CNS Trauma - Exam 3 Flashcards
What part of the brain is responsible for problem solving, creative thinking and personality?
frontal lobe
What part of the brain is responsible for memories?
temporal lobe
What part of the brain is responsible for basic life functions?
brain stem
What part of the brain is responsible for visual functions, reading and understanding language?
parietal lobe
What part of the brain is responsible for vision?
occipital lobe
What part of the meninges is superficial and fuses brain to skull?
dura mater
What part of the meninges reduces friction and is filled with CSF as a shock absorbed?
arachnoid mater
What part of the meninges is very vascular and needs a lot of oxygen due to the high metabolic rate of neurons?
pia mater
What is a primary brain injury? What is another name for it?
Traumatic Brain Injury (TBI) is an alteration in brain function, or other evidence of brain pathology, caused by an external force
Traumatic Brain Injury (TBI)
What is a secondary brain injury? What does it lead to?
A cascade of molecular injury mechanisms that are initiated at the time of initial trauma and continue for hours or days
Neuronal Cell Death
What are some examples of things that fall under the secondary brain injury category?
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
What 4 things need to be avoided when treating a traumatic brain injury?
hypotension
hypoxia
hyperglycemia
Increased Intracranial Pressure (ICP)
**How do you calculate MAP?
**How do you calculate CPP? What is it?
CPP is cerebral perfusion pressure
What does hypocarbia (tachypnea/alkalosis) and HTN cause? What does it lead to?
cause vasoconstriction which increases resistance and decreases ICP
**What is the goal MAP in TBI? What is a normal ICP?
**GOAL: ≥ 80
normal ICP: 10-15mmHg
** What is the Cushing reflex? (increased/decreased) ICP?
HTN, bradycardia and decreased respiratory drive
increased ICP
What are some treatments that can be performed in the ER that lower ICP?
Patient positioning - Elevate Head of bead to 30° - It can lower ICP by 10-15mm Hg
Glucose: 80-180 - decreases metabolic demand
Temperature control: 36-38° C (96.8 - 100.4 Fahrenheit)
O2 Sat >90
Seizure Tx (IV Lorazepam)
Seizure Prophylaxis (IV Phenytoin)
Especially if GCS <10
**What does their glucose need to be specifically between in order to lower ICP? **What does their temperature need to be between?
glucose between 80-180
Temperature control: 36-38° C (96.8 - 100.4 Fahrenheit)
What is the preferred seizure prophylaxis when trying to lower ICP? Especially if GCS _____
(IV Phenytoin)
Especially if GCS <10
What are the 3 MC age ranges for pts with a TBI?
0-4
15-24
>75
**What are the 2 reversal agents for warfarin?
Vit K and 4-factor PCC
**What is the reversal agent for heparin/LMWH?
protamine sulfate
**What is the reversal agents for dabigatran?
idarucizumab
dabigatran is pradaxa, Praxbind is reversal agents
**What are the two reversal agent for apixaban, betrixaban. edoxaban, rivaroxaban?
andexanet alfa (Andexxa)
4-factor PCC
If a pt was in a car accident, what two questions do you want to know?
Was the pt wearing their seatbelt?
Was the airbag deployed?
What are the ABCDE of the physical exam when evaluating a trauma pt?
**Rewrite the entire Glasgow Coma scale. What are the differences between localizing and withdrawl?
do it!!!
localizing - 5 points - pts pushes the providers hand out of the way to remove the source of the pain
withdrawl - 4 points - moves the body out of the way of the source of pain
** What is the difference between decorticate and decerebrate posturing? What is the scoring for each?
decorticate is 3
decerebrate is 2
What is the GCS scale for a minor, moderate and severe brain injury? **When do you need to intubate?
minor: GCS 13-15
moderate: GCS 8-12
severe: GCS less than 8
less than 8 need to intubate!!
T/F: The GCS is usually done upon arrival to the ED and that score sticks with the pt for the entire visit
FALSE!!! the GCS needs to be checked multiple times during the encounter and can change at any time
**What are the 3 inclusion rules according to the Canadian CT rule
Age >16 <66
Not on blood thinners (Baby ASA OK)
No seizure after injury
What are the high risk criteria according to the Canadian CT rule?
GCS <15 at 2 hrs after injury
Suspected or confirmed skull fracture
Signs of basilar skull fracture
≥ 2 episodes of vomiting
What are the medium risk criteria according to the Canadian CT rule?
Retrograde amnesia ≥30 minutes before event
Dangerous Mechanism
What is considered a “dangerous mechanism” according to the medium risk canadian rule CT?
