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Clin Med B 2 > (Enochs + some)Lecture 5: CNS Trauma > Flashcards

(Enochs + some)Lecture 5: CNS Trauma Flashcards

1
Q

What is a TBI?

A

Traumatic brain injury, which is an alteration in brain function.

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2
Q

What is a primary brain injury?

A

The insult that caused the TBI.

  • Explosion
  • MVC
  • Penetrating head trauma
  • etc
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3
Q

What is a secondary brain injury?

A

The cascade of molecular injury mechanisms initiated at time of trauma and continues. (Neuronal cell death)

electrolye imbalances, mitochondrial dysfunction, apoptosis, scondary ischemia from vasospasm, ect

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4
Q

What conditions do we need to avoid for TBI patients?

A
  • Hypotension
  • Hypoxia
  • Hyperglycemia
  • ICP
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5
Q

What is CPP?

A

Cerebral perfusion pressure = MAP - ICP

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6
Q

What two things result in decreased ICP?

A
  • Tachypnea/alkalosis (inducing hypocarbia)
  • HTN

causes vasoconstriction and therefore decreases ICP

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7
Q

What is goal MAP in TBI?

A
  • > = 80 in order to keep CPP high.

CPP = MAP - ICP

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8
Q

What physical exam triad helps us determine increased ICP?

A

Cushing reflex:

  1. HTN
  2. Bradycardia
  3. Decreased respiratory drive

HIB
HTN
Irregular breathing
Bradycardia

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9
Q

What happens to ICP in TBIs?

A

Increases, so we need to increase MAP to counteract it.

CPP = MAP - ICP

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10
Q

For a patient with increased ICP, what can we do to help lower it?

6

A
  • Elevate patient head
  • Glucose between 80-180
  • Prevent any fever (96.8-100.4)
  • Keep O2 > 90%
  • IV Lorazepam to treat seizures
  • IV phenytoin to prevent seizures (esp. for GCS < 10)
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11
Q

What is the trimodal age group for TBI?

A
  1. 0-4
  2. 15-24
  3. > 75
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12
Q

What is the ABCDE for trauma?

A
  • Airway (C-spine and maintain airway)
  • Breathing (ventilation)
  • Circulation (pulses)
  • Disability (GCS, neuro)
  • Exposure (undress pt and check injuries)

A patient that can communicate clearly is already cleared A-D

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13
Q

What are the 3 severity ratings for GCS?

A
  1. Mild = 13-15
  2. Mod = 9-12
  3. Severe = 8 or less

If it’s 8, then you intubate (mnemonic)

Most TBIs are mild (75%)

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14
Q

What is the inclusion criteria for Head CTs?

A
  • Age 16-66
  • Not on blood thinners (except baby asa)
  • No seizure after injury
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15
Q

What are the 4 high risk criteria that prompt a Head CT for head trauma?

A
  1. GCS < 15 2 hours post injury
  2. Suspected/confirmed skull fracture
  3. Signs of basilar skull fracture
  4. > = 2 eps of vomiting (brainstem injury)
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16
Q

What are the 2 medium-risk criteria that prompt a Head CT for head trauma?

A
  1. Retrograde amnesia >= 30 mins prior to TBI
  2. Dangerous mechanism (hit by car as a pedestrian, ejected from car, fell from >3 ft or 5 stairs)
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17
Q

What criteria is used for determing Head CT criteria for children < 16?

A

PECARN

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18
Q

How does a concussion typically present in terms of S/S?

A
  • Loss of memory prior to event
  • Confusion
  • HA, N/V, dizziness
  • Visual changes
  • LOC (rare)
  • AMS

Any neurological symptom can techincally occur

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19
Q

How does a concussion injury look like?

A

Coup contrecoup injury

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20
Q

What are the more alarming S/S in a concussion?

A
  • Focal neurologic deficit
  • Visual field deficit
  • Pupil abnormality
  • Horner syndrome

Stroke can be caused by traumatic hemorrhage

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21
Q

What is the ED treatment in a concussion

A
  • no less than 2 hr of obs after injury in ED setting and 24 hrs at home.
  • any change in neuro status = CT brain w/o

rest, no studying/TV/exercise or ETOH. NO NSAIDS.

