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Neuro: Clin Med IIB > CNS Trauma > Flashcards

CNS Trauma Flashcards

1
Q

_____: an alteration in brain function, or other evidence of brain pathology, caused by an external force
This is also known as a _____, the initial insult

A

Traumatic brain injury (TBI)
Primary brain injury

head being struck by an object
head striking an object
Acceleration/deceleration of brain without direct external impact
FB penetrating the brain
force from a blast/explosion

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2
Q

A cascade of molecular injury mechanisms that are initiated at the time of initial trauma and continue for hours or days

A

secondary brain injury
neuronal cell death

Neurotransmitter-mediated excitotoxicity causing glutamate, free-radical injury to cell membranes
Electrolyte imbalances
Mitochondrial dysfunction
Inflammatory responses
Apoptosis
Secondary ischemia from vasospasm, focal microvascular occlusion, vascular injury

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3
Q

Treating secondary assaults is critical to keeping TBI patients (especially moderate and severe) from worsening. How does one do this?

A

Avoid hypotension, hypoxia, hyperglycemia, and Increased Intracranial Pressure (ICP)

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4
Q

what components are responsible for the pathophys of TBI?
what is the formula?

A

Mean Arterial Pressure (MAP), Intracranial Pressure (ICP), Cerebral Perfusion Pressure (CPP)

CPP = MAP - ICP

*Trust the machine - MAP is an estimate. Based on normal heart rate as well.

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5
Q

____ and ____ cause vasoconstriction (increasing resistance) there decreasing ICP

A

Hypocarbia (tachypnea/alkalosis)
HTN

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6
Q

What needs to be kept high enough to make sure that the blood gets to the brain providing O2, glucose, etc… to function?
Goal?

A

MAP
>= 80

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7
Q

normal ICP range?

A

10-15 mmHg (brain, arterial blood, venous, CSF)

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8
Q

what is the cushing reflex?

A

a physiological NS response to increased ICP

HTN, bradycardia, decreased rsp drive

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9
Q

Tx to lower ICP

A
  1. Elevate Head to 30° - lower ICP by 10-15mm Hg
  2. Glucose: 80-180 - decreases metabolic demand
  3. Temp control: 36-38° C
  4. O2 Sat >90
  5. Seizure Tx - IV Lorazepam
  6. Seizure Prophylaxis - IV Phenytoin)
    - esp GCS <10
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10
Q

Trimodal age group for TBI

A

0-4
15-24
>75

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11
Q

Canadian CT Head Injury / Trauma Rule indications

A

1-3 = inclusion criteria
4-7 = high risk criteria
8 & 9 = Medium Risk

  1. Age >16 <66
  2. Not on blood thinners (Baby ASA OK)
  3. No seizure after injury
  4. GCS <15 at 2 hrs after injury
  5. Suspected or confirmed skull fracture
  6. Signs of basilar skull fracture
  7. ≥ 2 episodes of vomiting
  8. Retrograde amnesia ≥30 minutes before event
  9. Dangerous Mechanism
    - Pedestrian hit by vehicle
    - Occupant ejected from vehicle
    - Fall from >3 fts or >5 stairs

1 major or minor RF = CT indicated

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11
Q

TBI is classified how by what score system?

A

mild, moderate, severe
Glasgow Coma Score

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11
Q

ALL trauma pts are examined using ____ followed by a ____.

A

ABCDE - airway, breathing/vent, circulation, disability, exposure
Secondary Survery

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12
Q

what is PECARN

A

indication for head CT for children <16

observation = 3 hrs from onset of injury

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13
Q

a classification of common sx associated with Mild TBI. However, it is often used synonymously.

A

Concussion

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13
Q

pathophys of mild TBI

A
  1. direct contact or acceleration / deceleration injury
  2. change in brain function w/o physical signs of brain damage
    - Loss of memory before event, visual changes (seeing stars), loss of consciousness for any period of time, any alteration of mental state
  3. has normal CT scan if obtained
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14
Q

what is a Coup Contrecoup Injury

A

Cortex contusions

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15
Q

Release of _____ and _____ are thought to cause swelling, secondary injury, and neurodegeneration.

A

excitatory neurotransmitters
inflammatory markers

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16
Q

the shearing (tearing) of axons that happens when the brain is injured as it shifts and rotates inside the bony skull.

A

Axonal rupture and shearing

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17
Q

15 y/o pt presents with
Confusion, Amnesia HA, dizziness, N/V after an accident during football practice
complains of sensitivity to light, sleep disturbances, difficulty thinking

what is this dx?

