The ABCs of Trauma


The problem with head injuries is that much of the damage has already occurred when the patient arrives at the hospital. This primary injury, that is, the injury which occurs at the time of the accident and perhaps in the several minutes that follow, is not generally something that can be prevented except by primary prevention orod thru skullf the accident itself or through public health measures (such as teaching people not to dive head first into shallow water, or designing automobile steering wheel columns so that they collapse in a collision rather than impale the driver through his/her chest—indeed, such impaling was a common cause of death in the cars of the 1960’s and before).

Everything that happens after the initial few moments of an accident can be modified or affected by first responders, EMT’s, paramedics, nurses, and physicians. The goal of these folks is to reduce any subsequent injury, the so-called secondary injury. Indeed, prevention of secondary injury is the holy grail of the trauma system generally, and, in the case of head injuries, the neurosurgeon in particular.

What exactly does this mean?

Here’s an example. Let’s say a little boy climbs a tree, as little boys will. Unfortuantely, this little boy, call him Billy, takes a tumble and falls twenty feet or so to the ground. Billy’s sister, call her Jane, sees the whole thing and rushes to his side. Billy is unconscious, maybe he’s breathing and maybe he isn’t. Maybe his neck is broken. Perhaps he has a punctured lung. His leg is skewed something awful, so that’s probably broken too. And who can say whether or not Billy has internal injuries—a ruptured spleen, torn intestine, etc.

Now, all of these things constitute primary injuries. Everything Jane does from here on out will result in some degree of secondary injury. Some actions will lessen it, others might make things worse.

If his neck is broken, moving it could result in paralysis. This is secondary injury. Even if he is paralyzed, moving his neck could make the paralysis worse.

What about that broken leg? Is there a pulse in the foot? If not, every minute that passes without restoring the pulse results in potential injury to the muscles, nerves, sinew, etc of the leg. This too is secondary injury.

What if Billy is bleeding? If he is bleeding profusely, it must be controlled (stopped) immediately, or Billy won’t make it. Thus, one of the first things a first responder must do is look for and control bleeding. But it’s not the first.

It’s not the first because controlling bleeding in somebody who is not breathing makes little sense. You can win the battle and lose the war in such a moment.

It’s all very confusing at first, but there is an order to these things. Everyone, from trained first responders up the line to trauma surgeons, are taught to follow the ABCs of trauma care:

A—Airway, B—Breathing, C—Circulation, in that order.

A quick glance will often tell if a patient is breathing. If he is, the airway (mouth, throat, treachea) must be reasonably clear, if not check first that the airway is not clogged with teeth, blood, dirt, vomit, etc. These things will need to be removed if they are present. Once clear, does he breathe? Could be the lungs are damaged, or the chest compromised in some way (a punctured lung, for example). Some of these things can be treated on the spot, others less so. Finally, if the patient is breathing, is he circulating blood? Are his fingers and lips blue? Is he bleeding? Profusely?

These are the things which kill immediately or at least very quickly. Of course, the experienced responder does these things more or less simultaneously, followed by a more thorough survey of the patient. It’s all a work in progress though, with reassessment after reassessment after reassessment until the patient gets to a higher level of care.

Then the real fight to prevent secondary injury begins. More on that another time.


Announcing The Hydrocephalus Owner’s Manual

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It just might be the most important book you read. Ever.

HydroCover0What, exactly, is hydrocephalus? How is it treated? What is a vp shunt? What are the signs and symptoms of vp shunt failure and when do you need to seek help for yourself or a loved one? What are the common sense tips you can do to minimize the chance of your child having a problem when they are away from home–living in a college dorm, for instance?
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You can also read it here for free, but it will be easier to read on the Kindle, and more convenient too. And this is the sort of thing you want to have available in a tough moment, when you might want to refer to it on the spot.