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22
Q

what indicates need for admission in Concussions

6

A
  • 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
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23
Q

What is CTE and what makes it more likely?

A

Chronic traumatic encephalopathy: 3+ concussions (football)

presents w short term mem loss, early dementia, impulsive behavior and depression

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24
Q

How long does it typically take to recover from concussion?

A

Around 6 days

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25
Q

What is post concussive syndrome

A

vage neuropsych s/s starting 7-10 days after injury that end within a year of injury.

get MRI if s/s are disabling.

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26
Q

What is the treatment for a linear skull fracture?

A

obs 4-6 hrrs in ED and dc w/ 24 hr obs if no s/s.

Little to no clinical significance

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27
Q

What is the treatment for a depressed skull fracture?

A
  • Usually open, so give tetanus + ABX (vanco + rocephin)
  • If it is greater than the skull’s thickness, surgery
  • Consult neurosurg

usually open because when youre depressed you open up to people

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28
Q

What bone is most commonly affected in a basilar skull fracture? what is the tx for this?

A
  • Temporal bone trauma
  • admit ALL pts with this
  • surgery for underlying bleeds, look for CSF leak from ear/nose
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29
Q

What are the hallmark signs of a basilar skull fracture?

A
  • Halo sign (CSF + blood from ear/nose)
  • Raccoon eyes
  • Battle sign (under the ear)
  • haemotympanum
  • bump on head
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30
Q

What is the treatment for an elevated skull fracture?

A

IV ABX + surgery

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31
Q

What is the ABX for all OUT PATIENT open fractures in general?

A

2g ancef/cefazolin

includes gunshots, stabbing, blasts

32
Q

If we suspect a skull fracture, what additional scans should we order?

A
  • Noncon CT brain and Cspine
  • Con CT chest + abd + pelvis

All of this ordered together is called a “Pan-Scan”

33
Q

What should you never place in a patient with a basilar skull fracture?

A

Nasal airway, as the cribiform plate could be fractured.

34
Q

what is a subdural hemorrhage

A

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

35
Q

What is the MC type of traumatic intracranial mass lesion?

A

Subdural hematoma

Usually due to vein tearing

36
Q

What are the 3 classifications for SDH?

A
  1. Acute <= 2 days
  2. Subacute <= 3-21 days
  3. Chronic > 21 days

Darker on CT = older

37
Q

What gender is SDH MC in?

A

Males

38
Q

what does subdural hemorrhage indicate in a neonate

A

child abuse:(

39
Q

If a patient has a new type of HA, what should be considered ASAP?

A

CT head w/o con

90% subdurals present w HA
worse w/straining = sus
seizures not common

40
Q

What is the criteria for surgical intervention of acute SDH?

A
  • Symptomatic
  • Bleed thicker than 10mm
  • Midline shift > 5mm
  • GCS decrease >= 2 since injury
  • Fixed or dilated pupils

Craniotomy. if not surg candidate then obs and repeat CT in 6-8 hrs

41
Q

When is surgery indicated for chronic SDH?

A
  • Risk of herniation
  • > 10mm thickness or 5mm midline shift
  • Anyone that has the potential to recover

Burr holes to relieve

42
Q
A
43
Q

What are the 4 types of brain herniation?

A
  1. Trans calvarial (going laterally)
  2. Transtentorial (towards center?)
  3. Tonsillar (downard)
  4. Subfalcine (upward/towards face?)
44
Q

What is the MC type of brain herniation?

A

Uncal transtentorial herniation

45
Q

What is the common presentation of brain herniation?

A

Ipsilateral fixed and dilated pupil

brain mass pressing on parasympathetic fibers of CN III

46
Q

what is an epidural hematoma

A

accumulation of blood between dura mater and skull

47
Q

What is the primary cause of a epidural hematoma?

A

Middle meningeal artery rupture

usually d/t blow to temporal area

48
Q

What does an epidural hematoma look like on CT?

A

Lens shaped

49
Q

What is the mnemonic for epidural hematoma S/S?

