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Junior - Neuro 2 > 5 - Head Trauma, Coma And Brain Death > Flashcards

5 - Head Trauma, Coma And Brain Death Flashcards

1
Q

Types of head traumas?

A
  • Epidural hematoma
  • subdural hematoma
  • concussion
  • diffuse axonal injury
  • post-concussion syndrome
  • post traumatic seizures and epilepsy
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2
Q

Types of herniation syndromes?

A
  • general
  • central (ranstentorial) herniation
  • uncal herniation
  • subfalcine herniation
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3
Q

epidural and subdural hematomas occur in relation to? (Big list)

A
  • Trauma
  • Tumor
  • Anticoagulation
  • ASA
  • Thrombocytopenia
  • Coagulopathy
  • Epidural catheters
  • Lumbar puncture
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4
Q

MC cause of epidural hematoma?

A

Trauma to the middle meningeal artery

  • Suspect in pts w temporal skull fx
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5
Q

Lucid intervals?

A

Epidural hematoma

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6
Q

CT findings for epidural hematoma?

A

Convex hyper-density in pariotemporal region

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7
Q

Common cause of subdural hematoma?

A

Trauma to back or front of head cause the dura and arachnoid space to separate causing the bridging veins to rupture

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8
Q

How do subdural hematomas present?

A

Gradual signs of cerebral compression occurring hours to days or even weeks later

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9
Q

CT of subdural hematoma shows?

A

Crescent shaped hyper- intensity between brain and skull

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10
Q

Definition for concussion?

A

Trauma-induced alteration in mental status (confusion, amnesia)

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11
Q

Loss of consciousness for concussion

A

Maybe, maybe not

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12
Q

Types of injuries that cause concussion?

A 
Cortical contusion
- coup countercoup 
Shear forces and tensile forces 
- torn vein
- torn artery
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13
Q

Why does the brain bouncing in the skull cause a concussion?

A

It causes a disruption of axonal transport leading to axonal swelling

  • release excitatory neurotransmitters
  • leads to free radical production
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14
Q

Clinical features of concussion?

A

Confusion
Amnesia
Loss of consciousness

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15
Q

Symptoms of concussion?

A
  • HA
  • dizziness
  • vertigo
  • lack of awareness
  • N/V
  • mood changes
  • light/noise sensitivity
  • sleep disturbance
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16
Q

If the concussion symptoms are getting worse it means?

A

Hemorrhage (probably not good)

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17
Q

Grades of concussion?

A

Grade 1: confusion <15min
Grade 2: >15 min
Grade 3: ANY loss of consciousness

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18
Q

When can concussion pts return to activities?

A

Grade 1: now
Grade 2: 1 week later
Grade 3: 1-2 weeks

Must be symptom free x 7 days before return to play

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19
Q

Concussion sideline eval?

A

Head injury: remove from play

No Play if:

  • any loss of consciousness
  • confusion >15 min
  • post traumatic amnesia

ER if any LOC

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20
Q

Types of amnesia?

A

Retrograde
Amnesia of the event
Antegrade (bad)

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21
Q

3 components of MACE?

A
  1. Hx of symptoms
  2. Screening neuro exam
  3. Cognitive screen w score
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22
Q

Who gets MACE?

A

Anyone who is:

  • dazed
  • confused
  • “saw stars”
  • loss of consciousness
  • head injury
23
Q

MACE interpretation?

A

MACE = <25: reeval in 24hrs or evac
MACE = 26-27: manage local unless deteriorates
MACE =/>28: RTD (thats return to duty for my coasty and weekend warriors)

24
Q

What is a diffuse axonal injury?

A

Brain injury with damage in the form of extensive lesions in the white matter tracts occurs over a widespread area
- associated with severe head trauma

25
Q

How well do people with diffuse axonal injury do?

A

No so good

26
Q

CT for diffuse axonal injury?

A

Punctate hemorrhage in deep white matter or corpus callosum

27
Q

What is post-concussion syndrome?

A

Complex disorder in which various symptoms such as HA and dizziness last for weeks/months after injury

The risk doesnt seem to be associated with the severity of the initial injury

Sometimes seen with

  • litigation
  • workers comp
  • depression
28
Q

What are post-traumatic seizures and epilepsy?