4/6 Hydrocephalus Owner’s Manual

Hydrocephalus: An Owner’s Manual Part 4 of 6

Signs & Symptoms of Hydrocephalus or Shunt Failure


The benefits of shunting include treating the hydrocephalus and its attendant signs and symptoms. Symptoms are what a patient complains of (headache, nausea, vomiting, double vision, blurred or decreased vision, clumsiness, etc.) and signs are what a physician discovers on examination (decreased consciousness, abnormal eye movements including sunsetting and crossed eyes, enlarging head circumference in infants, etc.).



The most important sign of hydrocephalus is the patient’s level of consciousness. The more advanced the hydrocephalus—that is, the greater the pressure in the head—the sleepier the patient becomes. In advanced cases, the patient can lapse into a coma, even death.



Headache is an important but too general symptom of hydrocephalus. In this context, it is rarely important in isolation, but gains more significance in the company of other symptoms, such as nausea and vomiting, double vision, and abnormal eye movements.

In a shunted patient, the combination of headache and one or more of these symptoms should not be ignored.


The Eyes

The eyes are very telling in shunt patients. Obviously abnormal eye movements—where such abnormal movements did not exist previously—must be investigated emergently.

In more subtle cases of shunt malfunction, the eyes may have a glassy appearance. Often the parents will notice this when others don’t. Such a child should be watched carefully.


Nausea & Vomiting

Much like headache, nausea and vomiting is too general to be of much use in isolation. It is more useful in the presence of other signs and symptoms, such as headache and/or double vision, which would suggest the need for emergent evaluation.

Nausea and vomiting associated with diarrhea, or without any other associations, are not likely related to the shunt, though if the symptoms persist beyond a few days evaluation by your doctor is advisable.


Belly Pain

While some shunt infections can cause belly pain, a non shunt problem (including a simple viral infection) is much more likely. This is not a cause for concern unless persistent, severe, and/or associated with vomiting or diarrhea, in which case see your physician. It is unlikely to be a shunt problem in any event.



Fever is too nonspecific to be of use when in isolation. Again, fever in the company of other findings (such as discussed under headache) may be more significant.


Irritability & Poor Feeding

These symptoms are seen in infants and perhaps others who lack the ability to communicate readily.

The patient becomes something other than himself, being more cranky, irritable, and not wanting to play. By poor feeding is meant a tendency not to take the bottle well or not wanting to eat. Some babies in this situation will spit up whatever they are fed, even small volumes. This can lead to dehydration and thus should be attended to with some urgency.


Seizures & Opisthotonus

Rarely is a seizure a sign of a shunt problem. This is true even in patients with an underlying seizure disorder. Many patients with shunts have underlying seizure disorders and the two are not necessarily related. The exception is in a patient with a sudden flurry of seizure activity and no discernable cause. In such a case, the shunt should be evaluated by a neurosurgeon.

There is one important notice that must be taken in regard to shunts and seizures. Opsithotonus is a condition loosely defined as extreme arching of the back and especially the neck. In opisthotonus, the patient’s head is thrown back forcibly and the appearance is one of extreme discomfort with the neck in extension. Attempts to straighten out the patient meet with great resistance and may be impossible. The patient may have a distant look in the eyes, or may be unconscious altogether. Opisthotonus may be intermittent or sustained.

Opsithotonus is not a seizure, though at times it is referred to confusingly as a ‘brainstem seizure’ or brainstem spell. It is an ominous discovery, indicating one of the herniations (brain shifts) alluded to above. Its importance cannot be overstated. Patients with opisthotonus are at a life-threatening moment and must be evaluated and perhaps operated on immediately. I once ran down three flights of stairs with a young child in my arms, his neck arched in opisthotonus all the way. The elevator had failed.

Opsithotonus is not a seizure, but to the uninitiated it can look like a seizure. In a patient with shunted hydrocephalus and no history of seizures, the report of a seizure should never be taken at face value. Given even the slightest bit of arching, one should assume a life-threatening shunt malfunction and act accordingly.

Disclaimer: The information contained in this blog is simply that, information. I am not doling out specific medical advice. Nothing contained herein is meant to replace a complete evaluation by a qualified member of the medical establishment. This page is nonfiction.