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It can occur in the sacrum or vertebral body abnormality of the B cells within the vertebral and cause back pain 140 mg malegra fxt otc erectile dysfunction gnc. It typically presents in Plain radiographs demonstrate an expansile elderly people (60+ years) with back pain and/or a osteolytic lesion similar in appearance to the aneu- progressive kyphotic deformity secondary to multi- rysmal bone cyst but differentiated by the fact ple vertebral body collapse order 140mg malegra fxt with amex erectile dysfunction remedies fruits. Plain radiographs demonstrate multiple lytic Management involves complete excision plus lesions with very little surrounding bony reaction discount malegra fxt 140 mg otc erectile dysfunction specialist doctor. Primary malignant spinal tumours are extremely Solitary plasmacytoma is of a similar histology rare 140mg malegra fxt amex erectile dysfunction medication new. The prog- Eighty-five per cent cause back pain – particularly nosis is very different – vertebrectomy is potentially at night – with associated constitutional symptoms, curative. The three common primary malignant spinal tumours are: Chordoma myeloma (multiple and solitary plasmacytoma) chordoma Chordoma is the second most common malignant sarcoma (osteosarcoma, chondrosarcoma, tumour. Complete resection can be curative, but this is often not pos- sible because of adjacent structures. Its Ewing’s sarcoma affects children and is highly appearance is similar to that of an aneurysmal bone cyst but chemosensitive. Chemotherapy is used as an adjunct aneurysmal bone cysts tend to affect the posterior elements before and following en bloc excision of the affected rather than the vertebral body spinal segment. The typical approach with medical oncologists, palliative care primary sites include breast, lung, prostate, kidney, and specialist nurses is essential. For example, chemosensitive tumours are usu- The malignant cells probably travel to the spine ally treated by neoadjuvant chemotherapy in via the thin-walled valveless paravertebral venous order to achieve 90 per cent tumour kill prior to plexus of Batson. Although 80–85 per cent of tumours may be radiosensitive, radiotherapy is only of value Investigation for reducing soft tissue compression. Renal cell, Blood tests gastrointestinal tract adenocarcinomata and melanoma are chemo- and radioresistant. Full blood count, urea and electrolytes, liver func- The management of spinal metastases is pal- tion tests, calcium, clotting and tumour markers, liative rather than curative. Relative contraindications to surgery Bence–Jones protein is present in patients with include widespread visceral or brain metastases, multiple myeloma. Lesions that are osteolytic (kidney, lung, colon and melanoma) cause bone destruc- Cervical spondylosis is a non-specific term that was tion with vertebral body collapse. The osteoblastic introduced by Schmorl in 1929 to describe ‘chronic metastases of carcinoma of the prostate cause bone degenerative changes caused primarily by interver- sclerosis. Cervical spondylosis may cause axial neck pain, cervical radiculopathy or cervical myelopathy. Bone scan Cervical myelopathy is an upper neurone lesion Beware of false negatives, e. Hypertrophic Cervical radiculopathy results in pain and changes secondary to wear and tear may encroach sensory changes affecting the distribution of the centrally on the spinal canal (myelopathy) or at the affected nerve root: exit foramina (radiculopathy). The neuro-anatomy of the cervical spine is C3 compression – occipital headaches, pain unique because the nerve roots exit above the around the mastoid process and pinna of pedicle of the same number (e. This is the opposite to the C5 compression – deltoid region with loss of thoracic and lumbar spine, where the nerve root biceps reflex exits below the pedicle of the same number (e. The pain may be axial or radicular in nature (radicular pain results Management in a band-like sensation wrapping around the chest, The natural history of cervical radiculopathy and which can be mistaken for a myocardial infarction). Sensory complaints are usually in the T10 der- matome regardless of the level of the root compres- sion. The clinical findings will be of an upper motor Cervical radiculopathy neurone lesion in the legs. Surgical decompression can