6. Head Injuries

Question 1

Epidural haematoma most likely from what vessels?

Answer 1

Meningeal arteries.
Most common bleeder is middle meningeal artery.

Or, laceration of venous sinuses.

Question 2

What is uncal herniation?

Answer 2

Herniation of the uncus (medial part of the temporal lobe) through the tentorial notch.

Question 3

Compression at the midbrain will result in weakness on which side of the body?

Answer 3

Opposite side

Question 4

What are the classic clinical signs of uncal herniation?

Answer 4

Pupillary dilatation on the injured side.

Motor weakness on the opposite side.

Question 5

Typical ICP?

Answer 5

10mmHg

Question 6

Why must MAP be maintained within normal range during TBI

Answer 6

If MAP is too low, there is underperfusion of the brain, leading to ischaemia and infarction.

If MAP is too high, brain swelling occurs with elevated ICP.

Question 7

Categories of brain injury based on GCS:

Answer 7

13-15: mild
9-12: moderate
<8: severe

Question 8

Target PCO2 in head injured patients

Answer 8

35mm Hg

In other words, avoid hyperventilation unless there are clear signs of current herniation

Question 9

What treatments are given in severely head injured patients?

Answer 9

These are usually given after consultation with a neurosurgeon:

• Mannitol
• Hypertonic saline

Question 10

What effect does brain injury have on BP?

Answer 10

Usually none.

Hypotension can occur in the terminal stages when medullary failure supervenes.

Question 11

Early sign of uncal hernaiation

Answer 11

Dilation of pupil, loss of pupillary response to light.

Question 12

Anticoagulation reversal for: antiplatelet therapy

Answer 12

Platelets

Question 13

Anticoagulation reversal for: warfarin

Answer 13

FFP, vitamin K, prothrombin complex concentrate, factor VII

Question 14

Anticoagulation reversal for: heparin

Answer 14

Protamine sulfate

Question 15

Anticoagulation reversal for: LMWH (e.g. enoxaparin)

Answer 15

Protamine sulfate

Question 16

Anticoagulation reversal for: direct thrombin inhibitors

Answer 16

Idarucizumab

Question 17

Anticoagulation reversal for: rivaroxaban

Answer 17

None

Question 18

Main contraindication to mannitol

Answer 18

Hypotensive patients (mannitol doesn’t work in hypovolaemic patients; mannitol is a potent diuretic)

Question 19

When should one give mannitol?

Answer 19

Acute neuro deterioration (inc. dilated pupil, hemiparesis, LoC)

Question 20

When should anticonvulsants be used in head injured pateints?

Answer 20

Only when absolutely necessary.

Not for routine use, as they can inhibit brain recovery.

Question 21

Typical anticonvulsants used in head injured patients with seizures

Answer 21

Phenytoin. 2g, given at 50mg/minute.

Can supplment with diazepam or lorazepam.

Question 22

Why is it important to control seizures?

Answer 22

Prolonged seizures can cause secondary brain injury.

Question 23

What is the role of antibiotics in head injured patients?

Answer 23

Broad spectrum Abx should be given prophylactically in patients with penetrating head injury