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MD4001 Clinical > Applied physiology:The Clinical Management of Head Injury > Flashcards

Applied physiology:The Clinical Management of Head Injury Flashcards

1
Q

How many head injury attendances are there per year in Scotland?

A

100,000

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2
Q

What is the male to female ratio of head injuries?

A

2:1

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3
Q

What age groups are most frequently affected by head injuries?

A
  • Early 20s and early 80s
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4
Q

What percentage of those who turn up to AandE with a head injury are admitted?

A

15% (children make up a 1/3, more challenging to assess)

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5
Q

What is the leading cause of death in under 45s?

A

Trauma (50% head injury)

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6
Q

What percentage of adult head injuries involve alcohol?

A

65%

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7
Q

What is a primary brain injury?

A
  • Occurs at the moment of impact
  • Pattern and extent of damage depends on nature of impact
  • Not treatable
  • Target prevention (public health issue)
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8
Q

What is a secondary brain injury?

A
  • Secondary processes after primary brain injury which occur at the cell and molecular level to exacerbate neurological damage
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9
Q

What is done to minimise the impact of secondary brain injury?

A
  • Optimise oxygenation
  • Optimise cerebral perfusion
  • Blood glucose
  • Hypo/hypercapnia - maintain normal CO2
  • Body temperature - maintain
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10
Q

What gene increases the risk of brain injury?

A

ApoE4

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11
Q

What processes can cause secondary brain injury?

A
  • Lactic acid increased ATP depleted
  • Membrane pump failure causing glutamate release
  • Free radical generation
  • Calcium mediated damage
  • Inflammatory response
  • Mitochondrial dysfunction
  • Early gene activation
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12
Q

What 2 things cause a rise in intracranial volume in traumatic brain injury?

A
  • Oedema (of specific cells or organ itself)

- Haematoma

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13
Q

What does secondary brain injury involve?

A
  • Ischaemia, excitotoxicity, and cellular energy failure
  • Neuronal death cascades
  • Cerebral oedema
  • Inflammation
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14
Q

How does primary brain injusry lead to secondary?

A
  • Activation of biomeolecular mediators of injury
  • Neuronal damage
  • Cytotoxic oedema
  • Cerebral vessel damage, opening of BBB
  • Increased interstitial fluid and tissue pressure
  • Vasogenic oedema
  • Decreased Cerebral perfusion pressure
  • Vasodilation
  • Increased cerebral blood volume
  • Increased intracranial pressure
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15
Q

What procedure is most commonly done to asses a head injury?

A

CT scan

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16
Q

What head imjury patients should be sent to hospital?

A
  • Extremes of age
  • Amnesia for events before or after injury
  • Any loss of consciousness
  • High energy injury
  • Vomitting
  • Seizure (previous neurosurgery)
  • Bleeding/clotting disorder
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17
Q

What are the different scorings for eyes in the GCS?

A
  • 4 - eyes open spontaneously
  • 3 - eyes open to speech
  • 2 - eyes open in response to pain
  • 1 - eyes do not open

Record NT If patient is unable to open eyes due to bandages, swelling etc.

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18
Q

What are the different scorings for verbal response in the GCS?

A
  • 5 - Orientated
  • 4 - Confused
  • 3 - Inappropriate words
  • 2 - Incomprehensable sounds
  • 1 - No response despite verbal and physical stimuli

Record NT if dysphasic, record T if intubated

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19
Q

What are the different scorings for motor response in the GCS?

A 
6 - Obeys commands
5 - Localises to central pain
4 - Normal flexion towards source of pain 
3 - Abnormal flexion
2 - Extension to pain 
1 - No response to painful stimuli
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20
Q

What are the different degrees of injury according to the GCS?

A
  • Minimal = 15
  • Mild 13-15
  • Moderate 9-12
  • Severe 8 or less
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21
Q

What is considered a coma on the GCS?

A

GCS of 8 or less

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22
Q

What is the mortality for a severe brain injury (GCS of 8 or less)

A

23% (over half have substantial disability at total recovery)

23
Q

What signs mean you should request a CT scan immeadiately in adult patients?

A
  • GCS <13 on initial assessment in AandE
  • GCS <15 2 hors after injury
  • SUspected open or depressed skull
  • Any sign of basal skull
  • Post traumatic seizure
  • 1 or more episode of vomitting (3 in kids)
  • Amnesia for events more than 30 mins before impact
24
Q

What are red flags (don not discharge) ?