be via an anterior Cervical myelopathy or posterior route directed at the location of the Numerous natural history studies indicate that some pathology. The spine can be decompressed ante- tear’ but previous injury and genetic predisposition riorly (discectomy or corpectomy) or posteri- increase the incidence. Degenerative disorders of the lumbar spine 225 The facet joints are true synovial joints and hence age of 20–40 years. The level most commonly develop osteoarthritic changes similar to that seen affected is L4/5 followed by L5/S1. The disc on the other It is important to remember the definitions hand is not a true joint and wear and tear changes of the terms used when describing the effect of are better described as ‘degenerative disc disease’ prolapsed discs: rather than osteoarthritis. Degenerative disc disease and facet complex sciatica: leg (Latin) degeneration are often symptomless. The disc extrusion: asymmetric migration of disc disc itself has no innervation but the posterior material through the annulus (see fig 10. The loss of the cauda equina caused by a massive central water within the disc results in a loss of disc disc prolapse resulting in bilateral sciatica, motor height, which then causes increased loading of the weakness, saddle anaesthesia and bladder or facet joints resulting in secondary osteoarthritic bowel dysfunction. This syndrome presents a changes within these joints (a potential cause of surgical emergency. The exception is a far lateral disc prolapse which may compress the exiting L4 nerve root. Protrusion Management Treatment should be conservative whenever possi- ble given the fact that the natural history of the disc prolapse is favourable. Seventy to ninety per cent of cases resolve with conservative treatment measures over an 8- to 12-week period, and of these 90 per Extrusion cent do not relapse. Of the 10 per cent who relapse, 90 per cent resolve in a further 8–12 weeks but 50 per cent will suffer further relapse. Conservative treatment consists of analgesia, anti-inflammatory medication, physiotherapy, selective nerve root injections/caudal epidural, all of which aim to reduce the inflammation around the nerve root sheath. The risks of lumbar microdiscectomy are small but include infection (wound, pyogenic discitis and epidural abscess), dural tear, vascular injury and recurrent disc prolapse. The causes L3/4→compression of L4 root→pain in the can be classified as congenital (achondroplasia with posterolateral thigh region and anteromedial short pedicles or other skeletal dysplasia – rare) and aspect of the lower leg, motor weakness of the acquired (degenerative – common). The narrowing quadriceps (knee extension) and absence of the of the spinal canal is described as being either in the knee jerk. The abnormality begins as degenerative changes within the disc cause a reduction of the disc Imaging height and posterior bulging of the annulus. The The investigation of a patient with sciatic leg pain reduction in disc height causes infolding of the liga- consists of the following. Plain radiographs are obtained to assess abnor- Degenerative osteoarthritic changes (hypertrophy malities of segmentation (in particular lumbosacral and osteophyte formation) result from the increased transitional vertebrae) and detect evidence of a loading of the facet joints. The combination of spina bifida occulta if surgical intervention is being these changes results in the typical trefoil-shaped considered. Bone and calcium metabolism 227 Normal Ultrasound studies of the circulation may be needed to exclude peripheral vascular claudication. Severe cases who fail to respond to conservative Caude treatment can be managed surgically with decom- equina Normal pression, which may be either open or distractive. Disc protrusion There is considerable argument within the lit- erature about the role of fusion at the time of an Spinal stenosis open decompression (fusion may be posterolateral or interbody). The indications for fusion include a Bulging degenerative spondylolisthesis, recurrent stenosis disc and a severe stenosis requiring complete facet joint removal with a resulting potential for instability. Distractive decompression involves placing a Thickened spacer between the spinous processes in order to ligamentum Facet joint indirectly decompress the canal by distracting the flavum hypertrophy segment.

