Brain Trauma Flashcards by michelle granstrom

The brainstem & cerebellum sit in which cranial fossa?

posterior cranial fossa

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Which is more concerning–the external or internal head injuries?

internal head injuries!

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Where is the grey matter in the brain?

on the outside
the white matter is on the inside
neuronal connections b/w the 2

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What is a concussion?

Transient alteration in mental function due to angular rotation of brain structures
No gross or microscopic changes
Loss of consciousness is typical
CT and MRI is normal

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T/F you need to have LOC to have a concussion.

False. May never lose consciousness & have a concussion.

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What are some symptoms of a concussion?

Headache
Nausea and or vomiting
Ringing in the ears
Dizziness
Vacant Stare
Feeling slowed down
“Seeing stars”
Sensitivity to light
Sleep problems
Feeling confused
Poor balance or coordination
Slow or slurred speech
Poor concentration
Delayed responses to answering questions
Decreased ability to play
Emotional or personality changes
Inappropriate behaviour
Excessive crabbiness

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T/F Linear fractures leave the brain exposed to the air & environment.

False. Compound fractures

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Anyone in the emergency room with black eyes w/o trauma to the eyes-you should think about what?

blood comes from base of skull fracture

**can also see blood accumulation behind the ear

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Why is it super important to pick up base of skull fractures?

b/c CSF may be leaking out & put patient at risk for meningitis

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Where are extra-axial intracranial hematomas located?

outside the brain

intra-axial is inside the brain

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What is an epidural hematoma?

blood accumulates outside of the dura & puts pressure on the brain & brainstem. Injure brainstem & lose consciousness.
**may begin from a skull fracture hurting the middle meningeal artery

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What is a good way to tell about brainstem compression?

pupil dilation & 3rd cranial nerve palsy (ipsilateral)

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T/F Epidural hematoma has a normal brain.

True.

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Who usu gets an epidural hematoma?

younger age group, more often men

often have lucid intervals

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T/F Epidural hematomas are more lethal than acute subdural hematomas.

False. Subdural worse–actual brain damage

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What is an acute subdural hematoma?

more lethal than EDH
no “lucid interval”
includes: 
tearing of bridging veins
parenchymal damage
Needs craniotomy
Mortality 50-90%

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What is a cerebral contusion?

Bruising of the brain
Causes swelling
May cause local dysfunction 
	or pressure problems
Typically frontal/temporal/
	occipital

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What is diffuse axonal injury?

Shear injury at grey/white interface related to rapid acc/deceleration
Severe dysfunction; coma
CT relatively normal
Little swelling
Can cause classical corpus callosum and rostral brainstem injuries

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Which things are involved in secondary injury following TBI?

cerebral edema & increased intracranial pressure
hypotension & hypoxemia 
cerebral hypoperfusion
Results: Neuronal death
Ultimately caused by cerebral ischemia
Increases morbidity

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What is the Monroe-Kelly Doctrine?

we have a finite amount of room in the head…don’t want to increase the volume of something else while treating.

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Why do you get a CT before you do a spinal tap?

b/c they could have a tonsillar herniation syndrome

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What are other examples of herniation syndromes?

uncal
subfalcine
central

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What are the components of the Glasgow Coma Scale?

Motor (1-6)
Verbal (1-5)
Eye-Opening (1-4)
3-15 is the range.

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Explain what 1-6 is for motor response.

1-no movement
2-abnormal extension
3-abnormal flexion
4-withdraws to pain
5-localizes to pain
6-obeys commands

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Which muscle should you prick to assess central pain?

trapezius.

Which part of the Glasgow is the most reliable--not altered by meds?

the motor section of everything

If you get a negative change in GSC w/i 2 points...what does this mean?

something is going wrong! Bad news.

What does a GSC score of 3-8 mean?

severe TBI

What does a GSC score of 9-12 mean?

moderate TBI

What does a GSC score of 13-15 mean?

mild TBI

What do you want to look at when you look at the pupils?

size of pupils symmetry of pupils reactivity to light (pupils are constricted w/ narcotics)

When should you check the pupils?

after resuscitation before administration of sedatives or paralytics or maybe every hour

What counts as pupil asymmetry?

Pupils that are greater than 1mm difference in size are considered asymmetric. This is bad.

