A to E: Disability - Head injury Flashcards
Outline the spectrum of traumatic head injury
Diffuse
- Subclinical: suggestive history but negative imaging
-
Diffuse axonal injury: loss of grey-white matter differentiation
- Due to shearing
Focal
- Contusions: coup; contre-coup
- Extra-axial bleeds: extradural; subdural; SAH
Differentiate between primary and secondary traumatic brain injury
- Primary: damage occuring at time of impact
- Secondary: injury as a result of neurophysiological and anatomical changes (min-days) following primary insult
- eg. cerebral oedema; haematoma; RICP
Explain coup and contrecoup injuries
Cerebral contusions due to trauma
Coup: same side as trauma
Contrecoup: opposite side to trauma
Give five complications of head injury
- Concussion; Post-concussion syndrome
- Intracranial haemorrhage
- Open/depressed skull fracture; basal skull fracture
- Seizures
- Gait/mobility problems
- Muscle weakness; spasticity; contractures
- Communication and swallowing problems
- Hypopituitarism
- Depression; anxiety; PTSD
- Cognitive impairments; challenging behaviour
What is a concussion?
- A mild traumatic brain injury
- Rapid onset
- Short-lived impairment of brain function
- Spontaneously resolves
What is post-concussion syndrome?
Various symptoms lasting weeks-months after a concussion:
- Headache; nausea
- Dizziness; balance and co-ordination problems
- Changes in appetitie, sleep, vision, and hearing
- Fatigue
- Depression; anxiety; irritability; cognitive impariments
Give four presenting features of a basal skull fracture
- Bump = extradural haematoma
Give five presenting features of traumatic brain injury
-
Reduced GCS
- Confusion; disorientation
- Coma
- Headache
- NaV
- Malaise
- CN injury: due to fractures or RICP eg. anosmia; hearing loss
- Bruising; bleeding
- Spinal injuries
Explain the illness course of traumatic brain injury
- Primary injury
- Triggers secondary inflammation and cerebral oedema
- Worsens over 48h; resolves <6 weeks
- RICP; cerebral hypoperfusion
- Brain herniation; coning
- Death
Give three indications for referral of a head injury to A+E
- GCS <15; LOC; focal neurological deficit
- Suspected skull fracture or penetrating head injury
- Amnesia for events before or after injury
- Persistent headache; >1 vomiting episode since injury
- Seizure
- High-energy head injury
- Previous brain surgery; bleeding/clotting disorders/drugs
- Current drug/alcohol intoxication
- Continuing clinical concern; safeguarding concerns
How does GCS affect the initial management of head injury?
- 15-14 (mild): consider discharge
- 13-9 (moderate) admission
- 8 or less (coma): refer to ITU for ventilator support
- Pain in AVPU correlates to GCS 8
Give three clinical features suggestive of raised intracranial pressure
- Nocturnal headache
- Headache onset when waking
- Headache worsened by straining and moving
- Altered state mental state
- early: lethargy, irritability, slow decision making, abnormal social behaviour
- late: stupor, coma, death
- Vomiting without nausea initially
- Unilateral ptosis; CN III and VI palsy
Outline the treatment of cerebral oedema
- Elevate head 30o
- Maintain MAP >90mmHg
- Mannitol
- Cold cap induced hypothermia
- Intubation: maintain mild hypocapnia
- Hypercapnia: cerebral vasodilation/hypoperfusion
Outline the immediate managment of a head injury
- A to E assessment
- ‘Bluelight’ if either GCS <9 or M <5, and frailty 5 or less
- Regular neurological observations
- Adequate IV opioids: pain can lead to RICP
- If appropriate: stabilise fractures; catetherisation
- Clinically important brain injury and/or c-spine injury
- High risk: CT head ± c-spine ± other body areas
- Low risk: re-examine <1h for imaging needs
- Reverse any anticoagulants
- Consider discussion with neurosurgery
Outline the criteria for performing a CT head scan
- Any high risk factor
- LOC or amnesia since injury + any medium risk factor
- 2h post-injury GCS <15