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Incrustations buy malegra fxt 140 mg with amex valsartan causes erectile dysfunction, conclu- axonal injury in the corpus callosum order malegra fxt from india impotence natural remedy, dorsolateral seg- sive histological evidence of irreversible neuronal injury cheap 140 mg malegra fxt with amex erectile dysfunction hypertension drugs, ments of the rostral brain stem adjoining the cerebellar are best seen using a cresyl violet stain; incrustations rep- peduncles buy discount malegra fxt on-line erectile dysfunction even with cialis, and the internal capsule, and in some cases resent the blebbing of the neuronal cytoplasm prior to hemorrhagic lesions are seen in the corpus callosum (Fig- breakup of the cell. There are three de- underlies the cellular damage, but rather the buildup of grees of traumatic axonal injury: mild, moderate, and se- tissue lactate secondary to the absence of blood flow. In grade 1 there are microscopic changes in the white tate is produced as a consequence of cellular metabolism matter of cerebral cortex, corpus callosum, brain stem, and and is normally removed by local blood flow. Lactate ac- cerebellum; grade 2 is distinguished by grossly obvious fo- cumulation results in local tissue acidosis and cellular in- cal lesions isolated to the corpus callosum; in grade 3 ad- jury. Studies have demonstrated axonal pathology after mild head injury in patients who Diffuse Traumatic Axonal Injury have died from unrelated causes (Blumbergs et al. Diffuse traumatic axonal injury is important because it Several techniques have been used to identify dam- contributes to at least 35% of the mortality and morbidity aged axons. In addition, traumatic axonal injury is 15–18 hours is required before they can be identified using considered to be an important cause of severe disability this technique. There is loss of normal physiological cellular activity, is not specific to traumatic axonal injury and may be seen which ultimately results in a breakdown of the blood- in any cause of axonal disruption, such as ischemia (Do- brain barrier. The swelling may be conges- tive, secondary to an increase in the cerebral blood vol- Penetrating Injuries ume, or due to edema, an increase in the water content of the brain tissue. Current understanding of the mechanisms In strict terms, a penetrating injury is one in which the ob- underlying brain swelling is incomplete, although prog- ject/missile enters the cranial cavity but does not exit, ress has been made from the study of molecules such as whereas a perforating injury is one in which the missile aquaporin 4. Sharp objects, such as tion to contusions, diffuse within one cerebral hemisphere knives, long nails, or metal poles, may pierce the skull and or diffuse in both cerebral hemispheres. The majority of extend into the underlying brain parenchyma causing lo- edema in trauma is cytotoxic, with only a small compo- cal damage. They produce a hemorrhagic tract through the nent of swelling due to vasogenic edema, most of this be- regions of parenchyma into which the missile extends ing seen in relation to focal swelling adjacent to contu- (Figure 2–13). Adjacent to contusions there is physical disruption considerably more damage, and the extent of the damage is of the tissues, including the blood-brain barrier, and loss of related to the velocity of the missile; high-velocity military the normal autoregulation within the local vasculature. As the missile travels through the parenchyma, it Diffuse swelling of one cerebral hemisphere. This sit- will produce pressure cavities that can lead to tissue dam- uation is most typically associated with an adjacent sub- age. If this is removed surgically, the hemi- penetrating ballistic injury will cause local tissue damage, 30 Textbook of Traumatic Brain Injury tle acute clinical concerns. As with adult head injury, the outcome in children is partly determined by the force of the injury and whether the injury is contact or noncontact. Head injury in childhood may be due to a variety of causes, including road traffic accidents, falls, injuries sus- tained in recreational and competitive activities, and as- sault. Unlike adult head injury, the severity of the injury and outcome in pediatric head injury is modified by the maturation of the developing skull and nervous system. The brain lies within the cranial cavity surrounded by cerebrospinal fluid and the relative protection of the bony skull. Pediatric head injury, while sharing some similari- ties with adult injuries, differs with respect to the imma- turity of many of the components of the developing ner- vous system. Hemorrhagic infarction in relation to the being joined by fibrous or cartilaginous tissue. Myelination of phasic inflammatory