Pedestrian hit by vehicle
Occupant ejected from vehicle
Fall from >3 feet or >5 stairs
or someone in the car died
What scale is used to determine if children need a CT or not? What age specifically?
the PECARN
children less than 16
**Draw the PECARN scale. What is considered “observation?”
*Observation = 4-6 Hrs from onset of injury
What are some s/s of a concussion? What is their GCS range? What will their CT look like?
Loss of memory from before the event, visual changes (seeing stars), loss of consciousness for any period of time, any alteration of mental state
mild TBI: 13-15
normal CT scan if obtained
What is a diffuse axonal injury? What 3 things does it cause?
happens as part of a TBI and excitatory neurotransmitters and inflammatory markers are release
thought to cause swelling, secondary injury and neurodegeneration
aka catacholimines comes out of neurons
What are some acute s/s of concussion?
confusion: +/- LOC
amnesia: may forget traumatic event
HA
dizziness
N/V
light sensitivity
sleep disturbancs
difficulty thinking
What are 4 neuro findings that may be associated with a concussion but are problematic and REQUIRE further work-up?
Focal neurological deficit - i.e. limb weakness, hemiparesis
Visual field deficit
Pupil abnormality
Horner Syndrome
** Remember: Strokes can be caused by ______
traumatic hemorrhage
____ and ____ are used in a sports setting to assess concussions. What is important to note about these tests?
SAC
SCAT5
Need to get one before the season starts (for baseline)
What is the official dx of a concussion according to UTD? What does the GCS have to be at least? When do you measure it?
“The diagnosis of concussion or mild TBI is made in an individual with a head injury due to contact; brief loss of consciousness may or may not have occurred. The patient typically has neurologic symptoms, including confusion or memory loss as described above, but does not have neurologic deficits that are associated with a Glasgow Coma Scale (GCS) score of less than 13, measured at approximately 30 minutes after the injury
What is the tx for a concussion in the ED?
observe for no less than 2 hours after injury in ED setting
observe for 24 hours (at home): need someone to be present while they are waiting at home
but needs to be at least 4 hours from the time of injury
in a concussion setting, ______ in neurological status necessitates _______
change
noncontrast CT brain
What are some indications for admission for a pt who has a concussion?
GCS <15 at 2 hours post injury
Abnormalities on CT if obtained (at hospital with neurosurgery)
Seizure
Bleeding disorders or on anticoagulants
Recurrent vomiting
No family or friends able to observe for 24 hours
What are the pt education points for concussion protocol when you send a pt home for 24 hours
rest: NO studying!!! NO exercise!!!!
avoidance of ETOH
avoid NSAIDs
NEED TO TELL THE PT to come back if condition worses
Repeated concussions are linked to _______. What is considered “recurrent” concussions?
chronic traumatic encephalopathy
3 or more - ↑risk for long term sequelae
What are 4 things that can happen as a result of chronic traumatic encephalopathy?
Short term memory loss
Early dementia
Impulsive behavior
Depression
What are s/s post concussive syndrome? What if the symptoms are “disabling?” When will s/s appear after concussion? What is the next step?
Vague neuropsych symptoms - HA, dizziness, irritability, anxiety, sleep disturbances, loss of concentration or memory, noise sensitivity
MRI if “disabling” symptoms
Many will experience symptoms 7-10 days after injury
Referral to TBI clinic / neurology if continuous symptoms
What are the 3 types of skull fracture? Give a brief description of each
linear and depressed
linear: little or no clinical significance
depressed: “not good”
basilar: occur with temporal bone trauma, fracture of the base of the skull
elevated: caused by significant damage
penetrating: gunshot wounds, stabbing, etc
What is the tx for a linear skull fracture?
Observed for 4-6 hours in ED and discharged with 24 hour observation if no symptoms
admit if suspicion or evidence of brain injury
What is the tx for a depressed skull fracture?
tetanus update if indicated
IV vanc and rocephin
greater than skull thickness will need surgical fixation
consult neurosurgery!!! they usually will want you to start anticonvulsants
What is the tx for basilar skull fracture? What bone?
ALL are admitted
sx for underlying bleeds and look for signs of dural tear
temporal bone trauma, fracture across the base of the skull
What is the “halo sign?” What skull fracture is it associated with?
CSF and blood mixed together that are leaking from the ear or nose
basilar skull fracture
What are 6 PE signs that you need to look for in a basilar skull fracture?
What is a battle sign? What type of skull fracture?
bruising behind the ears and at the base of the neck
basilar skull fracture
What is the tx for an elevated skull fracture?
IV Antibiotics
Surgical Consultation
What is the tx for penetrating skull fracture?
