Acute 3 Flashcards
What is part of the primary survey in head/spinal injury?
- A-E
- Neuro obs every 30 mins if GCS <15
- Look for fracture
Which patients should receive a CT within 1 hour?
- GCS <13 on arrival
- GCS <15 2 hours post
- Suspected open or depressed skull fracture
- Signs of basal skull fracture
- Seizure post trauma
- Focal neurological deficit
- More than 1 episode of vomiting
Wha patients should receive a CT within 8 hours?
- Those on warfarin
- LOC or amnesia + 1 of:
- > 65
- History of bleeding or clotting disorder
- Dangerous mechanism (e.g. fall >5 stairs, car vs pedestrian)
- > 30mins retrograde amnesia
What should you do with a patient with GCS of 8 or below?
Intubate
What is a primary head injury?
- Initial insult
- Clinicians have no control
What is a secondary head injury?
- Further head injury from physical and chemical brain changes (e.g. hypoxia, swelling, bleeding)
- Clinicians reduce and prevent these
What are the features of an epidural haematoma?
- Low energy impact
- LOC –> lucid period with headache –> rapid decline
- Rupture of middle meningeal artery
- Associated with temporal bone fracture
What is the imaging of choice for suspected intracranial bleed?
Non-contrast CT head
What does an epidural haematoma show on CT?
Hyperdense lentiform lesion limited by suture lines
What mass effects may occur as a result of epidural haematoma?
- CN3 palsy (down and out, midriasis)
- Uncle herniation
What is the management of epidural haematoma?
Craniotomy and evacuation
Acute subdural haematoma?
- Fresh blood: hyperdense crescentic lesion on CT not limited to suture lines
- Rupture of bridging veins
- Caused by acceleration-deceleration injury
- Treated with decomkpressive craniotomy
Chronic subdural haematoma?
- Old blood: hypodense crescentic change on CT not limited by suture line
- Typically occurs in elderly and alcoholics (vessels more friable) a couple weeks after minor head trauma
- Presents with confusion, LOC, weakness or cortical dysfunction
- Treated with Burr hole drainage
What are the features of subarachnoid haemorrhage?
- Thunderclap headache
- Meningism
What are the risks factors for subarachnoid haemorrhage?
- Black woman
- Hypertension
- Smoking
- Chronic alcohol use
- Cocaine use
- Family history
What conditions are associated with subarachnoid haemorrhage?
- Sickle cell anaemia
- Neurofibromatosis
- Connective tissue disorders
- Aortic coarctation
- AD polycystic kidney disease
What are the 2 main causes of subarachnoid haemorrhage
- Trauma (usually)
- Can be due to aneurysm
What investigation are done in subarachnoid haemorrhage?
- CT head
- Lumbar puncture within 12 hours
- CT angiography to find source
What will show on lumbar puncture in subarachnoid haemorrhage?
- Raised red cells (although if decreases on serial punctures then likely due to traumatic LP)
- Xanthochromia (yellow colour from bilirubin)
What its the management of subarachnoid haemorrhage?
- Surgical coiling or clipping
- Nimodipine (CCB to prevent vasospasm)
- Management of hydrocephalus and seizure if occur
What needs to be assumed in any force that results in LOC?
C-spine injury until proven otherwise
What is the most commonly injured region of the spine?
C-spine followed by thoracolumbar junction
What are some A-E consideration for airway in spinal injury?
- Can’t do head tilt, chin lift
- Laryngeal stimulation will cause massive vagal response
- This can cause cardiac arrest
- give atropine to prevent
What are some A-E consideration for breathing in spinal injury?
- Diaphragm or IC muscle paralysis can occur
- More proximal = worse
- Phrenic nerve roots are C3, 4, 5
- Intercostal nerve roots are T1-11
What are some A-E consideration for circulation in spinal injury?
- Neurogenic shock can occur in level above T6
- Be careful with resus as can cause acute pulmonary oedema
Other things to be aware of in SC injury?
- Urinary retention
- Can get spinal shock (different to neurogenic shock; flaccidity below levels)
- American spinal cord injury criteria
What is the investigation of choice in suspected C-spine injury?
CT C-spine is gold standard
What are features of complete spinal cord section?
- UMN signs and radicular pain at level
- Complete sensory-motor loss below level
What are the features of spinal cord hemisection (Brown-Sequard)?
- Ipsilateral: UMN signs at level; LMN signs, DCML (soft touch, vibration, proprioception) and spinothalamic loss (crude touch, paint temperature) below level
- Contralateral: spinothalamic loss 2 levels below
Autonomic dysreflexia?
- Complete spinal cord injury at T6 or above
- Autonomic stimuli –> sympathetic outflow –> no PNS inhibition
- Urinary retention or faecal impaction
- HTN, flushing, sweating and death