What are fixed & dilated pupils?

Pupils that are greater than or equal to 4mm in diameter and constrict less than 1mm in reaction to bright, direct light are considered fixed and dilated. **braindead or close to it. ONly 1 hour to act.

What are the ATLS management of trauma?

``` Airway Breathing Circulation Cervical Spine--immobilization, collar on. Disability Exposure-secondary assessment ```

T/F Hypoxemia is bad. GSC < 12 intubate.

False. Everything true, but GSC<8.

When should you intubate?

Persistent hypoxemia (Sat < 90%) with oxygen Apnea Airway compromise Unconsciousness (comatose) or unresponsiveness with a (GCS < 9)

What should you keep the SaO2 at?

Keep SaO2 saturation > 90%

T/F SBP < 90mm Hg w/ a TBI patient is acceptable.

FALSE You need to prevent hypotension. | This increases mortality

What is the Cushing response with BP?

the brain is injured, & the BP pushes way up. Cushing's triad includes: hypertension bradycardia

What are some signs of cerebral herniation?

In an unconscious and unresponsive patient: Patient with dilated and unreactive pupil(s) Patient with asymmetric pupils Patient non-responsive to painful stimuli Patient displaying extensor posturing

What is the treatment for mild head injuries?

start off with mild activity once symptoms resolve-->non-contact training if symptoms don't return-->return Strict w/ return to sport.

When do you admit people with mild head injuries?

``` Reasons for admission and observation: patients with altered levels of consciousness at the time of evaluation focal neurological symptoms or signs open penetrating injuries a history of neurological deterioration confusion skull fracture difficulty in assessing the patient the absence of supervision by a responsible adult ```

What is the role of surgery in TBI?

Measure ICP (ICP monitor or a ventricular CSF drain) Give more room (decompressive craniectomy) Remove any mass lesions (craniotomy and evacuation of a hematoma)

What is a normal intracranial pressure?

<10mmHg

When you have herniation, what intracranial pressure do you aim for?

<25 mmHg

What is the equation for cerebral perfusion pressure? What is the target of CPP?

CPP= MAP- ICP | CPP should >60mmHg (want to keep up oxygenation)

How do you treat an inappropriate ICP?

``` Head up 30 degrees Sedate Control temp Intubation and pCO2 control 35-40 mmHg Drain CSF (ventricular drain) Mannitol 23% Saline Lasix Barbiturates Hypothermia Close monitoring and reassessments! ```

How can we reduce mortality & morbidity of TBI patients?

Rapid transport to a trauma care facility Prompt resuscitation CT scanning Prompt evacuation of significant intracranial hematomas ICP monitoring and treatment

What is the main guideline for trauma patients?

Hypotension (SBP < 90 mm Hg) or hypoxia(apnea of cyanosis in the field or a PaO2 < 60 mm Hg)must be scrupulously avoided, if possible, orcorrected immediately

What is mannitol? What is its MOA?

sugar water reduces extracellular fluid compartment use this to reduce pressure when there is swelling in ICP

What is the goal of 23% saline treatments used in Iraq conflict?

shrinks extracellular fluid compartment to give the brain more room

What is the MOA of barbiturates? What is the con of barbiturates?

MOA: reduce neuronal activity & thus cerebral metabolism | Side Effects: hurts cardiac & immune functions--possible sepsis

Are steroids use for ICP patients?

What are the possible complications of a head injury?

``` Mental dysfunction Motor or other deficit Coma CSF leak- meningitis Taste disorder- common Memory problems Headaches Vertigo Deafness Concentration problems Hydrocephalus death ```

T/F The older you are...the more likely you are to die from your head injury.

True.

T/F GSC helps predict your prognosis.

True.

What is CTE?

chronic traumatic encephalopathy loss of neurons is found with accumulation of tau proteins seen in repeated concussions

Penetrating trauma can be okay?

yeah, if they don't transfer a lot of energy or hurt a critical structure

Why are gunshot wounds worse than knife wounds to head?

b/c they are high energy

You treat gunshot wounds to head conservatively if GSC >___? & if they have one of the following...

``` GSC>5 track crosses more than 1 lobe track passes through ventricles track crosses midline -passes through geographical centre of brain ```