IV abx
surgical consultation
**What do you need to give ALL open skull fractures?
immediate IV or IM ABX
What is the diagnostic imaging for a pt with all suspected skull fractures? What else do you need to consider?
brain CT w/o contrast
cervical spine CT
What does the basic trauma imaging, “Pan-Scan” include? What labs?
Non Contrast CT brain and cervical spine as well as contrasted CT of chest and abdomen with pelvis.
consider POC glucose (Accu-chek), ETOH, and UDS if altered mental status, +/- Ammonia if history of Liver problems. Of course, basic laboratory workup (CBC, CMP, UA)
What should you NOT due with regards to a pt with a suspected basilar fracture when trying to improve ventilation status?
Never place a nasal airway with suspected basilar fracture as trauma to the brain could be caused if the cribriform plate is fractured
______ is the MC type of traumatic intracranial mass lesion. What does it look like on CT?
subdural hematoma (SDH)
“crescent shape” on CT
What is subdural hematoma usually caused by? artery or vein? slower or faster to develop?
Usually caused by tearing of VEINS and blood conforms to the surface shape of the brain - therefore, thin bleeding shows on the CT.
VEIN
slower to develop
What is considered a chronic subdural hematoma? Which one is more severe, subdural or epidural hematoma?
Chronic is greater than 3 weeks
Subdural is more severe than epidural hematoma
What are the 3 classifications of a subdural hematoma? What dose a darker appearance on CT indicate?
Acute = < 2 days
Subacute = 3-21 days
Chronic = > 3 weeks
Darker = Older on CT
What pt population is most likely to have an subdural hematoma?
elderly males who are alcoholics due to increased head trauma and increased bleeding time
**subdural hematomas have some increased findings with _____ due to increased head trauma, prone to ______, liver disease causing increased ______
alcoholics
thrombocytopenia
bleed times
What are 2 risk factors for subdural hematoma?
head trauma: especially whiplash type injuries
blood thinners
How do subdural hematomas present?
HA!! any NEW TYPE of HA should consider CT scan
Associated N/V, very severe pain, or worsening with cough, sneeze, exercise or seizure should raise your suspicion
basically any neuro symptom has the potential to originate from a bleed
How do you diagnose a subdural hematoma?
CT
Labs: CBC, CMP (think electrolyte, hyponatremia and liver dysfunction), PT/PTT/INR +/- toxicology
What is the tx for a subdural hematoma? **What are the indications? What do you need to consider?
sx is often the option! (craniotomy)
**Generally surgery will happen for anyone symptomatic, bleed thicker than 10mm on CT, midline shift > 5mm, GCS decreased by ≥2 from onset of injury, fixed or dilated pupils.
Antithrombotic Mgt. if surgery needed
What do you do with subdural hematoma pts who do NOT meet criteria for sx?
Patients who do not meet surgical criteria are observed in hospital and likely have repeat CT of brain at around 6-8 hours
What is the tx for chronic subdural hematoma? What is considered chronic?
sx! -> Burr Hole, but only for patients who have the potential to recover
Also >10mm thickness or >5mm midline shift or have a brain herniation
What is the MC type of brain hernation? What is it caused by?
Uncal Transtentorial Herniation
increased pressure in the brain
**______ is a PE finding that is a very strong indicator for a brain herniation. Why? What are 2 additional PE findings that may or may be present?
single fixed dilated pupil
Brain mass presses on the parasympathetic fibers of the 3rd cranial nerve (Oculomotor) causing increased sympathetic stimulation
-Can also cause contralateral hemiparesis
-Possible loss of consciousness
Where is an epidural hematoma? **What area of the brain has been impacted? **What artery?
Accumulation of blood between the Dura Mater and the skull
**Usually from blow to the Temporal Area
**Almost always involves the Middle Meningeal Artery
**What will an epidural hematoma look like on CT? artery or vein? Who is the MC pt?
Looks like an egg
artery
adolescents and young adults due to trauma
What are 6 non-trauma related causes of an epidural hematoma?
Infection
hemorrhagic tumors
Pregnancy
Epidural abscess
Sickle Cell, Lupus
Neurologic surgery complications
**What is a huge difference in presentation that the PANCE loves to test for epidural hematomas?
Blunt trauma to the temple with likely LOC followed by a “Lucid Interval” where the patient’s neuro exam would be normal
What is the tx for an epidural hematoma?
neurosurgery consult for hematoma evacuation
OR
serial CT and medical management
need to consider reversal of anticoag use but call made by neurosurgery
What is an subarachnoid hemorrhage? What is the usually cause?
blood flowing into the subarachnoid space between the pia and arachnoid membranes
heat trauma but can be a ruptured cerebral aneurysm or AV malformation
aka VERY BAD
What are the risk factors for a Subarachnoid Hemorrhage?
head trauma
brain aneurysms
AV malformation
bleeding disorders
blood thinner usage
**What is the classic PANCE presentation question about SAH?
Sudden onset of Thunderclap HA - WORST HA of life
What are some common additional s/s of SAH?