A
  • Loss of consciousness, drowsiness, confucion, fits
  • Painful headache which doesn’t settle, vomitting or visual disturbances
  • Clear fluid from ear or nose, bleeding from ears, new deafness (CSF rhinorrhoea test for glucose or beta 2 transferrin)
  • Problems understanding or speaking, loss of balance, difficulty walking or weakness in arms or legs
25
Q

What must you remeber when opening the airway?

A

Cervical spine (often needs CT)

26
Q

What facotors are to remebered when administering oxygen?

A
  • Monitor SpO2
  • Monitor ABGs
  • GCS < 8 intubate
27
Q

How common are convultions with severe head injuries?

A

15%

28
Q

WHat are convulsions treated with?

A

Phenytoin in ealry head injury

29
Q

How is demand for oxygen minimised in severe brain injuries?

A
  • Treat pyrexia (brain metabolic rate increases 6-9% for every degree rise in temperature)
  • Treat convulsions with phenytoin
  • Think about sedation (propofol / midazolam)
30
Q

What happens to cerebral vessel diameter as PaCO2 increases?

A

Increases/dilate , intracranial blood volume will increase, has negative impact on cerebral perfusion pressure

31
Q

What is the target directed therapy for CO2?

A

PaCO2: 4.5 - 5 kPa

32
Q

What percentage of patients with brain injuries are hypotensive?

A

25%

33
Q

How can you calculate Cerebral perfusion pressure?

A

CPP = MAP - ICP

  • Mean arterial pressure
  • Intracranial pressure
34
Q

Normally autoreguation maintains blood flow between what pressures?

A

MAP 50 and 150 mmHg

35
Q

What do cerebral arterioles react to?

A

Local changes in environement (pressure and chemical)

36
Q

When can Cerebral blood flow (CBF) become blood pressure dependant?

A

In a traumatised or ischaemic brain

37
Q

After a severe head injury what Cerebral Perfusion Pressure should we look to maintain?

A

Maintain CPP aboe 60 - 70 mmHg

38
Q

What should the Intracranial Pressure be?

A

ICP less than 20mmHg (invasive pressure monitor)

39
Q

What can the other causes of hypotension be?

A
  • Chest trauma
  • Pelvic fracture
    Stop bleeding, IV fluids (n. saline)
40
Q

How should venius drainage be encouraged?

A
  • Nurse head up tilt (15-30deg)

- Check straps and ties are not obstructing venous flow

41
Q

What in a patient’s history suggests he/she is at risk of intracranial mass?

A
  • High impact injury
  • Significant retrograde amnesia
  • History of coagulopathy
  • Post traumatic seizure
42
Q

What in an examination suggests patient is at risk of intracranial mass?

A
  • GCS 12/15 or less
  • GCS 13/15 or 14/15 and failing to improve within 2 hrs of injury
  • Clinical signs of skull fracture
43
Q

What does peri-orbital brusing suggest?

A

Anterior cranial fossa fracture

44
Q

What can Battle’s sign (Brusing behind the ear) suggest?

A

Petrous temporal bone fracture

45
Q

What is associated with an extradural haematoma?

A
  • Skull fracture
  • Middle meningeal artery
  • 1/3 due to venous bleeding
  • Classically a lucid interval
  • Good out come if treated
  • Relatively uncommon
46
Q

What does an extradural haematoma look like on imaging?

A
  • ‘Lentil shaped’ swelling

- Biconvex swelling

47
Q

A subdural haematoma is due to what vessels rupturing?

A

Veins trave3lling from the brain surface to the saggital sinus

48
Q

How common are subdural haematomas?

A
  • Common
  • Complicates 20-30% of head injuries
  • Prognosis worse
49
Q

What does a subdural haematoma look like on imaging?

A
  • Bleed along the surface of the brain

- Cresentric

50
Q

What is a subarachnoid haemorrhage due to?

A
  • More commonly caussed by head injury but associated with ruptured berry aneurysm
51
Q

What is an intracerebral haemorrhage like?

A
  • Stretching and shearing injury
  • Impact on inside of skull
  • Often contre coup injury (injury is on opposite side of impact)
52
Q

What is a clinical sign of herniation?

A
  • Dilated or unreactive pupil(s) - uncal herniation - oculomotor nerve squashed
  • Extensor posturing
  • Decrease in GCS of 2 or more points
53
Q

What can decrease intracranial pressure (ICP) on a temporal basis (buy time)?

A

Temporary hyperventilation

54
Q

How can you decrease a patient’s pCo2 after being ventilated?

A

20% Mannitol (0.24-1g/kg)

  • Decreases blood viscosity
  • Osmotic diuretic
  • Hypertonic saline
  • Tranexamic acid
  • Tight control of blood glucose (avoid high glucose but dangerous to be too low)

MD4001 Clinical (4 decks)

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