(Enochs + some)Lecture 5: CNS Trauma Flashcards
What is a TBI?
Traumatic brain injury, which is an alteration in brain function.
What is a primary brain injury?
The insult that caused the TBI.
- Explosion
- MVC
- Penetrating head trauma
- etc
What is a secondary brain injury?
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
What conditions do we need to avoid for TBI patients?
- Hypotension
- Hypoxia
- Hyperglycemia
- ICP
What is CPP?
Cerebral perfusion pressure = MAP - ICP
What two things result in decreased ICP?
- Tachypnea/alkalosis (inducing hypocarbia)
- HTN
causes vasoconstriction and therefore decreases ICP
What is goal MAP in TBI?
- > = 80 in order to keep CPP high.
CPP = MAP - ICP
What physical exam triad helps us determine increased ICP?
Cushing reflex:
- HTN
- Bradycardia
- Decreased respiratory drive
HIB
HTN
Irregular breathing
Bradycardia
What happens to ICP in TBIs?
Increases, so we need to increase MAP to counteract it.
CPP = MAP - ICP
For a patient with increased ICP, what can we do to help lower it?
6
- 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)
What is the trimodal age group for TBI?
- 0-4
- 15-24
- > 75
What is the ABCDE for trauma?
- 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
What are the 3 severity ratings for GCS?
- Mild = 13-15
- Mod = 9-12
- Severe = 8 or less
If it’s 8, then you intubate (mnemonic)
Most TBIs are mild (75%)
What is the inclusion criteria for Head CTs?
- Age 16-66
- Not on blood thinners (except baby asa)
- No seizure after injury
What are the 4 high risk criteria that prompt a Head CT for head trauma?
- GCS < 15 2 hours post injury
- Suspected/confirmed skull fracture
- Signs of basilar skull fracture
- > = 2 eps of vomiting (brainstem injury)
What are the 2 medium-risk criteria that prompt a Head CT for head trauma?
- Retrograde amnesia >= 30 mins prior to TBI
- Dangerous mechanism (hit by car as a pedestrian, ejected from car, fell from >3 ft or 5 stairs)
What criteria is used for determing Head CT criteria for children < 16?
PECARN
How does a concussion typically present in terms of S/S?
- Loss of memory prior to event
- Confusion
- HA, N/V, dizziness
- Visual changes
- LOC (rare)
- AMS
Any neurological symptom can techincally occur
How does a concussion injury look like?
Coup contrecoup injury
What are the more alarming S/S in a concussion?
- Focal neurologic deficit
- Visual field deficit
- Pupil abnormality
- Horner syndrome
Stroke can be caused by traumatic hemorrhage
What is the ED treatment in a concussion
- 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.
what indicates need for admission in Concussions
6
- 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 is CTE and what makes it more likely?
Chronic traumatic encephalopathy: 3+ concussions (football)
presents w short term mem loss, early dementia, impulsive behavior and depression
How long does it typically take to recover from concussion?
Around 6 days
What is post concussive syndrome
vage neuropsych s/s starting 7-10 days after injury that end within a year of injury.
get MRI if s/s are disabling.
What is the treatment for a linear skull fracture?
obs 4-6 hrrs in ED and dc w/ 24 hr obs if no s/s.
Little to no clinical significance
What is the treatment for a depressed skull fracture?
- 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
What bone is most commonly affected in a basilar skull fracture? what is the tx for this?
- Temporal bone trauma
- admit ALL pts with this
- surgery for underlying bleeds, look for CSF leak from ear/nose
What are the hallmark signs of a basilar skull fracture?
- Halo sign (CSF + blood from ear/nose)
- Raccoon eyes
- Battle sign (under the ear)
- haemotympanum
- bump on head
What is the treatment for an elevated skull fracture?
IV ABX + surgery
What is the ABX for all OUT PATIENT open fractures in general?
2g ancef/cefazolin
includes gunshots, stabbing, blasts
If we suspect a skull fracture, what additional scans should we order?
- Noncon CT brain and Cspine
- Con CT chest + abd + pelvis
All of this ordered together is called a “Pan-Scan”
What should you never place in a patient with a basilar skull fracture?
Nasal airway, as the cribiform plate could be fractured.
what is a subdural hemorrhage
collection of blood below inner layer of dura but external to brain and arachnoid membrane
What is the MC type of traumatic intracranial mass lesion?