response: in the acute phase there is the human brain begins in utero and continues into early cytokine expression and neutrophilic infiltration; the de- adult life. Myelination is particularly active in the first layed response involves white matter degeneration seen 2 years of life. As a result of these ongoing processes of distant from the site of direct tissue injury and develops maturation, the child’s brain responds differently than an some days after the injury (Williams et al. The age at which the head injury is sustained has been Blast Injuries demonstrated to be important in determining the vulnera- bility to and recovery from a focal injury in a piglet model. Traditionally, the study of blast injuries has focused on the Piglets of different ages were injured using a scaled corti- damage caused by blast waves to air-filled viscera such as cal impact model and then sacrificed at 7 days postinjury. However, increasingly, Assessment of the brains demonstrated smaller lesions in and particularly in relation to the recent conflicts in Iraq the younger animals despite comparable injury inputs and Afghanistan, attention has been focused on possible (Duhaime et al. The authors concluded that vulner- injuries to solid viscera, and the brain in particular. The ability to mechanical trauma increased progressively dur- abrupt pressure changes associated with a blast can lead to ing maturation. Magnetic resonance imaging assessment a mild head injury and, in particular, concussion. It is im- white matter injury in the form of traumatic axonal injury portant not to confuse a linear skull fracture with sutures is controversial. Depressed fractures are usually asso- neuronal cell body in an animal model of blast injury. A ciated with high-velocity impacts, such as is seen in road possible explanation as to why damage to axonal transport traffic accidents. Diastatic fractures are traumatic separa- mechanisms have not been convincingly demonstrated in tions of bones of the vault at sites of sutures and are nor- blast-injury models, as demonstrated in both blunt force mally only seen in the first few years of life. Growing frac- and penetrating head injuries, may be either that a differ- tures can develop if intracranial tissue herniates through ent white matter degenerative process occurs or that the the fracture defect. In infants venous bleeding from bone is seen more frequently Although head injury is relatively common in the pediat- as the cause of extradural hematoma, unlike the situation ric population, the vast majority of cases are mild with lit- in adults in which most are arterial. Pure subdural hemor- Neuropathology 31 rhages (hemorrhages not associated with underlying in- tracerebral hemorrhage) are seen in 6% of patients. Al- though subdural hemorrhage is most commonly seen in relation to trauma, and in infants it often raises the possi- bility of nonaccidental injury, in pediatric cases particu- larly a number of alternative causes need to be considered (Kemp 2002) (see Table 2–3). Intracerebral lesions were seen in 17% of fatal pediatric patients, with burst lobes be- ing seen in 8% of patients. A type of contusional injury associated with very young children (under approximately 6 months of age) is the glid- ing contusion, a parasagittal white matter injury often as- sociated with focal hemorrhage (Figure 2–14). In children diffuse brain swelling is encountered with no underlying cause, being present in 21% of patients in one study (Graham et al. In these patients the swell- ing is considered to be secondary to hyperemia, although other studies have suggested the degree of hyperemia is in- sufficient to cause cerebral swelling. Gliding contusions in a child’s brain, with bral ischemia remains uncertain, and it has been suggested a survival of approximately 2 years after a period of that this hyperemic response may be protective against is- traumatic brain injury. The incidence of this type of injury may be The contusions lie in the parasagittal white matter and are often, modified in light of recent improvements in acute manage- as in this case, bilateral (arrows). Pathological studies of nonaccidental injuries are lim- nonaccidental injuries, and this can be used to identify chil- ited and are complicated by case selection bias. They demonstrated that the injuries sustained by the child were influenced by the age of the child. Infants ap- peared to be susceptible to localized axonal injury at the cer- Vegetative State vicomedullary junction, a feature not seen in any of the older children. Acute subdural bleeding and retinal hemorrhages recognized ranging from mild concussion, in which con- were common and were seen in 72% and 71% of cases, re- sciousness is often preserved, to severe diffuse traumatic spectively.