N/V, Nuchal rigidity, back pain, and even BL leg pain. Photophobia and visual changes are common. Focal deficits may appear.
seizure in 25% of patients
sudden LOC in 45% of patients
CT imaging for SAH is pretty sensitive before the _____ mark since onset
CT imaging is generally close to 100% sensitivity before 6 hours
What is the first step in diagnosing a SAH? Then move on to ______
CT w/o contrast will be first step especially if within the first 6 hours
Lumbar puncture if high suspicion and NEG CT Scan
What will the lumbar puncture show in a pt with SAH?
↑ Opening pressure
↑ RBC count consistent through all 4 tubes
Xanthochromia
**What is the gold standard in diagnosing SAH?
CTA of Brain - gold standard (98% sensitive at any time)
______ may be preferred over CT/LP for acute onset of headache with concern for SAH and no significant risk factors. Negative test rules out SAH with ______
CT/CTA
99.5% confidence
What is the tx for SAH? What do you need to keep MAP below?
neurosx consult!! -> surgical clipping or coil of aneurysm
BB therapy to keep MAP below 130
- Esmolol, Labetalol (Short half lives)
If a pt with SAH is showing signs of ICP, what do you do?
Patients with signs of ↑ICP should be intubated and hyperventilated to a PCO2 of 30-35 (normal is 35-45). Consider Mannitol - Decreases ICP ~50% in 30 minutes. Lasix can decrease IVP.
What is an intraparenchymal hemorrhage? What is the dx and tx?
a normal bleed that shows up like a stroke
dx: CT w/o contrast
tx: call neurosurgery
Draw the dermatomes map
What level does the spinal cord end at? What level is the pudendal nerve? What do you need to assess?
L1
S2-4 pudendal nerve
need to perform DRE
**What is the NEXUS criteria used for? **Draw the chart criteria. What is the imaging of choice?
need for imaging due to cervical neck injury
answer NO to all the questions then imaging is NOT required
CT is the imaging of choice
for significant trauma in clinical practice, what is the CT order consist of?
Brain
Cervical Spine
Chest w/
Thoracic Spine*
Lumbar Spine*
Abdomen and Pelvis w/
*Not automatic in my facility - add if concern for fracture or spinal cord injury.
A pt with spinal trauma, what do you need to document?
Multiple Neurologic Assessments should occur throughout patient’s stay. Document Improvement or Deterioration accordingly.
What is a C1 fracture associated with? Will you see neuro deficits? What is the tx?
C2 fracture and usually occurs with axial loading (rock falls on head)
NOT associated with neuro deficits
tx: rigid C-collar and refer!!
What is a C1 rotary subluxation? What is the tx? Atlas or axis?
a rare condition that occurs when the C1 vertebra rotates on the C2 vertebra
torticollis after a major or minor trauma
tx: pain control: NSAID, opioid, Benzo, Muscle Relaxer and SOFT cervical brace and refer to therapy +/- neurosurgery
C1= atlas
What are the 2 different types of a C2 fracture? axis or atlas? What is the tx?
Odontoid Fx and Posterior Element Fx
Posterior = Hangman’s fx
Tx: pain control, RIGID cervical brace, refer!
C2= Axis
_____ is the most common level of cervical fx in adults. What do you do for fractures and dislocations of C3-C7?
C5
tx:
pain control
RIGID cervical brace
refer!
What parts of the vertebra when fractured are considered always stable? sometimes stable? always unstable?
What is the tx for thoracic spine fractures? What 3 types of vertebra fractures are LESS worrisome?
TLSO Brace, Pain meds
refer for surgical intervention
Transverse Process, Spinous Process, and Pars Interarticularis fx are less worrisome
What is considered a complete spinal cord injury? incomplete? What is the tx?
complete: no demonstrable sensory or motor function below a certain level
incomplete: some degree of motor or sensory function remains
Restrict Motion (do use rigid C-collar, no backboard), IV fluids, medications (pain, pressers if neurogenic shock, ABX if indicated, TRANSFER!
**What are concerns for cauda equina syndrome? **What is the tx?
Saddle Anesthesia
Urinary Retention
Difficulty Walking
Low Back Pain
Poor Rectal Tone
Change in Bowel or Bladder in any way
**tx: URGENT MRI, pain meds, URGENT neurosx consult!!
