11 - Intracranial Trauma Flashcards
What are the general types of brain trauma?
- Penetrating
- Skull FX
- Bleeds
- Diffuse axonal
- Concussion
What are the signs and symptoms of brain trauma?
- Raccoon eyes
- Battle signs
- CSF /blood in ear canal
- Skull depression
- Penetrating object
- Confusion/memory loss
- Neuro changes
- Vital signs
- Mechanism
- Persistent vomiting
Describe the history tips for brain trauma
- Trauma (mechanism)
- Anticoags
- Change in mental status (confusion/LOC)
- Neuro deficits
- What can be explained with intoxication???
- Personality changes (case)
What three things does the Glasgow coma scale consider?
- Eyes
- Verbal
- Motor
What do you need about the Glasgow scale for brain trauma?
- A dead person has a Glasgow of 3 (but you can have a 3 and still be alive)
- Normal is 15
- 8 = intubate
What are the “triggers” for a brain CT?
- Above s/s (before)
- Any abnormal neuro exam
- Mechanism
- Anticoagulants and ANY hit to head ***
- Too much etoh on board to eval
If you’re on anticoags, you get a CT
Describe the imaging studies you will run on brain trauma patients
- CT no contrast give best images acutely…blood looks hyper dense (very white)
- At 72 hours, the blood chemistry changes and the blood starts to look like brain…now CT with contrast or MRI is scan of choice
Describe a penetrating brain trauma
- 35% of TBI (traumatic brain injury) deaths
- GSW (gun shot wound) primary
- How they look when they come in predictive of outcome when FB is removed
What is a basilar skull fracture?
- Linear skull fx at base of skull
- Can tear membranes of brain, leaking CSF
- Raccoon eyes, csf in ears/nose, battle signs
- High infection risk
Look behind ears for bruising - it can be anywhere on the base of the skull
CSF looks like yellowish fluid with some blood in it
What is a hematoma?
Just a collection of blood
What can a CT of the brain show you?
- CT scan of brain looks for shear injury, bleed, stroke, tumor
- Will NOT show a concussion ***
How do you treat a brain bleed?
- ABCs
- Intubate for Glasgow below 8 ***
- If you have a long transport from hospital to hospital, intubate at 12
- Stabilize the patient
- Evacuate the bleed or watch and wait
- If the patient is on coumadin, give vitamin K
What is the treatment for traumatic brain injury?
- Craniotomy and evacuation for significant bleed (observe for smaller) so if your facility doesn’t do, need transfer
- If patient has an obvious brain injury do NOT keep at small hospital to get CT – transfer to trauma center…time is brain***
THE TREATMENT FOR TRAUMA IS SURGERY
What are Burr holes?
- Mainly makes for good TV (Izzy on Grey’s Anatomy)
- Do not drill where skull depression but on side of the dilated pupil (if only one) and on the advice of a surgeon
This is not what is typically done - it is more of a last resort to save a life
What are the different types of brain bleeds and injuries?
- Subdural Hematoma
- Epidural hematoma
- Intraventricular
- Diffuse Axonal Injury
- Subarachnoid
Describe the characteristics of a subdural hematoma
- Most common type of bleed – present in 1/3 brain trauma
- Mortality 20 – 50 % (depending on severity of bleed and comorbidities)
- The very young and very old are at risk (shaken baby, older with brain atrophy)
- Shaken baby - 24% head trauma in under 2 = child abuse
KNOW THE AGES
Describe the bleed in a subdural hematoma
- Path – low pressure venous bleeding of bridging veins…pulls arachnoid away from dura
- Blood can cause increase ICP or direct pressure or ischemia
- May cross suture lines
- Crescent shapes
- Usually not associated with skull fx
How do you differentiate between a subdural or epidural hemorrhage?
Subdural = whole brain Epi = half of the brain
What are the risk factors for subdural hematoma?
- Trauma especially with LOC
- Anticoags (fall + anticoags = CT)
- Hemophiliacs
- Etoh abuse
Describe the relationship between alcoholics and subdural hematomas
Why an increased risk?
- Poor nutrition
- Falls
- Liver makes clotting factors
- Brain atrophy
What happens after a subdural crisis?
- Recurrent hematoma
- Infection
- Seizures
Describe the characteristics of a epidural hematoma
- Bleeding between skull and dural layer – most have skull fractures
- 1-2% head trauma
- Mortality 5-43%
- Injury stabilizes quickly…what they come in with is what they are left with
- Age extremes
- 20% “lucid interval” (frequent board question)
- Lesion more localized, elliptical shaped
What is an intraventricular bleed?
- Usually from minor head trauma (one I saw was big etoh’er passed out…no neuro changes, felt great)
- Usually watch
What is a diffuse axonal injury?
- Rapid acceleration-deceleration forces (car accident)
- Often small changes on CT are huge changes in neuro status
- Poor prognosis
- Persistent vegetative state is common
- A shaken baby can see this too
What is the subarachinoid hemorrhage?
Very easy to miss, present like a headache, drive ER docs nuts
- Bleeding between arachnoid and pia layer
- Usually nontraumatic
- From rupture of AVM, tumor or Berry Aneurism
- What makes ER doctors nuts
6-25 per 100,000
- Intracranial
What is the epidemiology of subarachnoid hemorrhage?
- Women > men
- Blacks > whites
- Ave age = 50
- HTN increases risk of rupture
Describe the death rates in subarachnoid hemorrhage
- Easy to miss
- 10-15% die before arrival
- 40% in a week
- 50% in 6 mo
What are the signs and symptoms of subarachnoid hemorrhage
- Headache – worst of life, sudden “thunderclap” but most have a “prodromal” HA about 2 weeks prior
- N/V/photophobia
- LOC
- Neuro changes in 25%
- Seizure
What is the treatment for a subarachnoid hemorrhage?
- Usually clip the vessel or coil it
Describe concussions
- Any temporary loss of normal brain function
- 300,000 in football players/yr
- 60% college soccer players
- 4-6X chance repeat
What are the signs and symptoms of concussion?
- Prolonged HA
- Visual disturbances
- Dizzy/balance
- Memory/amnesia/confusion
- Difficulty concentrating
- Nausea and vomiting
Very aggressive about treating concussions now
What is the “second impact” effect?
- Second Impact
- Hit again after incomplete concussion recovery – can lead to serious and permanent brain damage
- Instant death can occur
- Big risk boxing, football, hockey, soccer
