brain trauma Flashcards
The brainstem & cerebellum sit in which cranial fossa?
posterior cranial fossa
Which is more concerning–the external or internal head injuries?
internal head injuries!
Where is the grey matter in the brain?
on the outsidethe white matter is on the insideneuronal connections b/w the 2
What is a concussion?
Transient alteration in mental function due to angular rotation of brain structuresNo gross or microscopic changesLoss of consciousness is typicalCT and MRI is normal
T/F you need to have LOC to have a concussion.
False. May never lose consciousness & have a concussion.
What are some symptoms of a concussion?
HeadacheNausea and or vomitingRinging in the earsDizzinessVacant StareFeeling slowed down“Seeing stars”Sensitivity to lightSleep problemsFeeling confusedPoor balance or coordinationSlow or slurred speechPoor concentrationDelayed responses to answering questionsDecreased ability to playEmotional or personality changesInappropriate behaviourExcessive crabbiness
T/F Linear fractures leave the brain exposed to the air & environment.
False. Compound fractures
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
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
Where are extra-axial intracranial hematomas located?
outside the brainintra-axial is inside the brain
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
What is a good way to tell about brainstem compression?
pupil dilation & 3rd cranial nerve palsy (ipsilateral)
T/F Epidural hematoma has a normal brain.
True.
Who usu gets an epidural hematoma?
younger age group, more often menoften have lucid intervals
T/F Epidural hematomas are more lethal than acute subdural hematomas.
False. Subdural worse–actual brain damage
What is an acute subdural hematoma?
more lethal than EDHno “lucid interval”includes: tearing of bridging veinsparenchymal damageNeeds craniotomyMortality 50-90%
What is a cerebral contusion?
Bruising of the brainCauses swellingMay cause local dysfunction or pressure problemsTypically frontal/temporal/ occipital
What is diffuse axonal injury?
Shear injury at grey/white interface related to rapid acc/decelerationSevere dysfunction; comaCT relatively normalLittle swellingCan cause classical corpus callosum and rostral brainstem injuries
Which things are involved in secondary injury following TBI?
cerebral edema & increased intracranial pressurehypotension & hypoxemia cerebral hypoperfusionResults: Neuronal deathUltimately caused by cerebral ischemiaIncreases morbidity
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.
Why do you get a CT before you do a spinal tap?
b/c they could have a tonsillar herniation syndrome
What are other examples of herniation syndromes?
uncal
subfalcine
central
What are the components of the Glasgow Coma Scale?
Motor (1-6)Verbal (1-5)Eye-Opening (1-4)3-15 is the range.
Explain what 1-6 is for motor response.
1-no movement2-abnormal extension3-abnormal flexion4-withdraws to pain5-localizes to pain6-obeys commands
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 pupilssymmetry of pupilsreactivity to light(pupils are constricted w/ narcotics)
When should you check the pupils?
after resuscitationbefore administration of sedatives or paralyticsor 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?
AirwayBreathing CirculationCervical Spine–immobilization, collar on.DisabilityExposure-secondary assessment
T/F Hypoxemia is bad. GSC < 12 intubate.
False. Everything true, but GSC<9.
When should you intubate?
Persistent hypoxemia (Sat < 90%) with oxygen ApneaAirway 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:hypertensionbradycardia
What are some signs of cerebral herniation?
In an unconscious and unresponsive patient:Patient with dilated and unreactive pupil(s)Patient with asymmetric pupilsPatient non-responsive to painful stimuliPatient displaying extensor posturing
What is the treatment for mild head injuries?
start off with mild activityonce symptoms resolve–>non-contact trainingif symptoms don’t return–>returnStrict 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 evaluationfocal neurological symptoms or signsopen penetrating injuries a history of neurological deteriorationconfusionskull 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- ICPCPP should >60mmHg (want to keep up oxygenation)
How do you treat an inappropriate ICP?
Head up 30 degreesSedateControl tempIntubation and pCO2 control 35-40 mmHgDrain CSF (ventricular drain)Mannitol23% SalineLasixBarbituratesHypothermiaClose monitoring and reassessments!
How can we reduce mortality & morbidity of TBI patients?
Rapid transport to a trauma care facilityPrompt resuscitationCT scanningPrompt evacuation of significant intracranial hematomasICP 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 waterreduces extracellular fluid compartmentuse 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 metabolismSide Effects: hurts cardiac & immune functions–possible sepsis
Are steroids use for ICP patients?
NO
What are the possible complications of a head injury?
Mental dysfunctionMotor or other deficitComaCSF leak- meningitisTaste disorder- commonMemory problemsHeadachesVertigoDeafnessConcentration problemsHydrocephalusdeath
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 encephalopathyloss of neurons is found with accumulation of tau proteinsseen 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>5track crosses more than 1 lobetrack passes through ventriclestrack crosses midline-passes through geographical centre of brain