A

acute sx of brain contusion
aka minor TBI

  • +/- LOC, mostly w/o - may occur immediately or several mins after trauma
  • Retrograde amnesia common
    Repeated ?s which were already asked & answered
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18
Q

Almost any neuro-psychiatric finding is possible in a minor brain contusion, but the following are unlikely and require further workup:

A
  1. Focal neurological deficit - i.e. limb weakness, hemiparesis
  2. Visual field deficit
  3. Pupil abnormality
  4. Horner Syndrome

Remember: Strokes can be caused by traumatic hemorrhage

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19
Q

possible assessments for brain contusion/concussion

A

SAC - Standard Assessment of Concussion
SCAT5
etc

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20
Q

management for brain contusion/concussion

A
  1. conservative observation
    - no <2 hrs after injury in ED setting
    - 24 hrs (at home)
    - No studying, TV, exercise
    - avoid ETOH and NSAIDS
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21
Q

pt with known concussion has now change in neurological status, what is their next step now?

A

noncontrast CT brain

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22
Q

indications for admission for brain contusion/concussion/mild TBI

A
  1. GCS <15 @ 2 hrs post injury
  2. Abnormalities on CT if obtained
  3. Seizure
  4. Bleeding disorders or on anticoagulants
  5. Recurrent vomiting
  6. No family or friends able to observe for 24 hrs
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23
Q

when to return to ER/Clinic for brain contusion/concussion/mild TBI

A

any worsening of condition → Consider CT

  1. Inability to awaken pt at time of expected wakening
  2. Severe or worsening HA
  3. Somnolence or confusion
  4. Restlessness, unsteadiness, or seizures
  5. Difficulties with vision
  6. Vomiting, fever, or stiff neck
  7. Urinary/bowel incontinence
  8. Weakness or numbness anywhere
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24
Q

pt with a concussion is asking when they can return back to their game, what timeline are you telling them?

A
  • each stage must be separated by at least 24 hrs
  • more rapid return considered for asx adults
  • If asx occur - drop back to previous levels
  • Same day return to sports is not recommended for any age
  • more conservative plan for children and adolescents
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25
Q

Repeated concussions are linked to ____

A

chronic traumatic encephalopathy

  • Short term memory loss
  • Early dementia
  • Impulsive behavior
  • Depression

+3 - ↑risk for long term sequelae, esp during childhood and adolescence

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26
Q

post concussion day 8 a pt is now experiencing
HA, dizziness, irritability, anxiety, sleep disturbances, loss of concentration or memory, noise sensitivity

what is this dx? tx?

A

Post Concussive Syndrome

  • Vague neuropsych sx
  • MRI if “disabling” sx
  • Many experience sx 7-10 d after injury; a very few will continue past 1 yr
  • Reassurance is often helpful; Referral to TBI clinic / neurology if continuous sx
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27
Q

types of skull fractures with tx

A
  1. linear - usually asx/minor; observe x 4-6 hrs, DC w/ 24 hr observation
  2. depressed - MC open - +/-** tetanus, IV Vanc + rocephin**
    - greater than skull thickness = surgery
    - consult; start anticonvulsants
  3. basilar - admit; surgery for underlying bleeds
  4. elevated - IV abx, surgery
  5. penetrating - IV abx, surgery, have significant hemorrhage
28
Q

ALL open fractures receive ?

A

immediate IV or IM ABX.
Cefazolin 2g once

29
Q

basilar skull fracture MC occur with what bone/trauma?

A

temporal bone trauma

30
Q

what signs are specific to basilar skull fracture?

A
  • dural tear - CSF leaks from ear/nose if blood present = halo sign
  • raccoon eyes
  • battle sign
31
Q

dx imaging for skull fracture

A

CT w/o contrast - all suspected skull fracture pts

Remember CT if concerned for skull fracture - even if Canadian CT Rules don’t indicate CT necessary (Chart your reasoning in medical decision making)

32
Q

Associated cervical spine fractures occur in 5-15% of skull fractures.
what other work-up can you get?

A
  1. Basic Trauma imaging:
    - “Pan-Scan” - Noncontrast CT brain and cervical spine + contrasted CT of chest and abd with pelvis
  2. Labs (if altered mental status beyond basic labs)
    - POC glucose (Accu-chek)
    - ETOH
    - UDS
33
Q

what must you NEVER do with a suspected basilar fracture that could cause brain trauma if the cribriform plate is fractured?