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A specific defect in absorption of glucose and galactose can be demonstrated by tolerance tests in which oral administration of these monosaccharides produces little or no increase in plasma glucose or + galactose purchase 140mg malegra fxt overnight delivery impotence cure. As these solutes accumulate in the lumen cheap malegra fxt 140mg otc impotence nutrition, the osmolality of the fluids increases and retards absorption of water buy 140 mg malegra fxt visa erectile dysfunction treatment in uae, leading to diarrhea and severe water loss from the body order malegra fxt 140mg amex erectile dysfunction doctors in orlando. At the same time, advances in molecular biology have allowed a better understanding of the genetic defect at the cellular level and how this leads to the clinical symptoms. In a polarized cell, the entry and exit of solutes such as glucose, + amino acids, and Na occur at opposite sides of the cell. Active entry of glucose and amino acids is restricted to the apical membrane, and exit requires equilibrating carriers located only in the basolateral membrane. The result is a net movement of solutes from the luminal side of the cell to the basolateral side, ensuring efficient absorption of glucose, amino acids, + and Na from the intestinal lumen. Transcellular transport Epithelial cells occur in layers or sheets that allow the directional movement of solutes not only across the plasma membrane but also from one side of the cell layer to the other. Such regulated movement is achieved because the plasma membranes of epithelial cells have two distinct regions with different morphologies and different transport systems. These regions are the apical membrane, facing the lumen, and the basolateral membrane, facing the blood supply (Fig. The specialized or polarized organization of the cells is maintained by the presence of tight junctions at the areas of contact between adjacent cells. Tight junctions prevent proteins on the apical membrane from migrating to the basolateral membrane and those on the basolateral membrane from migrating to the apical membrane. Thus, the entry and exit steps for solutes can be localized to opposite sides of the cell. The polarized organization of the epithelial cells and the integrated functions of the plasma membrane transporters form the basis by which cells accomplish transcellular movement of both glucose and sodium ions. Specific membrane proteins that function as water channels explain the rapid movement of water across the plasma membrane. These water channels are small (30 kDa), integral membrane proteins known as aquaporins. Of the thirteen known mammalian aquaporins, eight are expressed in the kidney, where water movement across the plasma membrane is particularly rapid. Water movement across the plasma membrane is driven by differences in osmotic pressure. The spontaneous movement of water across a membrane driven by a gradient of water concentration is the process known as osmosis. The water moves from an area of high concentration of water to an area of low concentration. Concentration is defined by the number of particles per unit of volume; thus, a solution with a high concentration of solutes has a low concentration of water, and vice versa. Osmosis can be viewed as the movement of water from a solution of high water concentration (low concentration of solute) toward a solution with a lower concentration of water (high solute concentration). Osmosis is a passive transport mechanism that tends to equalize the total solute concentrations of the solutions on both sides of every membrane. If a cell that is in osmotic equilibrium is transferred to a more dilute solution, water will enter the cell, the cell volume will increase, and the solute concentration of the cytoplasm will be reduced. If the cell is transferred to a more concentrated solution, water will leave the cell, the cell volume will decrease, and the solute concentration of the cytoplasm will increase. The driving force for the movement of water across the plasma membrane is the difference in water concentration between the two sides of the membrane. For historical reasons, this driving force is not called the chemical gradient of water but the difference in osmotic pressure. The osmotic pressure of a solution is defined as the pressure necessary to stop the net movement of water across a selectively permeable membrane that separates the solution from pure water. When a membrane separates two solutions of different osmotic pressure, water will move from the solution with low osmotic pressure (high water and low solute concentrations) to the solution of high osmotic pressure (low water and high solute concentrations). In this context, the term selectively permeable means that the membrane is permeable to water but not solutes. In reality, most biologic membranes contain membrane transport proteins that permit solute movement. The osmotic pressure of a solution depends on the number of particles dissolved in it, the total concentration of all solutes, regardless of the type of solutes present. Many solutes, such as salts, acids, and bases, dissociate in water, so the number of particles is greater than the molar concentration. For + − example, NaCl dissociates in water to give Na and Cl, so one molecule of NaCl will produce two osmotically active particles. The equation2 giving the osmotic pressure of a solution is (3) where π is the osmotic pressure of the solution, n is the number of particles produced by the dissociation of one molecule of solute (2 for NaCl, 3 for CaCl ), R is the universal gas constant (0. A solution is hyperosmotic with respect to another solution if it has a higher osmotic pressure and hyposmotic if it has a lower osmotic pressure. Equation 3, called the van’t Hoff equation, is valid only when applied to very dilute solutions, in which the particles of solutes are so far away from each other that no interactions occur between them. Interactions between dissolved particles, mainly between ions, cause the solution to behave as if the concentration of particles is less than the theoretical value (nC). A correction coefficient, called the osmotic coefficient (Φ) of the solute, needs to be introduced in the equation. Therefore, the osmotic pressure of a solution can be written more accurately as (4) The osmotic coefficient varies with the specific solute and its concentration. At any given T, because R is constant, equation 4 shows that the osmotic pressure of a solution is directly proportional to the term nΦC. This term is known as the osmolality or osmotic concentration of a solution and is expressed in Osm/kg H O. Most physiologic solutions such as blood plasma contain2 many different solutes, and each contributes to the total osmolality of the solution. The osmolality of a solution containing a complex mixture of solutes is usually measured by freezing point depression. The freezing point of an aqueous solution of solutes is lower than that of pure water and depends on the total number of solute particles. Compared with pure water, which freezes at 0°C, a solution with an osmolality of 1 Osm/kg H O will freeze at −1. The ease with which osmolality can be measured has2 led to the wide use of this parameter for comparing the osmotic pressure of different solutions. Accumulation of solutes can also produce volume changes by increasing the intracellular osmolality. Volume regulation is particularly important in the brain where cell swelling can have serious consequences because expansion is strictly limited by the rigid skull. Tonicity A solution’s osmolality is determined by the total concentration of all the solutes present. In contrast, the solution’s tonicity is determined by the concentrations of only those solutes that do not enter (“penetrate”) + the cell.

