21. Burns, trauma 2

Question 1

What types of primary brain injury are there?

Answer 1

• cerebral lacerations
• cerebral contusions (coup and contrecoup)
• diffuse axonal injyry /shearing injury

Question 2

What are some secondary brain insults (not direct trauma)?

Answer 2

brain hypoxia from:
- hypotension
- anaemia
- cerebral oedema
hypo/hyperglycaemia 
seizures

Question 3

Assessment of head injured child

Answer 3

Airway - protect/patent
Breathing - may be irregular, distress, resp failure
Circulation -brady, htn, low CO
Disability: pupil size and reaction, level of conscious state - AVPU, GCS (eye opening 1-4, verbal response 1-5, best motor response 1-6) - max 15, <8 = coma

Question 4

AVPU scale

Answer 4

Alert to voic
V responds to voic
P responds only to pain
U unresponsive to all stimuli
Also check pupil size and reactivity

Question 5

What are the absolute indications for head CT (in child)?

Answer 5

• respiratory irregularity/loss of protective laryngeal reflexes
• unresponsive or only responding non -purposefully to pain
• GCS persistently <8
• signs of basal skull fracuter on secondary survey
• focal neuro deficit
• suspicion of open or depressed skull fracture

Question 6

relative indications for CT

Answer 6

LOC> 5mins
amnesia>5mins
persistent vomiting
clinical suspicion of non accidental injury
GCS persistently less than 14 if > 1yr old

Question 7

What things need to be taken into account in a secondary survery with head injury?

Answer 7

• scalp: lacerations, bruises, boggy swellings, battle’s sign (also mastoid ecchymosis, is an indication of fracture of middle cranial fossa of the skull, and may suggest underlying brain trauma. Battle’s sign consists of bruising over the mastoid process, as a result of extravasation of blood along the path of the posterior auricular artery)
• eyes - racoon eyes, pupillary reaction, fundoscopy
• ears: CSF leak, blood behind drum
• nose: CSF leak
• mouth: teeth loose or #, tonuge or mucosal laceration

Question 8

Management of head injury

Answer 8

• avoid hypoxia; apply O2
• avoid hypotension; IV access, use drugs that maintain CV stability - eg ketamin,e, not sympatholytics like fentanyl, propofol.
• elevate head 30%
• avoid venous obstruction
• maintain temperature
• avoid hypo/hyperglycaemia
• avoid hyponatremia (saline over loading)

Question 9

Key points of brain injury management

Answer 9

• ABC
• check for decompensating head injury - GCS/AVPU
• thorough secondary survey
• head CT if indicated - no delay
• aim to prevent secondary damage