A

place a nasal airway

34
Q

a collection of blood below the inner layer of the dura but external to the brain and arachnoid membrane

A

subdural hematoma (SDH)

35
Q

MC type of traumatic intracranial mass lesion

A

subdural hematoma (SDH)

caused by tearing of veins and blood conforms to surface shape of brain = thin bleeding on CT.

Chronic = > 3 weeks

36
Q

which is more damaging that is associated with parenchymal damage—subdural hematoma or epidural hematoma

A

SDH

37
Q

what this

A

SDH

38
Q

Three Classifications based on time with SDH

A

CT findings over-rule exact days)

  1. Acute = < 2 d
  2. Subacute = 3-21 d
  3. Chronic = > 3 wks

Darker = Older on CT

39
Q

SDH is MC in who?

A

male
elderly - atrophied brains = fewer sx

40
Q

RF/causes of SDH

A
  1. Head Trauma - esp whiplash type injuries
  2. Coagulopathy or use of Blood thinners
  3. 25-50% of chronic SDH pts have no or very mild head trauma hx.
41
Q

presentation of SDH

A
  1. HA!!
    - Any new type HA - consider CT. - Associated N/V
    - very severe pain, or worsening with cough, sneeze, exercise should raise your suspicion.
    - Seizures in Acute not uncommon (28%)
    - Any neurologic sx has potential to originate from a bleed - Decreased LOC, hemiparesis, personality changes, motor deficits, gait changes, aphasia, etc…
42
Q

work-up for SDH

A
  1. Dx - CT
    - MRI shows more but not ordered often
  2. labs
    - CBC - platelet counts
    - CMP - lytes; hyponatremia can cause brain swelling, clues to liver dysfunction
    - PT/PTT/INR
    - Toxicology if suspected.
43
Q

tx for acute SDH

A
  1. consult neurosurgery - Craniotomy
    - Antithrombotic Mgt.
  2. pts who do not meet surgical criteria - observe, repeat CT at 6-8 hrs.
44
Q

criteria for craniotomy for acute SDH

A
  • surgery for anyone symptomatic
  • bleed thicker >10mm on CT
  • midline shift > 5mm
  • GCS decreased by ≥2 from onset of injury
  • fixed or dilated pupils.
45
Q

tx for chronic SDH

A

consultation with neurosurgery - Burr Holes

  1. Urgent surgical management for worsening condition or who develop signs of brain herniation
  2. Surgery for those with potential recovery
  3. Also >10mm thickness or >5mm midline shift
46
Q

MC brain herniation

A

Uncal Transtentorial Herniation

Caused by increased pressure in the brain

47
Q

PE of brain herniation (uncal)

A

fixed, dilated pupil (Ipsilateral)

  • Brain mass presses on parasympathetic fibers of CNIII = increased sympathetic stimulation.
  • Can also cause contralateral hemiparesis
  • Possible loss of consciousness
48
Q

Accumulation of blood between the Dura Mater and the skull

A

Epidural Hematoma

49
Q

Epidural Hematoma MC involves what bone and artery

A

temporal area
middle meningeal artery

50
Q

CT imaging shows a lens like shape as the Dura Mater is pushed away from the skull,
what is this dx?

A

epidural hematoma

51
Q

epidural hematoma is MC in who?

A

adolescents and young adults
Associated skull fractures present in 75-95%
85% are arterial
non-traumatic rare- infection, hemorrhagic tumors, preg, epidural abscess, sickle cell, lupus, neurosurg complications

52
Q

pt that had a moment of LOC is now presenting with a normal neuro exam, what is this presentation?

A

“lucid interval” in epidural hematoma
followed by quick decompensation with significant worsening of Sx/Sx.

  • Not always the case
  • Likely sx include: HA, N/V, seizures, visual field changes, weakness, numbness
53
Q

tx for epidural hematoma

A
  • Urgent neurosurgical consultation = hematoma evacuation
  • Some monitored w/ serial CT scans and meds
  • Consideration for reversal of anticoagulant will be made by neurosurgery
54
Q

blood flowing into the subarachnoid space between the pia and arachnoid membranes.

A

subarachnoid hemorrhage (SAH)

55
Q

causes of subarachnoid hemorrhage (SAH)

A

MC - head trauma
“nontraumatic hemorrhage” - ruptured cerebral aneurysms, arteriovenous malformation

56
Q

pt presents to you with the worst HA of their life, describing it as a “thunderclap”

what is this dx and what other s/s would they have?