A
  • Epidural hematoma
  • Luc E (lucid interval)
  • Looks like an Eye on CT
  • Middle meningEEEal artery

Blunt trauma to the temple with likely LOC followed by a “Lucid Interval” where the patient’s neuro exam would be normal. Compensation is occurring. This is followed by quick decompensation with significant worsening of Sx/Sx.

50
Q

What is the treatment for epidural hematomas?

A
  • Surgical hematoma evacuation
  • Monitoring with serial CT scans
51
Q

what is a subaracnoid hemorrhage

A

blood flowing into the subarachnoid space between pia and arachnoid membranes

52
Q

What is the classic symptom of SAH?

A

Thunderclap headache/worst HA of their life

53
Q

What are the S/S of a SAH?

A
  • N/V
  • Nuchal rigidity
  • Back pain
  • BL leg pain
  • Seizures 25% dt sudden rise in pressure
  • Sudden LOC at onset 45%

s/s may take 6 hours to present

54
Q

What is the first step in working up a SAH?

A

CT w/o con

most reliable in first 6 hrs

55
Q

When would we do an LP for SAH and what would we see?

A
  • get LP if high suspicion and CT negative
  • Increased opening pressure
  • Increased RBC count in all tubes
  • Xanthochromic (yellow) CSF
56
Q

What is the gold standard imaging for a SAH?

A

CTA of Brain

57
Q

What meds do we use to reduce MAP < 130 in SAH?

A
  • Esmolol
  • Labetalol

Short half-lives

58
Q

For a patient with increased ICP and SAH, what interventions do we do?

A
  • Intubate and hyperventilate to REDUCE PCO2 to 30-35.
  • Consider mannitol to reduce ICP
  • Lasix to reduce IVP
  • Surgical clipping/coiling of aneurysm
  • Neuro ICU
59
Q

What is the can’t miss condition in spinal cord injuries?

A

Cauda Equina syndrome

60
Q

What is the most commonly injured area of the spine?

A

Cervical

61
Q

What is NEXUS criteria used for?

A

Determination of whether a C-spine injury requires imaging

62
Q

What is the NEXUS criteria?

A
  • Midline posterior Spinal tenderness present
  • Painful distracting injury present
  • Intoxication present
  • Focal Neurological Deficits present
  • Encephalopathy (or ALOC) present

All must be negative to clear a patient without imaging.

63
Q

What exam should we not neglect in testing the spinal cord’s motor function?

A

DRE to test sphincter tone

64
Q

For significant trauma, what CTs do we order?

A
  • Brain
  • C-spine
  • Chest w/ con
  • Abd/Pelvis w/ con

Con for organs

Can add thoracic and lumbar if needed.

Cranium to coccyx

65
Q

How do we treat a C1/atlas fx?

A

Rigid-C collar

Often associated with a C2 facture and without deficits

66
Q

How do you treat torticollis/C1 rotary subluxation?

A
  • Pain control (NSAID, opioid, benzo, muscle lax)
  • Restrict motion with SOFT collar
  • Refer

Soft collar because we don’t want to forcefully correct it.

67
Q

What are the two types of a C2 facture? How is it treated?

A
  • Odontoid fx
  • Posterior element/hangman’s

Tx w/ pain control and rigid cervical brace

68
Q

What is the most common cervical fx in adults? How do we treat cervical fx and dislocation

A

C5

tx w pain control and rigid cervical brace

69
Q

What is the most stable part of a vertebrae?

A

Anterior

70
Q

How do thoracic fx typically occur?

A
  • Anterior wedge/compression: Axial loading with flexion
  • Burst/chance/fracture = dislocation
71
Q

How do you manage anterior wedge/compression of the thoracic spine?

A

TLSO brace and pain meds

72
Q

what suggests complete v 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)
73
Q

What is the treatment for a spinal cord injury?

A
  • Restrict via rigid c-collar
  • No backboard
  • IV fluids
  • Pain meds
  • Transfer
74
Q

What S/S might suggest cauda equina syndrome?

A
  • Saddle anesthesia
  • Urinary retention
  • Difficulty walking
  • LBP
  • Poor rectal tone
  • Change in bowel or bladder in anyway
75
Q

What scan should we order for cauda equina syndrome?

A

MRI

tx with pain meds and urgent surg consult.

76
Q

good review pic

A

Clin Med B 2 (44 decks)

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