess the throat and upper airway
• Bronchoscopy to look at the lower airways
• Arteriogram to evaluate the arteries of the neck and upper chest (x-rays are never done on the veins), used most in Zones I and III
During your victim's trauma room evaluation, and through the uncertain early hospital course, the clock just keeps on ticking. If you need a subplot for your injury-strewn story, consider two doctors who disagree on which stabbed neck to explore. Make it the neck of a prominent citizen or a sup
ermodel.
Turn up the heat. Penetrating neck trauma lets you play around with treatment options.
Blunt Neck Injuries
These are usually less severe although it's possible to clot off a carotid artery with blunt neck trauma, sometimes resulting in a stroke. Near hanging, garotting as a threat or an interrupted choking attempt all leave soft tissue swelling and the possibility of airway blockage.
It may not happen immediately; your heroine may turn purple at midnight.
Tick tock.
Indirect Trauma to the Neck
Neck Fractures and Dislocations
A broken neck can kill your character quicker than a jab in the throat. But the trauma patient who suffers from quadraplegia—loss of function of the arms and legs—may be the most unfortunate victim of chance. For the writer, a neck injury or a head injury with the potential for neck damage opens unlimited possibilities.
For example: paralysis—if that's the end point you are seeking— may occur:
• At the time of the accident
• When emergency personnel or a well-meaning friend first attempts to move the victim
• During transportation to the hospital
• When the ER doctors move the patient into the trauma room
• When the victim is being moved to x-ray for views of his cervical
spine
• During a surgical mishap
The neck bones may splinter in numerous ways, but we're interested in two patterns only: (1) stable neck fractures and (2) unstable neck fractures.
Stable neck fractures are present when the majority of the vertebral bone is intact, the ligaments are still holding and there is no x-ray suggestion of dislocation. On the other hand, an unstable fracture is characterized by smaller bone fragments, torn ligaments and the overriding of one vertebra on the next. This sliding of one bone on the one above or below creates a shearing effect and pinches the spinal cord. The result is a damaged cord and interruption of information traveling to the brain and back down to muscles and other organs. It can lead to paralysis.