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Syndromes

  • Ventricular fibrillation and ventricular tachycardia
  • Are both knees affected?
  • Intense joint pain
  • Biopsies and cultures of affected organs or tissues
  • Laxopol
  • If the medication was prescribed for the patient
  • Complete blood count
  • Bulging fontanelles
  • Digitoxin and digoxin test to check levels
  • Washing of the skin (irrigation) -- perhaps every few hours for several days

Air entry at the bases and vocal resonance The chest wall should be carefully palpated completes the examination cheap 140 mg malegra fxt with amex impotence ring. Plain radiographs and duplex scanning of the Abdomen and pelvis (lower torso) vessels should be carried out if a vascular injury is suspected (see below) cheap malegra fxt 140mg online erectile dysfunction doctors northern virginia. Any wounds are documented buy malegra fxt cheap online erectile dysfunction effects on women, espe- Disposal cially if they could have breached the abdominal After completing the secondary survey the patient cavity discount malegra fxt 140 mg overnight delivery impotence zoloft. There may be signs of visible bruising (seat may require further imaging or may need to be belt) or distension. Local tenderness in a conscious transferred to the intensive care or high dependency patient can be helpful, especially if there is tenderness unit, the ward or the operating theatre. The bladder area should be percussed A further rapid assessment of the patient should (if a catheter has not been passed), to detect any blad- be carried out before they are transferred. The presence of normal bowel sounds All patients with major injuries should be admit- is encouraging but these may disappear in the face of ted for at least 24 hours, as a number of patients continuing intra-abdominal haemorrhage or spread- develop late symptoms and problems. It is important that the admitting teams repeat The genitalia must be checked and the exter- the secondary survey to avoid missing injuries nal urethral meatus inspected for the presence of that may have been overlooked in the resuscitation blood. The whole process should be repeated the next especially if associated with urethral bleeding, sug- day to ensure that other injuries have not been missed. In these circumstances a suprapubic be guided by the progress and further assessment rather than a urethral catheter may be a better of the injured patient. All patients who are thought to have multiple Displaced sacral fractures can be felt on rectal injuries should have a brain scan, any neck injuries examination. The upper and lower limbs must be carefully exam- Patients who are fully responsive with a Glasgow ined for lacerations, swelling, bruising, deformity and, score of 15 can be discharged home with a respon- in the conscious patient, loss of power. All the pulses in sible person who can bring them back to hospital the limbs must be palpated and recorded and, in a con- should they develop new symptoms (e. Glasgow coma scale Patients with severe localized head injuries Eyes open Spontaneously 4 should be resuscitated and transferred to a neu- To verbal command 3 rosurgical unit. No response 1 Patients who do not require transfer to a neuro- Best motor response surgical unit but require further observation as well to verbal command Obeys verbal command 6 as those with multiple injuries should be admitted to an Intensive Care Unit where they can be sedated, to painful stimulus Localizes pain 5 ventilated (if necessary), their pupils assessed and Flexion withdrawal intracranial pressure monitored. Disorientated and converses 4 The ‘cerebral perfusion pressure’, which is the intracerebral pressure subtracted from the blood Inappropriate words 3 pressure, should, ideally, be maintained between Incomprehensible 60 and 80mmHg. No response 1 Cerebral oedema is the usual cause of a raised pressure if a haematoma has been excluded. Maximum score is 15 (min 3) The pressure may be lowered by continued hyperventilation, head elevation, manitol in repeated aliquots (0. Rotational and contre-coup Scale or where there is a question of alcohol or drug injuries may also occur. Compound open fractures of the skull 123 These injuries can be reduced or prevented by wearing suitable protection (e. This (A) damage is potentially avoidable by careful manage- ment including intubation and ventilation. All scalp injuries must be taken seriously as they can be