(4) Approach to Traumatic Brain Injury Flashcards
history for head injuries: HPC
What happened at the time?
* identify mechanism of injury and LOC, amnesia
What happened before?
* Identify any retrograde amnesia or others factors which influence evaluation
(e.g. alcohol/drugs)
What happened afterwards?
* Identify any vomiting, antegrade amnesia, further episodes of LOC
All of these questions also identify any additional injuries or safeguarding concerns
History: PMH, medications, allergies, social
**Past Medical History: ** bleeding/clotting disorders, previous head injury
Medications: anticoagulants , agents which may alter conscious level
Allergies: specifically general or local anaesthetic agents, tetanus immunisation or antibiotics
Social: Premorbid functional state
examination
- Full cranial and peripheral nervous system examination
- Pupils
- Basal skull fracture
- Wounds
- Neck/Secondary Survey
- GCS
GCS parameters
- Eye opening reponse /4
- Verbal response /5
- Motor response /6
eye opening response
4: Spontaneous
3. Open to verbal command, speech or shout
2. Eyes open to pain (not applied to face)
1. No eye opening
verbal response
- Oriented
- Confused conversation but able to answer questions
- Inappropriate responses
- Incomprehensible sounds or speech
- No verbal response
motor response
- Obeys commands for movement
- Purposeful movement to painful stimulus
- Withdrawn from pain
- Abnormal flexion (spastic) - decorticate posture
- Abnormal extension (rigid)- decerebrate posture
- No motor response
summary of the GCS
Minor brain injury: 13-15 points
Moderate: 9-12
Severe: 3-8
when to CT head within 1 hour
- GCS less than 13 on inittial assessment in ED
- GCS less than 15 at 2 hours after the injury on assessment in ED
- Suspected open or depressed skull fracture
- Any signs of basal skull fracture
- Post traumatic seizure
- Focal neurological deficit
- More than 1 episode of vomiting
when to CT head within 8 hour
- > 65
- any history of bleeding or clotting disorders
- dangerous mechanism of injury
- more than 30 mins retrograde amnesia of events immediately before the head injury
Types of brain haemorrhage
- Extradural
- Subdural
- Subarachnoid
type of bleed
Extradural
- Arterial bleed appears lentiform in appearance as blood is unable to cross tight adhesions of dura mater in skull.
- Does not cross suture lines
type of bleed
Subdural
* Slower bleed from bridging veins in the subdural space.
* Will cross suture lines
type of bleed
Contusion/ subarachnoid haemorrhage
* Also shows coup and contra coup lesions
signs of basal skull fracture
- Panda eyes
- Cerebrospinal fluid leakage from the ear or nose
- Battle sign- bruising behind the ears
- Haemotympanum
Post Concussive syndrome
Variable symptoms including headache, dizziness, poor concentration. Usually resolved within two weeks
Secondary Impact Syndrome
Further head injury can lead to herniation and death.
Gradual return to sports (in particular contact sports), brain rest, drink fluids (but not alcoholic ones).
Several sports have specific guidance inc RFA
Neuro Obs
If GCS < 15 obs every 30 mins
Once admitted ½ hrly for 2 hrs, 1hrly for 4 hrs then 2 hrly
Pain Management
Ensure adequate analgesia as pain will increase ICP
Hypoxia/Hypercapnia
- Airway
- Oxygen but don’t overventilate
Oedema
Mannitol
Hypotension
- CPP= MAP-ICP
- Maintain adequate blood pressure
- 30 degree head up
Reversal of anticoagulation
- Vitamin K
- Prothrombin complex e.g.Octaplex
role of neurosurgeons
decompress expanding haematoma
