Clinical Assessment of a case
University of sulaymany
[pic]
college of medicine
for (forth, fifth, sixth ) stage medical student
Prepared & collected by:
Dr .Soran Mohamad Gharib
2008
Clinical Assessment of a case
Of head injury
Head injuries;
"No head injury is so slight that it should be neglected, or so sever that life should be despaired of"
Trauma imparted to the cranium can take the form of:
Translational acceleration force
Translational deceleration force
Rotational force
Direct, focal, sharp penetrating force
Blunt force
Why most cerebral contusions occurs with out skull fractures and why patients with skull fractures are often awake with only a minor neurological dysfunction? What is Coups and Countercoups injury?
Things to remember…..
*Letters in the word "scalp" can define different layers of the scalp that may be injured;
S stands for Skin
C stands for subcutaneous tissue
A stands for Aponeurosis
L stands for loose areolar tissue
P stands for Pericranium
*identify the severity of the primary brain injury and record a base line of neurological disability.
*Get initial information from the witnesses and ambulance crew about the nature and the velocity of the trauma, initial state of consciousness, post-traumatic amnesia, headache, vomiting or fits.
Things to remember…..
*consider the possibility of other life threatening injuries
*record initially any history of drug intake or concomitant medical illness.
*Decide, as early as possible, when to refer to a specialist neurosurgical care, and, to the same degree, not to refer without a good indication.
*Patient must be reexamined many times at frequent intervals.
*Understand the standard "Evaluation score" so called Glasgow Coma Scale.
*Consider the need for "advance trauma life support system protocol (ATLS)" along with stabilization of airway, breathing, circulation, disability and exposure (ABCD and E).
*You may need to immobilize the cervical spine, as there is a high possibility of associated cervical spine injury.
Things to remember…..
*Perform a correct, informative and reliable detailed neurological examination to pick up, as early as possible, signs of focal neurological damage and that of rise in intracranial pressure.
*Not to aim always at referring the victim without recording the result of your observations.
*Use your armamentariums, a "narrow spot" torch light, a hammer, gloves, little of neuroanatomy and neurophysiology, and a real will to be helpful.
*Keep on looking to a copy of "Glasgow Coma Scale", repeat applying it for all head injury cases.
Glasgow Coma Scale;
[pic]
Factors affecting Glasgow coma scale other than cerebral injury;
Limitation of eye opening may occur in facial trauma and periorbital Edema affecting assessment of eye opening.
Upper limb is more representative of the motor reflex than the lower limb. Presence of fracture, that may be missed, can affect interpretation of motor response.
Language and endotracheal intubations may affect assessment of verbal responses
Scalp injuries;
Scalp never gapes unless the galea aponeurotica has been divided.
Collection of blood beneath the Aponeurosis tends to involve the whole area between the occipitofrontalis muscles.
Effusions beneath the Pericranium are limited to the suture lines
Subpericranial heamatoma may feels exactly like a depressed fracture
Scalp injuries
Proper examination need complete shaving of the scalp hair.
Bleeders from the scalp injury can be controlled by pressure application, hemostat application or by eversion of the galea.
Depressed skull fractures may underlie a scalp injury.
Scalp heamatoma always overlie a skull fracture in infants.
Scalp lacerations tend to bleed very heavily
Common types of skull fracture;
Simple linear; It may be confused with suture lines. Those that cross the middle meningeal artery can cause extradural hemorrhage.
Depressed; It needs suturing of overlying scalp wound before referral for debridement and elevation.
Base of the skull fractures; may present with "Raccoon eyes“, Mastoid bruises or CSF leak.
Orbital blow-out fractures; Cause diplopia and require repair.
Fracture base of the skull;
Anterior Cranial fossa #....danger of CSF Rhinorrhoea
[pic]
Middle Cranial Fossa Fracture;
Suspected when there is blood or blood diluted with CSF escaping from the external auditory meatus.
In tympanic membrane rupture, blood will clot, but will not in case of blood mixed with CSF
There may be an associated facial palsy, deafness or nystagmus in cases of fracture middle cr. Fossa.
Bruises over the mastoid process (Battle's sign) appearing one or two days after trauma confirm the diagnosis of middle cr. Fossa fracture
Fracture Posterior Cranial Fossa;
The main danger is the torn of a venous sinus.
Deep coma may be present. Pupils become dilated and inactive.
Periodic "Chyne-Stockes" respirations are present.
Irregular pulse indicate brain stem lesion and the case is fatal.
If a slowly developing heamatoma accumulate, nystagmus and ataxia is present.
Brain injuries;
Primary;
1. Concussion; defined by a period of amnesia
2. Cortical contusions and lacerations
3. Bone fragmentation injury
4. Diffuse axonal injury
5. Brain stem contusions.
Secondary;
1. Intracranial heamatoma
2. Cerebral edema
3. Hypoxemia
4. Ischemia
5. Infections
6. Epilepsy
7. metabolic-endocrine disturbances.
