Closed injury Flashcards
What scores are for what TBI on GCS?
Mild TBI (i.e. Concussion) : GCS 14 or 15
Moderate TBI: GCS 9-13
Severe TBI: GCS <8
GCS:
- Eye Opening
- Verbal Response
- Motor Response
(4) Opens eyes spontaneously
(3) Opens eyes in response to voice
(2) Opens eyes in response to painful stimulus
(1) Does not open eyes
(5) Oriented, converses normally
(4) Confused, disoriented
(3) Utters inappropriate words
(2) Incomprehensible sounds
(1) Makes no sounds
(6) Obeys commands
(5) Localizes painful stimulus
(4) Flexion, withdrawal to painful stimulus
(3) Abnormal flexion to painful stimulus (decorticate response)
(2) Extension to painful stimulus (decerebrate response)
(1) Makes no movements
How high should you maintain MAP in head injury patients?
Current guidelines recommend maintenance of a mean arterial pressure >80 mm Hg to maintain adequate CPP
What can happen when the patient has low PaCO2 levels in a head injury patient?
Care should be taken not to hyperventilate the patient, as low PaCO2 levels may cause excess cerebral vasoconstriction and resultant hypoxemia.
What is an epidural hematoma?
An epidural hematoma occurs between the skull and dura mater. On CT scan this appears as a biconvex hyper-dense collection of blood that does not cross suture lines (Image 1).
What is a subdural hematoma?
A subdural hematoma (SDH) collects between the dura and arachnoid mater, appearing as a crescent shape that may cross suture lines on CT scan
Traumatic subarachnoid hemorrhage
This appears as hyper-dense blood within the CSF on CT scan (Image 3). Patients may complain of severe headache, meningeal signs, or photophobia. These injuries may be missed on early CT scans, with improved sensitivity 6-8 hours post-injury.
Where do brain contusions typically occur and what side of the brain are they usually on?
Contusions typically occur in the frontal and temporal lobes or occasionally the occipital lobes. They may occur at the site of trauma or the opposite side of the brain (contracoup injury).
When do brain contusions usually turn into intracerebral hemorrhages?
Contusions may convert to intracerebral hemorrhage (ICH) several days after the initial injury, so any changes in neurologic status should be investigated by serial CT scans.
How do diffuse axonal injuries usually happen?
What is normally seen on CT?
- Diffuse axonal injury results from shearing forces on axonal fibers of the white matter and brainstem. The mechanism of injury is typically a sudden deceleration, such as from a motor vehicle collision.
- punctate hemorrhages along the gray-white junction of the cerebral cortex and in deep structures of the brain
What are signs of a basilar skull fracture?
When should you give antibiotics?
- Signs of basilar skull fracture include CSF otorrhea or rhinorrhea, hemotympanum, periorbital or retroauricular ecchymosis (“raccoon eyes” and Battle signs), deafness, or 7th nerve palsy
- Any fractures with overlying lacerations are considered open and IV antibiotics should be given.
What is the danger with increased intracranial pressure and what is the sign of it (response to it)?
- An increase in the ICP may result in decreased perfusion of the brain, causing hypoxemia and further exacerbating injury.
- Increased ICP may also result in herniation of the brain parenchyma.
- The response to increasing ICP is termed the Cushing reflex, consisting of hypertension, bradycardia, and respiratory irregularity.
What are the four herniation syndromes?
- Uncal herniation occurs when the uncus of the medial temporal lobe is displaced inferiorly through the tentorium. This results in an ipsilateral fixed and dilated pupil and contralateral motor paralysis.
- Central transtentorial herniation occurs from midline lesions of the frontal or temporal lobes with downward displacement of the parenchyma through the tentorium. Clinical features include bilateral pinpoint pupils, bilateral Babinski’s signs, and increased muscle tone.
- Cerebellotonsillar herniation occurs when the cerebellar tonsils are displaced through the foramen magnum, resulting in bilateral pinpoint pupils, flaccid paralysis, and sudden death.
- Upwards transtentorial herniation results from posterior fossa lesions, consisting of conjugate downward gaze with lack of vertical eye movements and pinpoint pupils. Development of the Cushing reflex or a herniation syndrome requires prompt intervention to relieve intracranial pressure and prevent further injury.
Concussion symptoms
headache, vomiting, weakness, numbness, dizziness, decreased concentration, memory problems, sleep disturbance, irritability, fatigue, visual disturbances, depression, or anxiety.
Tips for temporarily decreasing ICP
Several temporizing bedside measures may be initiated to decrease ICP prior to definitive intervention. The head of the bed should be elevated to 30 degrees. If there is concern for spinal injury this may be accomplished via reverse Trendelenburg positioning. Mannitol may be used as an osmotic diuretic if the patient is not hypotensive, or hypertonic saline if hypotension is present. If not done previously, the patient should be intubated and adequately sedated to prevent agitation and increase in ICP. Seizures should be treated with benzodiazepines and IV antiepileptics. If there is concern for impending herniation a temporary course of hyperventilation may be instituted, with a goal PaCO2 of 30-35 mm Hg.