complicated by the presence of an associated skull fracture which may be linear, stellate or depressed (see below). They should, therefore, be carefully debrided before being primarily closed by sutures under local anaesthesia. The depression loss of consciousness, anxiety, depression and even can occasionally be felt but should be visible on a personality changes. All these forms of brain damage may be associated Any scalp wounds overlying a fracture should be with skull fractures or penetrating injuries. Prevention is by early adequate correc- to admission and a careful neurological assessment. Cerebral pressure An intracranial haematoma results from an intrac- monitoring is rarely useful or practicable. It may cause a rise in intracra- nial pressure and cause a reduction in the level of Management consciousness, respiratory depression, a fall in the pulse rate and a fall in blood pressure. They are caused by bodyweight and hyperventilating the patient while a tear of the middle meningeal artery or one of its transferring them to a scanner. As the thin temporal bone burr hole often has to be extended to become fractures it tears the middle meningeal artery, which a craniotomy to expose the bleeding point and then rapidly bleeds into the extradural space. Investigation Prognosis Clinical diagnostic indicators The mortality following an extradural haematoma The injury is often not severe but followed by increas- is about 5–10 per cent because many cases are com- ing headache, vomiting and drowsiness. If the condition is left untreated, fixed dilated These haematomata commonly complicate high- pupils and coma eventually presage respiratory speed road injuries and are more common than arrest. Monitoring may show a deterioration in their Glasgow score with the development of localizing signs, although these may be present ab initio. This is achieved through burr holes and drain an extradural haemorrhage and ligate the middle flaps (see Fig. Thirty per cent of patients treated by drainage make only a moderate recovery and frequent (30 per cent of all severe head injuries) 30 per cent usually die. The large subdural/ These haematomata are far more common in elderly subarachnoid space allows the blood to spread out people and often follow minor trauma. They are common in epileptic and alcoholic patients and in patients on anticoagulants. Investigation Clinical diagnostic indicators Patients often develop symptoms days or weeks after an injury that may have been forgotten. Headache, loss of intellect, fluctuations in consciousness and eventually localizing signs (hemiparesis) are the common modes of presentation. Prophylaxis These patients are usually unconscious when they with anticonvulsants remains controversial as their arrive at the A&E with a Glasgow score of 3. Treatment is with antibiotics, Headache, irritability and lack of attention are which should also be given prophylactically in this common after all serious head injuries but tend to type of injury to prevent infection developing. Post-traumatic stress disorder with depression The common causes of maxillofacial injuries are and anxiety is often diagnosed but difficult to prove. Many may require long-term care at home wars or need to be looked after permanently in facilities insurgencies. Investigation Conscious patients without neck symptoms Clinical diagnostic routines have never been found to have an unstable cervical When examining the skull, eye and orbit: spine or have subsequently progressed to develop neurological deterioration. It is, therefore, unnec- inspect and palpate the cranium essary to go to great lengths to maintain spinal cord palpate the orbital margins protection in a conscious patient who has not had test visual acuity a head injury and does not complain of neck pain. There is no need for further investi- test the red reflex gations if all neck movements are full and pain-free check for diplopia and eye movements and there are no neurological signs in the limbs. Difficulties arise in the unconscious patient, espe- When examining the nose check for: cially if they are intubated and ventilated. In these circumstances the management options include: lacerations contusions Treat the cervical spine as if it is unstable until epistaxis the patient regains full consciousness. When examining the maxilla check for: A stiff collar is effective unless there is overt bleed- ing from a wound in the neck.

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