Types of intra cranial heamatoma;
Intracerebral; Hyper dense on CT-scan, small ones may enlarge. Large ones may need evacuation.
Extradural; Result From bleeding middle meningeal artery. Trauma may be trivial. Lucid interval is characteristic. Surgery without delay is essential.
Acute subdural; It is the most common. Develop from torn bridging veins or from cortical lacerations. It May be sub acute.
Chronic subdural; It is most common in children and elderly, and present with progressive neurological deficit. They should be drained if continue to enlarge.
Indications for CT scan;
The patient is persistently drowsy or has a more seriously depressed consciousness level
There are lateralizing neurological signs
There is neurological deterioration
There is clinical evidence of fracture base of skull
Category of head injury;
Category I: The patient is unconscious;
Examine the scalp.
Inspect the nostril and back of the throat.
Examine the external auditory meatus.
Compare the size of the pupils and reaction to light.
Make a general survey of the body for other injuries.
Assess how deep the patient is unconscious.
Coma is a state of absolute unconsciousness in which the patient dose not respond to any stimuli and reflexes (including the corneal and swallowing reflexes) are absent.
Semi coma means that the patient responds only to painful stimuli and reflexes are present.
Search for paralysis. Pinch the soles of the feet; only one leg may be drawn up.
Palpate and Percuss the lower abdomen for evidence of over filled bladder.
Set half- hourly Chart for pulse rate, respiratory rate, and temperature. Make a behaviors chart
Place and have the patient kept on his side with a clear air way (remove blood and mucus from mouth and nose).
Consider at any time the need for endotracheal intubations
Arrange for safe referral with an informative preliminary report.
Category II: The patient is conscious or semiconscious;
Record the degree of mental confusion
Assess for;
Stupor; No sensible answers can be obtained but the patient obeys simple commands.
Delirium; Appear out of touch from his surroundings, relevant answers to obvious questions are possible, but irritable when disturbed, may be aggressive, noisy and try to get out of bed.
Confusion; Overall, some degree of coherent conversation is possible.
**Any impairment of consciousness, when combined with radiological evidence of skull fracture, is associated with high incidence of intracranial bleeding and heamatoma.
Quick Cranial N examination;
Olfactory (1st) use non irritant smell.
Optic (2nd) test for visual fields.
Ocuolomotor (3rd) lid and eye movements, pupillary reflex and laccommodation.
Trochlear (4th) diplopia on looking downwards.
Trigeminal (5th) inability to clench teeth
Abducent (6th affected eye does not follow an object laterally
Facial (7th) facial m. paralysis.
Acoustic (8th) hearing and caloric test.
Glossopharangeal (9th) loss of test in the posterior third of the tongue.
Vagus (10th) loss of soft palate movement. Uvula to the opposite side.
Accessory (11th) Failure to shrug the shoulder
Hypoglossal (12th) Deviation of the protruded tongue to the affected side.
Significant Signs occurring during the period of observation of a case of Head;
"To wait until the clinical diagnosis is certain is to wait until the patient is near death"
Monitor the followings during observation period:
Pulse rate
Temperature
Respiration
Fits
Neck rigidity
Lucid interval
Lateralizing Neurological signs
Signs of Cerebral irritation
Lucid Interval;
* Classical sign of middle meningeal bleeding and formation of extradural heamatoma.
* Very variable, occurring for few minuets up to several days.
* Completely absent in cases of:
1) Alcoholism
2) Severe concomitant brain injury.
3) Combination of extradural and intracerebral bleeding.
* In this case, you may suspect this by:
1) Presence of heamatoma of the temporalis muscle on the affected side.
2) The gradual onset of hemi paresis and hemiplagia.
3) Deepening coma.
4) Presence of "Hutchinson's pupil".
Differential Diagnosis of Lucid interval;
In cases of subdural hemorrhage, its occurrence is more common, and it is not associated with lucid interval, however, lateralizing neurological signs may be present.
Sub arachnoids hemorrhage can be suspected from signs of cerebral irritation and positive tap of blood with CSF.
Intracerebral bleeding may be associated with extra or sub dural heamatoma or may occur alone. Lateralizing signs are usually absent.
Lateralizing neurological signs;
Contra lateral hemiplagia of extradural heamatoma associated with absent abdominal reflexes, increased triceps jerks, and positive "Babaniski's" sign.
Difficulty in speech (Aphasia), which may be the first lateralizing sign if the lesion is left sided in a right handed patient because "Broca's" speech area is left sided in right handed.
