ER- Head Flashcards
etiology of TBI
alcohol and drugs 70% of the time
leading cause of morbidity and mortality following trauma
head injury
patient lost consciousness, what must you do?
CT their head
TBI management
GCS, thorough neuro exam, CT head, drug screeen, maintain C-spine precautions. Consult- trauma, neurosurgery, opthalmology, plastic surgery, and speech therapy
Primary and secondary brain injuries
concussion-compression, sudden deceleration, rotational acceleration, systemic insults, intracranial insults, and cerebral ischemia-reperfusion injury
sudden deceleration can result in what kind of hematoma?
subdural hematoma- tearing of bridging veins on the side opposite the area of impact
most imp factor in generating parenchymal tears
rotational acceleration
what is though to be responsible for loss of consciousness with head trauma?
brain stem movement at the time of impact- (brain stem controls respiration)
what kind of injury would result in hypotension, decreased end organ perfusion, systolic BP less than 90 mmHg, anemia, electrolyte disturbances, hypoglycemia or hyperglycemia, and hyperthermia?
systemic injury
prolonged elevation in ICP a/w
poor outcome
Patient presents with acute subdural hematoma. What is mortality rate if operation occurs more than 4 hours after injury vs. less than 4 hours after injury?
90% mortality rate if operation MORE than 4 hours after injury, compared to 30% mortality rate if less than 4 hours after injury
what occurs in cerebral ischemia-reperfusion injury
transmembrane shift of sodium and calcium INTO cell and potassium OUT of cell, oxygen radical formation, lipid peroxidation
should you take a major scalp laceration seriouslY?
YES, can cause hemorrhagic shock
should you take trivial scalp injury seeriously?
YES, may overlie a penetrating skull injury that can cause meningitis or brain abscess
if laceration plus skull fracture-
neuro consult
if isolated laceration-
fix and discharge
Skull fracture types
stellate- occur with more force. Depressed fractures- still more force
most skull fractures are…
linear
basilar skull fracture can cause…
injury to cranial nerves. If fracture extends to paranasal sinuses or mastoid air cells, can cause CSF leak and meningitis
“racoon eyes” seen in
basilar skull fractures
penetrating skull injuries are at risk to develop
meningitis or brain abscess
what is prone to laceration type injury?
pontomedullary juction following hyperextension of the head on the neck
concussion=
transient loss of consciousness
concussion may result from..
temporary dysfunction of cortical hemispheric neurons bilaterally OR reticular activating system
difference between concussion and contusion
concussion= little of no apparent tissue damage. contusion= tissue injury with capillary damage and interstitial hemorrhage
classifications of contusion
coup, intermediate, and contrecoup
contusion can produce neurologic deficit d/t tissue injury, but more often exert their major effect as…
a nidus for hemorrhage, swelling, or post-traumatic epilepsy
What can mark Diffuse axonal injury?
petechial hemorrhages at the interface of gray and white matter
preferred scan for Diffuse axonal injury?
MRI , but can also see on CT
diffuse axonal injury triad of damage involving:
corpus callosum, dorsal lateral quadrant of the midbrain, microscopic damage within the subcortical white matter
diffuse axonal injury result from
strain-shear forces in deceleration or rotational acceleration injury
difference between intracerebral hemorrhage vs. contusion
contusion- rupture of capillaries. intracerebral hemorrhage-rupturing of blood vessels
management of small vs. large intracerebral hemorrhage
small-non-surgical, control ICP, maintain perfusion. large- surgical decompression
types of intracranial hematomas
intracerebral hematomas, subdural, epedural hematomas, subarachnoid hemorrhage
epidural hematoma- rupture of
middle meningeal artery
subdural hematoma- damage to
cortical bridging veins
subarachnoid hemorrhage- damage to
saccular aneurysm
tx of subdural hematoma
acute- craniotomy. chronic- burr hole evacuation
tx of epidural hematma
emergency craniotomy and evacuation, IV mannitol and hyperventilation to PCO2 of 25-30 mmHg to buy some time
difference in subdural and epidural appearance radiographically?
subdural- crescent shaped. epidural- lens shape
epidural hematoma usually a/w
temporal bone fracture
How to decrease ICP in ER?
IV mannitol and hyperventilation to PCO2 of 25-30 mmHg, elevate head of bed
patient presents with concussion accident followed by period of lucidity, followed by headaches, loss of consciousness again, and progressive neurologic deterioration
epidural hematoma
effects of mannitol in managing cerebral blood flow
given as bolus- increases intravascular volume, SBP, CPP
what happens if mannitol given too rapidly?
can cause hypotension
hyperventilation in managing cerebral blood flow
reduces ICP by constricting pial and cerebral arterioles, causes alkylosis
herniation of medulla through foramen magnum
cushing response
herniation of cerebellar tonsils through foramen magnum
further brain stem compression and medullary ischemia
herniation of medial portion of temporal lobe
midbrain compression, LOC, decerebrate rigidity
herniation of cerebellum upward through tentorial hiatus
bilateral decerebrate rigidity
clinical sign seen when herniation has occured through foramen magnum?
