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Senior - Emed 4 > 2 - Head Trauma > Flashcards

2 - Head Trauma Flashcards

1
Q

How is TBI classified?

A

Mild, moderate and severe

Based on Glasgow Coma Scale (GCS)

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2
Q

Most TBI (80%) are defined as?

This type of TBI is aka?

A

Mild - GCS 14-15

Concussion

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3
Q

Outcomes of moderate TBI? (GCS 9-13)

A

Mortality - <20%

Long disability - HIGH

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4
Q

Long term outcomes of sever TBI (GCS 3-8)

A

Mortality - 40%

Only 10% have a “good” recovery

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5
Q

If youre gonna die from a severe TBI when do you usually do it?

A

The first 48hrs

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6
Q

Why do brain injuries tend to cause decreased brain perfusion and cellular hypoxia?

A

CPP, MAP, ICP and systemic factors all work together to regulate blood flow to brain.

With brain injury these factors (autoregulation) are not working which causes the hypo perfusion to occur

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7
Q

CPP, MAP, ICP formula

A

CPP = MAP-ICP

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8
Q

What is the lower limit of the brains ability to autoregulate cerebral blood flow?

A

CPP <60mmHg

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9
Q

Tx for traumatic hypotension?

A

aggressive fluid resuscitation

Injury Leads to ischemia so you must use aggressive fluid resuscitation

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10
Q

If yo dont have an ICP monitor how can you ensure blood flow to brain?

A

maintain a MAP of >/= 80

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11
Q

Primary brain injuries include?

A
  • Contusion (bruise to parenchyma)
  • hematomas
  • diffuse axonal injury (inj to axons)
  • direct cellular damage
  • loss of BBB
  • disruption of neurochemical hemostasis
  • loss of the electrochemical function
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12
Q

Types of brain hematomas?

A 
Subdural
Epidural
Intraparenchymal 
Intraventricular
Subarachnoid
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13
Q

What causes secondary brain injuries?

A

Secondary neurotoxic cascade
- a massive release of neurotransmitters (glutamate) into the presynaptic space w activation of N-methyl…propionic acid

Causes an ionic shift -> mitochondrial damage and cell death/necrosis

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14
Q

How long does the secondary injury last?

A

Apoptosis caused by the injury has been reported to occur longer than 1 yr after injury

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15
Q

The secondary neruotoxic cascade should not be confused with?

A

Secondary insults
- HOTN, hypoxemia etc
That accelerate damage

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16
Q

Brain edema results from 2 distinct processes and can be fatal in TBI, they are?

A

Cellular swelling (cytotoxic edema)

Extracellular edema (direct damage to BBB)

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17
Q

Pathophysiology of brain edema?

A 
water content rises
ICP increases 
- direct compressive tissue damage
- vascular compression-induced ischemia
- brain parenchyma herniation
- brain death
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18
Q

4 major brain herniation syndromes?

A

Uncal transtentorial
Central transtentorial
Cerebellotonsillar
Upward posterior fossa

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19
Q

MC brain herniation?

A

Uncal herniation

- uncus of temporal lobe is displaced inferiorly through medial edge of the tentorium

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20
Q

What causes uncal herniation?

A

Expansion lesion in the temporal lobe or lateral middle fossa

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21
Q

Uncal herniation s/s?

A

Ipsilateral fixed and dilated pupil
- compression of CN III -> unopposed sympathetic tone

Contralateral motor paralysis
- compression of pyramidal tract

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22
Q

What causes central transtentorial herniation?

A

Midline lesions

Less common

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23
Q

Central transtentorial herniation s/s?

A

Bilateral pinpoint pupils
Bilateral babinski’s sign
Increased muscle tone

Then:
Prolonged hyperventilation
Fixed midpoint pupils
Decorticate posturing

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24
Q

What is cerebelllotonsilar herniation?

A

When the cerebellar tonsils herniate through the foramen magnum

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25
Q

Cerebellar tonsillar herniation s/s?