Inequality of the pupils, The so called "Hutchinson's pupil, occurring in extradural heamatoma
Hutchinson's pupil;
[pic]
Cerebral irritation;
Patient is found curled up in bed
avoiding light (Photophobia)
eye lids are closed
temperature is moderately raised
the patient is irritable
This indicates blood in the CSF.
Delayed effects of head injury;
Post traumatic epilepsy
Cerebrospinal fluid fistula
Post-concussion symptoms
Neurological and Neuro-psychological deficits
Neuroendocrine and metabolic disturbances
Examination of the Vascular System
Examination of the Arterial Circulation
Arteries accessible for clinical examination are:
Common Carotid and bifurcation in the neck
the facial and superficial temporal over the skull
the subclavian artery behind the clavicle
the axillary artery in the axilla
the Brachial artery at the elbow
the radial and ulnar arteries at the wrist
the femoral artery below the mid inguinal point
the popliteal artery in the popletial fossa
the posterior tibial artery behind the medial malleolus
the anterior tibial artery between the two malleoli
the dorsalis pedis artery between the first and second metatarsals just medial to the flexor hallusis longus tendon
the abdominal aorta in thin subject when compressed against the vertebral column
Clinical assessment of the arterial circulation
Examine in warm environment
Examine the heart
Assess Blood pressure in both arms
Assessment of ischemic limb
Inspection
Skin; white marble, redness or blueness.
A purple blue cyanosis may be obvious.
When cyanotic areas become fixed, the ischemia is irreversible.
Gangrene turn skin permanent blue/black colour first seen caudally in the toes
Clinical assessment of the arterial circulation
The Vascular (Buerger's) angle
Capillary filling time and “Buerger’s positional test”
Inspect for venous filling-Guttering of veins
Inspect carefully pressure areas for Thickening of the skin, a purple or blue discoloration, blistering, ulceration or patches of black, red, dead gangrene. Pressure areas are:
bottom, back and lateral surface of the heal and ball of the foot
skin over the malleoli
skin over the head of the fifth metatarsal
tips of the toes and areas between the toes
Clinical assessment of the arterial circulation
Palpation
Assess temperature
Capillary refilling time
Felling the pulse
Auscultation
An audible bruite is caused by turbulent flow beyond a stenosis or irregularity in the artery wall.
Blood flow in the vessel is assessed by a hand-held Doppler probe which can detect pulstile flow when the pulse pressure is impalpable to the fingers.
Symptoms and signs of acute ischemia (remember the letter “P”)
Pain, severe, sudden onset as a result of ischemia of muscles and nerves
Parasthesia progressing to
Paralysis
Pallor of the limb
Pulselessness
Perishingly cold limb
Poor capillary circulation resulting in
Prolonged capillary refilling time
Perceptively empty veins
Poor power, sensation and limb reflexes
Pulse Doppler flowmetry confirm absent pulsation
Persistent ischemia lead to hardness of muscles, blistering of the skin and development of gangrene starting in the toe and spreading proximally
Clinical manifestations of chronic ischemia
Intermittent claudication (limping)
Pre-gangrene
Gangrene
Ischemic ulcers
Ischemic ulcers
Site tips of the toes and over pressure points
Size small to large flat
Shape often elliptical
Tenderness mild, moderate or sever
Temperature; surrounding tissue is usually cold due to ischemia
Edge punched-out or sloping
Floor grey-yellow slough covering flat pale granulation tissue
Depth; is often very deep and penetrating
Discharge clear fluid, serum or pus
Ischemic ulcers
Base may be stuck or may be part of any underlying tissue
Lymph Nodes: not enlarged unless there is secondary infection
State of local tissue: surrounding tissue may show signs of ischemia.
Distal pulses are invariably absent
Doppler pressure index is reduced
Neurological examination numbness, Parasthesia, and absent sensation may indicate trophic ulcer
General examination may show evidence of vascular disease or diabetes
Examination of the venous circulation
Veins are either superficial or deep.
In the upper limb flow is from peripheral to proximal veins.
In the lower limb, in addition, flow is also from superficial to deep veins
Valves are sited
at any junction between superficial and deep veins
in the perforating veins
along the deep and superficial veins
limb veins have three principle functions
pathway to return blood to the heart
blood storage
thermoregulation.
Thrombosis of superficial veins (superficial thrombophlebitis)
Clinically, the vein become
Firm,
Palpable
Redness and stiffness in the overlying skin which become warm and tender .
It may be complicated by suppuration or extension of the thrombus along a perforating vein to the deep veins causing deep venous thrombosis.
Examination of a case of deep vein thrombosis
Observe for inequality of circumference and any prominent veins over the dorsum of foot.