A

SAH

  • N/V, Nuchal rigidity, back pain, BL leg pain.
  • Photophobia and visual changes common. Focal deficits may appear.
  • Seizures in 25% of pts d/t increased ICP
  • Sudden LOC in 45% at initial onset.
  • may take 6 hrs to present
56
Q

work up for SAH

A
  1. first: CT w/o contrast
    - most reliable in first 6 hrs - 100% Sensitive
    - LP if high suspicion and NEG CT Scan
    — ↑ Opening pressure
    — ↑ RBC count in all 4 tubes
    — Xanthochromia
    - CTA of Brain - gold standard (98% sensitive at any time)
  2. Labs: CBC, CMP, Coags, Troponin, Type and Screen for possible surgery, ABG if rsp compromise
57
Q

tx for SAH

A
  1. Urgent neurosurgical consultation
  2. BB - keep MAP <130
    - Esmolol, Labetalol (Short half lives)
  3. signs of ↑ICP - intubated + hyperventilated to PCO2 30-35.
    - Mannitol - Decreases ICP 50% in 30 min.
    - Loops can decrease IVP.
  4. Surgical Clipping or coiling of Aneurysm
  5. Neuro ICU
58
Q

Spinal trauma includes:

A
  1. Fractures - Compression or Burst are common
  2. Penetrating Injuries
  3. Blunt Carotid and Vertebral Artery Injuries
  4. Spinal Cord injuries
    - Traumatic stenosis = Cauda Equina Syndrome with injury to lower back
    - Paraplegia and Quadriplegia
59
Q

presentation of spinal trauma

A

Injury location often determines PE findings:

  1. 55% - Cervical - Neck and UE
  2. 15% - Thoracic - Thorax
  3. 15% - Thoracolumbar Junction (T11-L1)
    - Difficult dx - damage can cause back, hip, urologic, gynecologic, lower abd pain and may be the cause of non-traumatic pain
  4. 15% - Lumbosacral - Pelvis and LE
60
Q

work-up for spinal trauma

A
  1. sensation - dermatomes
  2. motor function: myotomes
    - can they move toes and fingers?
    - All get a DRE to asses sphincter tone.
  3. +/- imaging via NEXUS
61
Q

what is the NEXUS criteria?

A

mild neck injury

S - midline posterior spinal tenderness present
P - painful distracting injury present
I - intoxication
N - focal neurological deficits
E - encephalopathy (or altered LOC)

If none present - imaging not needed. If significant concern - CT is the imaging of choice.

62
Q

cause and tx for C1 fracture (atlas)

A
  • 40% associated with C2 Fx
  • occurs with axial loading (Rock falls on head); not associated with neuro deficits
  • tx: Rigid C-Collar; Refer
63
Q

cause and tx for C1 rotary subluxation (atlas)

A
  1. Torticollis - after major or minor trauma, URI, or RA
  2. Tx:
    - Pain - NSAID, opioid, Benzo, Muscle Relaxer
    - Restrict motion - soft cervical brace - don’t force to regular position
    - Refer - Therapy and neurosurgery
64
Q

cause and tx for C2 fracture (axis)

A
  1. 2 Types - Odontoid Fx and Posterior Element Fx
    - Posterior = Hangman’s fx
  2. Tx: Pain control, Rigid cervical brace, Refer
65
Q

cause and tx for C3 - C7 Fx and Dislocations

A
  1. C5 is MC level of cervical fx in adults
    - Increase in neuro injury when facets are involved
  2. Tx: Pain control, Rigid cervical brace, Refer!
66
Q

causes and tx for thoracic spine fx

A
  1. Anterior Wedge / Compression - Axial loading with flexion. Most stable. Also think elderly, osteoporosis falls.
    - Tx - TLSO Brace, Pain meds
  2. Burst, Chance, Fracture-Dislocation
  3. Tx: Refer - surgery
67
Q

tx for Spinal Cord Injury

A

Tx:
- Restrict Motion (rigid C-collar, no backboard)
- IV fluids
- meds - pain, pressers if neurogenic shock, ABX if indicated
- TRANSFER!

68
Q

difference between complete vs incomplete spinal cord injury

A

Complete - no demonstrable sensory or motor function below a certain level
Incomplete - some degree of motor or sensory function remains (Much better prognosis for recovery)

69
Q

what s/s would concern for cauda equina injury?
tx?

A
  • Saddle Anesthesia, Urinary Retention, Difficulty Walking, Low Back Pain, Poor Rectal Tone, Change in Bowel or Bladder in any way
  • Urgent MRI, Pain meds, Urgent Neurosurgery Consult, IV Steroids (controversial - leave to neurosurgery)

Neuro: Clin Med IIB (13 decks)

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