A

Pinpoint pupils
Flaccid paralysis
Sudden death

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26
Q

Upward transtentorial herniation s/s?

A

Conjugate downward gaze
No vertical eye movements
Pinpoint pupils

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27
Q

GCS down and dirty?

A

Eye opening 1-4 pts
Verbal response 1-5 pts
Motor response 1-6 pts

Severe 3-8
Moderate 9-13
Mild 14-15

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28
Q

Which GCS score independently correlates w outcome almost as well as the full score?

A

The motor score

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29
Q

Warning signs for underlying brain injury?

A

Focal neurologic deficit
Seizures
Emesis
Depressed LOC

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30
Q

If intubation is necessary? (regarding GCS)

A

Get a preintubation GCS first if you can

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31
Q

In an unresponsive pt

Single fixed, dilated pupil =

A

Intracranial hematoma w uncal herniation

- rapid surgical decompression

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32
Q

Unresponsive pt

Bilateral fixed and dilated pupils

A
  • Increased ICP
  • poor brain perfusion,
  • bilateral uncal herniation
  • drug effect (atropine)
  • severe hypoxia
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33
Q

Unresponsive pt

Bilateral pinpoint pupils

A

Opiate exposure

Central pontine lesion

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34
Q

Decorticate posturein is?

A

(Upper extremity flexion and lower extension)

Severe intracranial injury above the level of the midbrain

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35
Q

Decerbate posturing is?

A

(Arm extension and internal rotation w wrist and finger flexion and internal rotation and extension of lower extremities)

Caudal injury

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36
Q

In a completely unresponsive pt you should assess?

A

Respiratory pattern
Eye movements

IOT assess brainstem function

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37
Q

Best way to get a CT on an uncooperative or compbative pt?

A

Intubation and sedation

- you may have to , blood in brain will kill them quickly

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38
Q

Cervical fractures in comatose TBI pts?

A

Approx 8%

4% are missed on initial assessment (oops)

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39
Q

If a head injury pt is intubated watch out for?

A

Hyperventilation

- causes cerebral vasoconstriciton

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40
Q

How to prevent hyperventialtion?

A

Use capnometry to keep PCO2 at 35-45 mmHg

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41
Q

Primary goals of tx for head injury pts in ED?

A

Cerebral profusion/oxygenation (intravascular volume and ventilation)

Prevent secondary injury
- correct hypoxia, hypercapnia, hyperglycemia, hyperthermia, anemia or hypoperfusion

Recognize and treat elevated ICP

Get neurosurgical intervention

Tx life threats

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42
Q

What is associated with 150% increase in mortality?

A

Systolic BP <90

Hypoxemia PaO2 <60

43
Q

S/s of elevated ICP?

A 
Change in mental status
Pupillary irregularities
Focal neurological deficits
Decerbrate/decorticate posturing
CT pathology
44
Q

Sedation and analgesia effects on ICP?

A 
May decrease baseline ICP
Prevent transient rises in CIP from
- agitation
- coughing
- gagging (ET tube)
45
Q

Why does it matter when you catch TBI?

A

TBI’s are progressive

early management helps prevent

  • more cell death
  • secondary injury (edema)
46
Q

Problems with induction agents ?

A

Etomidate - lower ICP

Propofol - HOTN

47
Q

Paralytics side effects?

A

Succinylocholine - short acting but avoid in burns, excessive injury

Rocuronium - short - safe in Hyper K

48
Q

When treating head injury what trauma management technique can make the patient worse?

A

Permissive hypotension - can worsen outcomes in pts w brain injury

49
Q

If fluid resuscitation is not effective?

A

Use vasopressors to preserve cerebral perfusion

50
Q

Why is pain management important with head injury?

A

Pain and increase in ICP can cause hypertension

Treat pain and assess for impending herniation (cushing reflex)

51
Q

Can/Should you raise the head of the bed?