Examine the ankle for pitting Oedema
Dorsiflexion of the foot produce pain in the calf muscle (Homan's sign)
Tender calf muscles
Palpate the popliteal space for tenderness in full leg extension position
Seek for tenderness in the thigh along the course of the femoral vein
Comparative circumferential measurement at identical points
Examination of a case of varicose veins
By inspection:
Inspect from back and front for varicosities of long, short or both saphenous veins.
Inspect the site of perforators which produce discrete venous bulges.
Inspect for the presence of swelling, skin pigmentation, pre-ulcerative lesions, ulcer mainly just above the medial malleolus and any scars due to healed ulcers.
Examination of a case of varicose veins
By palpation:
Palpate over the course of long and short saphenous veins
Perform the "cough impulse test"
Perform the percussion or "Tap" sign.
Perform Brodie-Trendelenburg test
Seek for the site of perforators (Fegan's method)
Test for the patency of deep vein (Perthe's test
Examination of the arterial circulation of the lower limbs
-Examination should be in aworm room.
-Exposure:
-from goin to toes,preserving his dignity by keeping his underwear on.
Inspection:
-colour:white/red.
Vascular angle:”buerger’s angle”
Lift the leg above the bed,raises it above the heart level.
Normal leg can be raised to 90 degree and still remain perfused.
The angle between the horizontal and the leg when it become white is vascular angle.
If the angle less than 20 it indicate sever ischemia
Capillary filling time:
After elevating the legs,ask the patient to sit up and dangle the foot over the site of the couch.
Anormal leg and foot remain healthy pink in colour.
Ischaemic leg slowly turns from white to pink and thentakes on a suffused purple-red colour.the time taken for the colour of the foot to change from white to pink is the capillary filling time.
In sever ischaemia it may be as long as15-30 seconds
-Venous filling:
in an ischaemic foot the veins collapse and sink below the skin surface to look like pale-blue gutter.this is called guttering of the veins.
-look at the-look at the pressure areas.
Trophic changes:
-loss of skin.
-loss of hair.
-Gangrene.
Ulcers:
Arterial(ischaemic) ulcers are found typically in the least well perfused areas and over the pressure points.
The lesions are punched out because there is no attempt at healing,and well described,may be very tender and the surrounding skin is cold.
They may vary in size but are usually smaller than venous ulcer.
There is no granulation tissue but may be a thin layer of slough at the base ,otherwise the base is flat and pale.
They may be very deep and penetrate surrounding tissue like bone..
Commenest differencial is with the neuropathic ulcer.
Palpation
-feel for skin temperature., use the back of hands ,comparing one side with other.
-examine the toes for capillary refill,use thmb to push hard over the pulp of the big toe on both sides.,normally the toe blunches but then return to the normal colour withn 2 seconds,.any longer than this is abnormal.
Only after all had been completed should you move on to examine the pulses
Femoral pulse:
-can be identified by the level of the groin skin crease .
anatomically dscribed at the mid- inguinal point ,halfway between
Anterior superior iliac spine and the pubic symphysis.
-compare one side with the other.
Popliteal pulse:
-the most convenien technique for feling the popliteal pulse is to extend the patient knee fully and place both haqnds around the top of the calf with the thumbs placed on the tibial tuberosity and the tips of the fingers of each hand touching behind the knee,over the lower part of the popliteal fossa.,the pulse demonstrated when the popliteal artery is compressed against the posterior aspect of the tibia.
-flexing the knee to 135 degree may make the lower half of the artery easier to feel but may make palpation of the upper half of the artery more difficult.
-sometime it can be feel by turning the patient in to the prone position and feeling along the course of the artery.
-when it is easy to feel it may be aneurysmal.
-compare.
Foot pulses
-the dorsalis pedis and the posterior tibial pulses can be palpated bilaterally and simultaneously.
-demonstrate the tendon of extensor hallucis longus.
-the DPA is immidately lateral to this tendon.
-swing your hand down to the medial malleolus and run your fingers posteriorly ,posterior tibial artery lie1/3 of the way along aline between the tip of the medial malleolus and the point of the hill.
Auscultate:
-check for bruit .
-measure blood pressure.
complete your examination by:
-examine the abdomen for an aneurysm.
-measure the ankle brachial pressure indicies on each side.
The pressure cuff is inflated over the upper arm and the systolic pressure measured at the brachial artery using a Doppler probe.
The cuff is then placed over the calf.
When the dorsalis pedis pulse has been located with the Doppler,the cuff is inflated until the pressure is high enough to occlude the artery and thus the Doppler sound disappear.
Slowly lower the cuff pressure until the Doppler sound restart,this is the ankle pressure.
The index is the ankle pressure dividedby the brachial pressure.
Normal index is 1.
In patient with the peripheral vascular disease the ratio begin to fall.
Patient with the intermittent claudication have an index of 0.5-0.8,.
Patient with the rest pain have an index ................
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