A

2% of head injury pts develop seizures or epilepsy

  • 25% of acute sever head injury
29
Q

What is brain herniation

A

Simply put a displacement of the brain tissue into a compartment that it doesnt belong in

LIFE THREATENING CONDITON

30
Q

Types of cerebral herniation?

A

Uncal
Central
Transfalcial
Foraminal

Pics on slide 125

31
Q

Stages of central (transtentorial) herniation?

A 
First: decreased alertness
Second: small, reactive pupils 
Third: decorticate posturing
4th: midposition pupils, decerbate posturing 
Final: pt becomes motionless

Death

32
Q

1st sign of uncal herniation?

A

3rd CN palsy

33
Q

Kernohan’s phenomenon?

A

Continued impaction of uncal herniation leading to ipsilateral hemiplegia

34
Q

Tx for uncal transtentorial herniation?

A

Decompressive trephination “burr holes”

35
Q

Which side should i drill my “burr holes”

A

Usually its on the side that you see 3rd CN problems but…
20% of cases have pupillary changes on the contralateral with ipsilateral motor changes so…
If you drill a hole and it doesnt get better drill one on the other side

36
Q

What does expansile frontal lobe mass cause?

A

Transfalcial herniation

37
Q

Where does transfalcial herniation herniate to?

A

Herniation of the cingulate guyrs beneath the falx and across the midline

  • leg weakness
38
Q

Differences between stupor and coma?

A

Both are impaired responsiveness to external stimulation

Coma: unarousable unresponsiveness
Stupor: midway between alertness and coma

39
Q

With a coma or stupor the injury is probably?

A

To the reticular activating system (neurons originating in the pons and midbrain, projecting to the thalamus and cerebral hemispheres)

Or significant damage to the cerebral hemispheres

40
Q

Cause of stupor and coma (list)

A
  • Trauma
  • Brainstem lesion
  • Cerebrovascular disease (SAH)
  • Meningeal irritation (meningitis, encephalitis)
  • Intoxications (sedative-hypnotics, alcohol, opioids)
  • Metabolic encephalopathy
  • Prolonged post-ictal state
  • Transtentorial herniation – with expanding mass lesion, subdural/ epidural hematoma
41
Q

Coma is a transitional state, what does that mean?

A

It us usually only a few weeks

They get better or it evolves into:

  • persistent vegetative state
  • brain death
42
Q

Glasgow coma scale?

A

Eye opening response: 4 pts
Verbal response: 5 pts
Motor response: 6 pts

If you’re dead you score at least 3

43
Q

Results of glasgow coma scale?

A

Minor brain injury: 13-15 pts
Moderate brain injury: 9-12 pts
Sever brain injury: 3-8 pts

44
Q

Decorticate posturing vs decerebrate posturing

A

Slide 137 but the big change is the hands

Decorticate: hands and elbows in flexion, central
Decerebrate: elbows extension, hands in flexion and out (angel wings)

45
Q

Neurologic exam of stupor/coma pt?

A 
Glasglow coma scale
Cranial nerves
Pupils
Eye movements
- oculocephalic maneuver (dolls eyes)
- caloric testing 
Corneal reflex
46
Q

Oculocephalic and caloric testing?

A

Slide 140

Oculocephalic (doll’s eyes)
- eyes follow you when head moves

Cold caloric response
- cold water in ear and eyes move toward the cold

47
Q

Lab studies for stupor or coma?

A 
Chem 7
LFT
PT
PTT
CBC
ABG

Lumbar puncture

48
Q

Preferred imaging for stupor/coma?

A

Neuroimaging: CT of head

49
Q

What GCS level gets a tube?

A

GCS = 8

50
Q

What is brain death?

A

Irreversible loss of function of the brain including the brainstem

  • trauma
  • hypoxic/ischemic insult
51
Q

What must be there to be considered brain death?

A

Evidence of acute CNS event compatible w brain death

Not reversible medical cause

Not drug/poisoning

Core temp >/= 32C (90F)

52
Q

3 cardinal features of brain death?

A

Coma/unresponsiveness (no pain response)

Absence of brainstem reflexes (pupils, oculocephalic, gag, grimacing)

Apnea

53
Q

Medical record must include:

A
  • Etiology and irreversibility of condition
  • absence of brainstem reflexes
  • absence of motor response to pain
  • absence of respiration w PCO2 >/= 60mmHg
  • confirmatory testing (as indicated)
  • repeated neurological exams (usually need 2)

Junior - Neuro 2 (4 decks)

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