A

Raising head may lower ICP

  • uncertain if this is beneficial
  • currently recommended
52
Q

Raising the head on a suspected spinal injury pt?

A

Elevating had of bed 30* can be safely accomplished before spine is cleared as long as head is secured

53
Q

How does sugar effect neurologic injury?

A

Hyperglycemia + neurologic injury = worse outcome

tight hyperglycemia control is recommended
- manage w insulin drip

54
Q

Signs of rising ICP

A 
Severe HA
Visual changes
Numbness
Focal weakness
N/v
Seizures
Change in mental status
Lethargy
HTN
Coma
Bradycardia
Agonal respiration
55
Q

Signs of impending transtentorial herniation

A
  • Unilateral or bilateral pupillary dilation
  • Hemaparesis
  • Motor posturing
  • Progressive neurologic deterioration
56
Q

In patients with rapidly deteriorating GCS you should try to get?

A

Repeat head CT to ID an expanding intracranial hematoma

57
Q

Drugs to lower ICP?

A

Mannitol and or hypertonic saline

58
Q

How does mannitol work?

A

Plasma volume expander (works in 30 min)

  • can improve O2 carrying capacity
  • results in net intravascular volume loss because of its diuretic effect
59
Q

What constitutes “hypertonic saline”

Whats the dose?

A

Most ED”s have 3% NaCl

- 250ml over 30 min

60
Q

If GCS = 8 the pt needs?

A

Intracranial bolt or extra-ventricular drain w monitoring capabilities

61
Q

What should you maintain CPP at?

A

55-60 mmHg

> 70 may result in injury to other organs

62
Q

What patients should get ICP monitoring with an normal CT scan?

A

2 or more of:

  • age >40
  • unilateral/bilateral motor posturing
  • systolic <90
63
Q

ICP > ___ increases morbidity and mortality?

A

> 20mmHg

64
Q

Pts with suspected skull fractures need?

A

Head CT

65
Q

How are skull fractures categorized?

A

By:

  • location
  • Pattern
  • open/closed
66
Q

Factors of skull fractures that have higher complications?

A 
Fx that cross:
- the middle meningeal artery, 
- a major venous sinus, 
- or linear occipital fx 
have high intracerebral complication rates
67
Q

Which skull fractures need IV abx?

A

Open skull fractures that are:

  • open
  • depressed,
  • involve a sinus,
  • associated w pneumocephalus
68
Q

Abx for Open skull fx?

A

Vancomycin 1gm IV
And
Ceftriaxone 2gm IV

69
Q

MC basilar skull fx?

A

Involves

  • the petrous portion of the temporal bone
  • External auditory canal
  • Tympanic membrane
70
Q

Basilar fx are associated with?

A

Dural tearing

- leads to otorrhea/rhinorrhea

71
Q

Never give an NG tube to?

A

Basilar skull fx if cribriform plate fx is suspected

72
Q

S/s of basilar skull fx?

A
  • CSF leak
  • Mastoid ecchymosis (battle sign)
  • Periorbital ecchymoses (raccoon eyes)
  • hemotympanum
  • vertigo
  • decreased hearing/deafness
  • CNVI nerve palsy
73
Q

Warning sing for CSF leak?

A

Pt complains of otorrhea or rhinorrhea

74
Q

How is CSF differentiated from rhinorrhea?

A

Collect fluid and analyze
- B transferrin

B2 transferrin isoform of transferring is found only in CSF - not blood, mucus or tears

75
Q

Pts with acute CSF leaks are at risk for?

A

Meningitis

  • give abx prophylaxis
  • consult neuro
76
Q

Preferred abx for CSF prophylaxis?

A

Ceftriaxone 2gm IV
And
Vancomycin 1gm IV

77
Q

Cerebral contusions usually occur?

A

Frontal and temporal lobes

- rarely in the occipital lobes

78
Q

What is a contrecoup injury?