ICP falls very fast, to 0
control of agitation and seizures
avoid electrolyte imbalance, hypoxia, fever. sedatives, paralytics, dilantin, diazepam
third leading cause of death worldwide
cva
CVA etiology
brain ischemia from hypoperfusion as a result of ischemia (thromboembolic- occlusion of vessel), hemorrhage, or systemic hypotension
ischemic stroke can occur as a result of
carotid circulation obstruction, vertebrobasilar obstruction, lacunar infarction
carotid artery circulation obstruction causing ischemic stroke may be caused by
either cardiac (a. fib, rheumatic heart disese, infectious endocarditis) or vascular (giant cell arteritis, SLE) cause
what has higher risk of early mortality and reinfarction - cerebral infarction or lacunar infarc?
cerebral infarction
patient presents with CVA and you are trying to determine the source- ischemic or hemorrhagic. presentation includes contralateral pure motor or sensory deficit, ipsilateral ataxia with crural paresis, dysarthria with clumsiness of hand
lacunar infarct causing ischemic stroke
prognosis of lacunar infarct
good- recovery in 4-6 weeks
what kind of hemorrhagic stoke can HTN cause?
intraparenchymal hemorrhage
HTN can cause microaneurysms most commonly in..
basal ganglia
“worse headache in my life”
subarachnoid hemorrhage caused by AVM’s, saccular aneurysm rupture
indication for promp surgical decompression
cerebellar hemorrhage
ischemic stroke tx
tpa 0.9 mg/kg. 10% given over 10 minutes. remaining given over 1 hour. give within 3-4.5 hours
berry aneursyms grade I-5
I- Neurologically intact, HA. II- HA, CN involvement. III- decreased LOC. IV-stupor. V- coma, brainstem involvement
tx of hemorrhagic stroke
supportive/conservative tx. mannitol and elvate head to decrease intracranial pressure. If SBP over 220, lower wtih IV labetolol to range of 170-200 mmHg. CPP maintained between 70-90 mmHg
when to consider carotic endarterectomy
in stoke patients who have nearly recovered but have carotid artery stenosis more than 70% in ipsilateral carotid a
how to prevent second stroke or MI from occuring after first stroke?
preventative therapy includes statins, antiplatelet therapy with ASA and dipyridamole, or clopidogrel
prognosis for CVA
survival for ischemic infarcts is beter than for hemorrhagic
BP management in hemorrhagic stroke
should not be brought down to normal in first 2 weeks after stroke. if SBP over 220, then lower to 170-200 with IV labetolol
correlation between stroke and TIA
risk of stroke highest in the 48 hours after TIA and declines to baseline by 3 months
TIA cuased by
emboli, cardiac or vascular
patient presents with vertigo, diplopia, weakness and numbness on ALTERNATING sides of body
TIA in vertebrobasilar distribution
patient presents with weakness and sensory deficits on contralateral side, amaruosis fugax if opthalmic artery involved
TIA in carotid distribution
gold standard in diagnosing TIA
Standard arteriography. can also do CT/MRI of head to r/o small CVA and tumor, carotid duplex ultrasonography
Hospital if the following TIA symptos:
within 48 hours of attack, attacks are crescendo, symptoms lasting more than 1 hour, symptomatic carotid stenosis, KNOWN cardiac source, or hypercoagulable state
Patient with TIA, do a standark arteriography that shows high -grade stenosis. next course of action?
surgery or stenting indicated
when is medical tx indicated in TIA
if poor surgical candidate or if vascular disease is extensive or vertebrobasilar
medical tx for TIA that is cardiac source-
warfarin INR 2-3. If Warfarin CI, then ASA 325 mg/day
medical tx for TIA that is non-cardiac source
Warfarin or ASA (used alone or with dipyridamole). clopidogrel
symptoms and signs of infectious meningitis
HA, fever, neck and back stiffness, kernig and brudzinski’s sign positive, sensory disturbance, and CSF abnormalities
organisms responsible in purulent meningitis
18-50: s. pneumonia, Neiseeria meningitis. over 50- listeria, gram negatives
dx and tx in purulent meningitis
dx- gram stain or culture of CSF. Tx- Vanco and cefotaxime or ampicillin
aseptic meningitis cause
viral usually- HSV
defining feature of aseptic meningitis
benign and self limited course
aseptic meningitis can resemble___ on CSF exam
partially treated bacterial meningitis
drug induced aseptic meningitis caused by
NSAIDS, sulfonamids, solid organ transplant agents
CSF examination on non-infectious meningeal irritation
pleocytosis, increased protein, low or normal glucose
organisms in health care associated meningitis
pseudomonas, staph, coag negative staph
encephalitis causes
viral- herpesvirus, arbovirus, rabies virus, flavivirus
CSF with RBC’s=
HSV encephalitis
diagnosis of encephalitis
CT head and LP. CSF may be normal or show lymphocytes
classic triad CNS infection
fever, stiff neck, altered mental status
nearly all patients with bacterial meningitis have 2 of the following
FEVER, STIFF NECK, ALTERED MENTAL STATUS, HEADACHE
if patient has papilledema, seizures of focal neurologic findings, do CT before LP to r/o
intracranial mass lesions
dx CNS infection
CBC, blood culture, LP, CSF analysis, CXR, latex agglutination test
tx meningitis
abx given prior to LP, LP should be done within 4 hours of abx start. Dexamethasone also given with first abx (most effective when causative agent is strep). to decrease ICP- mannitol, hyperventilation, ventriculostomy catheter placement
heache behind 1 eye, a/w drinking. treated with oxygen.WANDER.
CLUSTER ha
bilateral headache, have stress
tension ha