Subdural hematoma
Usually due to vein tearing
What are the 3 classifications for SDH?
- Acute <= 2 days
- Subacute <= 3-21 days
- Chronic > 21 days
Darker on CT = older
What gender is SDH MC in?
Males
what does subdural hemorrhage indicate in a neonate
child abuse:(
If a patient has a new type of HA, what should be considered ASAP?
CT head w/o con
90% subdurals present w HA
worse w/straining = sus
seizures not common
What is the criteria for surgical intervention of acute SDH?
- 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
When is surgery indicated for chronic SDH?
- Risk of herniation
- > 10mm thickness or 5mm midline shift
- Anyone that has the potential to recover
Burr holes to relieve
What are the 4 types of brain herniation?
- Trans calvarial (going laterally)
- Transtentorial (towards center?)
- Tonsillar (downard)
- Subfalcine (upward/towards face?)
What is the MC type of brain herniation?
Uncal transtentorial herniation
What is the common presentation of brain herniation?
Ipsilateral fixed and dilated pupil
brain mass pressing on parasympathetic fibers of CN III
what is an epidural hematoma
accumulation of blood between dura mater and skull
What is the primary cause of a epidural hematoma?
Middle meningeal artery rupture
usually d/t blow to temporal area
What does an epidural hematoma look like on CT?
Lens shaped
What is the mnemonic for epidural hematoma S/S?
- 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.
What is the treatment for epidural hematomas?
- Surgical hematoma evacuation
- Monitoring with serial CT scans
what is a subaracnoid hemorrhage
blood flowing into the subarachnoid space between pia and arachnoid membranes
What is the classic symptom of SAH?
Thunderclap headache/worst HA of their life
What are the S/S of a SAH?
- 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
What is the first step in working up a SAH?
CT w/o con
most reliable in first 6 hrs
When would we do an LP for SAH and what would we see?
- get LP if high suspicion and CT negative
- Increased opening pressure
- Increased RBC count in all tubes
- Xanthochromic (yellow) CSF
What is the gold standard imaging for a SAH?
CTA of Brain
What meds do we use to reduce MAP < 130 in SAH?
- Esmolol
- Labetalol
Short half-lives
For a patient with increased ICP and SAH, what interventions do we do?
- 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
What is the can’t miss condition in spinal cord injuries?
Cauda Equina syndrome
What is the most commonly injured area of the spine?
Cervical
What is NEXUS criteria used for?
Determination of whether a C-spine injury requires imaging
What is the NEXUS criteria?
- 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.
What exam should we not neglect in testing the spinal cord’s motor function?
DRE to test sphincter tone
For significant trauma, what CTs do we order?
- Brain
- C-spine
- Chest w/ con
- Abd/Pelvis w/ con
Con for organs
Can add thoracic and lumbar if needed.
Cranium to coccyx
How do we treat a C1/atlas fx?
Rigid-C collar
Often associated with a C2 facture and without deficits
How do you treat torticollis/C1 rotary subluxation?
- Pain control (NSAID, opioid, benzo, muscle lax)
- Restrict motion with SOFT collar
- Refer
Soft collar because we don’t want to forcefully correct it.
What are the two types of a C2 facture? How is it treated?
- Odontoid fx
- Posterior element/hangman’s
Tx w/ pain control and rigid cervical brace
What is the most common cervical fx in adults? How do we treat cervical fx and dislocation
C5
tx w pain control and rigid cervical brace
What is the most stable part of a vertebrae?
Anterior
How do thoracic fx typically occur?
- Anterior wedge/compression: Axial loading with flexion
- Burst/chance/fracture = dislocation
How do you manage anterior wedge/compression of the thoracic spine?
TLSO brace and pain meds
what suggests complete v incomplete spinal cord injury
- 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)
What is the treatment for a spinal cord injury?
- Restrict via rigid c-collar
- No backboard
- IV fluids
- Pain meds
- Transfer
What S/S might suggest cauda equina syndrome?
- Saddle anesthesia
- Urinary retention
- Difficulty walking
- LBP
- Poor rectal tone
- Change in bowel or bladder in anyway
What scan should we order for cauda equina syndrome?
MRI
tx with pain meds and urgent surg consult.
good review pic