A

Contusion that occur at the opposite side of blunt trauma

79
Q

When do intracerebral hemorrhages occur?

A

Several days after contusions

- get a series of CT scans and track mental status

80
Q

How do isolated subarachnoid hemorrhage present?

A

Headache
Photophobia
Meningeal signs

That really narrows it down

81
Q

What causes traumatic subarachnoid hemorrhage?

A

Disruption of the paranchyma and subarachnoid vessels

- presents with blood in CSF

82
Q

What is the MC CT abnormality in TBI pts?

A

Traumatic subarachnoid hemorrhage

83
Q

TBI with subarachnoid hemorrhage prognosis?

A

3x higher mortality risk

84
Q

When is a CT scan best for diagnosing subarachnoid hemorrhage?

A

CT scans 6-8hrs after injury are sensitive for detecting traumatic subarachnoid hemorrhage

85
Q

What is an epidermal hematoma?

A

Collection of blood in the potential space between:

  • skull
  • dura matter
86
Q

Classic hx for epidural hematoma?

A

Significant blunt head trauma w LOC/altered sensorium

Followed by a lucid period and subsequent rapid neurologic demise

Trauma -> LOC -> lucid -> crash

87
Q

What causes subdural hematoma?

A

Sudden acceleration-deceleration of brain parenchyma w

- tearing of bridging dural veins

88
Q

Subdural vs epidermal hematoma?

A

Subdural - collects slowly
Epidermal - collects faster

But:
Subdural hematoma is often associated w concurrent brain inj and underlying parenchymal damage

89
Q

How does brain atrophy affect subdural hematoma?

A

Old and alcoholics w brain atrophy are more susceptible to acute subdural hematoma

90
Q

Who is at a higher risk for subdural hematoma?

A

Alcoholics
Elderly
Kids <2
Clumsy (even small falls can cause)

91
Q

When do acute subdural hematomas present?

A

W/in 14 days of the injury

After 2 weeks becomes chronic

92
Q

Chronic Subdural pts can be difficult to diagnose because?

A

They often have no recall of the injury

93
Q

How do acute and subacute and chronic subdural hematoma’s look on CT?

A

Acute:
- Hyperdense (white) crescent shaped lesions that cross suture lines

Subacute:

  • isodense and more difficult to ID
  • contrast may help

Chronic:
- hypodense (dark) - Iron in the blood has been metabolized

94
Q

Surgery and subdural hematomas?

A

Acute - surgery
Subacute - surgery
Chronic - no surgery (maybe)

95
Q

Intracranial injury comparison?

A

Slide 66

96
Q

What is diffuse axonal injury?

A

Disruption of axonal fibers in the white matter and brain stem

  • seen after blunt trauma
  • MVA, shaken baby etc
97
Q

CT scan for diffuse axonal injury?

A

May appear normal

Classic findings:
- punctuate hemorrhage injury along grey-white junction of cerebral cortex and w/in the deep structures of the brain

98
Q

Tx for diffuse axonal injury?

A

Tx is limited

Attempt to prevent secondary damage by :

  • reducing cerebral edema
  • limiting pathologic increase in ICP
99
Q

Why are bullets more traumatic than other penetrating injury?

A

They are scary…

But seriously:

  • cavitation - creates a cavity 3-4x larger than the bullet itself
  • maj of injury is from the kinetic injury
100
Q

Prognosis of bullet to head?

A

GCS > 8 - 25%

GCS <5 - 100%

101
Q

Tx for bullet to head?

A

Intubate
Prophylactic abx
- vanc 1gm IV
- ceftriaxone 2mg IV

102
Q

Contrast stab wounds with bullet?

A

Stab wounds are relatively low energy

- damage is only the area contacted with the penetrating obj

103
Q

Tx for penetrating trauma?

A

Broad spectrum abx
Operation
Leave impaled obj in place until surgery

104
Q

What do you call an elephant that doesnt matter?

A

An irrelevant

Senior - Emed 4 (6 decks)

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