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Trauma and Accident > Head Anatomy, Assessment, Injuries: Uncal Herniation, High ICP, 1ary/2ndary Head Injury, Basal Skull Fracture, ED, SD, SA, IC Hemorrhage, Contusion, Diffuse Axonal Injury, Concussion > Flashcards

Head Anatomy, Assessment, Injuries: Uncal Herniation, High ICP, 1ary/2ndary Head Injury, Basal Skull Fracture, ED, SD, SA, IC Hemorrhage, Contusion, Diffuse Axonal Injury, Concussion Flashcards

1
Q

How to calculate cerebral perfusion pressure

-what makes up ICP

A

CPP = MAP (50-150mmHg) - ICP

ICP

  • CSF volume
  • blood volume
  • brain volume
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2
Q

Epidemiology of head injury

Risk factors

A

Almost half in children
Risk factors
-alcohol
-extremes of age

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3
Q

Clinical signs of head injury

A

Head

  • bruising
  • laceration
  • palpable fracture

Basal fracture

  • racoon eyes
  • Battle signs
  • CSF, blood from ear or nose
  • CN7, 8 palsy

Neuro signs

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4
Q

How to assess severity of head injury

  • GCS after initial resus
  • what does each score mean?
A

GCS
Severe U8
Moderate 9-12
Mild 13-15

Eyes
4 -spontaneous
3-V
2-P
1-U
Speech
5-spontaneous
4-confused
3-words
2-sounds
1-none
Motor
6-spontaneous
5-localising
4-withdrawal from pain
3-flexed on pain
2-extended on pain
1-none
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5
Q

Assessment of head injury

-what would you do?

A

LOC - GCS

Focal neuro deficit

  • pupil size and response - unequal/unresponsive pupils due to ext compression of nerve
  • limb mv (long tract involvement)
  • posture, reflexes

Signs of ICP

  • Cushings triad - bradycardia, irregular RR, wide BP
  • headache, vomiting, confusion

Head injury + low BP => look for bleed elsewhere
-bleed in brain always causes ICP

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6
Q

When to admit to hospital

A 
Reduced consciousness
Skull fracture
Persistent neurological symptoms/signs
Difficulty assessing patient - alcohol
Significant medical conditions - coagulopathy
No carer around
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7
Q

Initial management of head injuries

A

AIM to optimise O2 supply and perfusion to prevent 2ndary brain injury

Airway - maintain, protect, O2
Breathing - support gas exchange
Circulation - maintain arterial pressure
Disability - assess, monitor for deterioration
Manage pain effectively
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8
Q

When would you do a CT head

  • 1hr of risk being identified
  • 8hr of injury
A 
GCS U13 initially/not 15 in 2hrs
Suspected open/depressed/basal skull fracture
Seizure
Vomited twice
Neurodeficit

LOC/amnesia since injury

  • 65+
  • Hx of bleeding/clotting
  • Dangerous MOI
  • Retrograde amnesia
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9
Q

When to refer to neurosurgery

A

Skull fracture with

  • confusion
  • depressed level of cosciousness
  • focal neuro signs
  • fits
Persisting coma, confusion
Worsening GCS, focal neurology
Seizure without full recovery
Penetrating injury
Depressed skull/BOS fracture
CSF leak
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10
Q

When to discharge from ED

A 
No LOC
Minimal post traumatic amnesia
No active vomiting
No severe headache
No seizures
Able to walk unaided, ADLs
Will leave accompanied by and stay with competent adult
No significant other risk factors - not on warfarin, no chronic ETOH
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11
Q

TBI - extradural hematoma

  • pathophysiology
  • presentation
  • causes
  • CT head findings
A

Bleed between dura and skull - often MMA

  • blow to side of head
  • acceleration, deceleration trauma

High ICP
Lucid interval

Lemon

Conservative
If ICP high => surgical decompression

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12
Q

TBI - subarachnoid hematoma

  • pathophysiology
  • causes
  • presentation
  • CT head findings
A

Spontaneous rupture of vessels in context of head trauma/ruptured aneurysm

Thunderclap occipital headache

Hyperdense blood in SA space
-if no signs but suspect SAH => LP 12hrs from onset to assess for RBC in CSF

Neurosurgery referral

  • Nimodipine
  • Phenytoin
  • Antiemetics, analgesia
  • Surgical coiling/clipping if caused by aneurysm
  • Ventricular draining if hydrocephalus
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13
Q

TBI - subdural hematoma

  • pathophysiology
  • causes
  • presentation
  • CT head findings
A

Bleed between dura and arachnoid, often around frontal, parietal

Low impact trauma in older adults, alcoholism, AC users

Raised ICP
Lucid interval but symptoms arise slower than extradural

Banana

Reduce ICP - surgical decompression

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14
Q

TBI - intracerebral hematoma/haemorrhagic stroke

  • pathophysiology
  • presentation
  • causes
  • CT head findings
  • management
A

Collection of blood within brain from

  • HTN
  • aneurysm, AVM, infarct
  • truma
  • brain tumour

Similar presentation to ischemic stroke
May have decrease in consciousness

Hyperdensity within brain

Conservative
-evacuative surgery needed if large clots + impaired consciousness

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15
Q

Secondary brain injury

  • what is it
  • effects of it
A

Original injury exacerbated by

  • cerebral edema
  • ischemia
  • infection
  • herniation

Cerebral autoregulation disrupted => more susceptible to ICP changes, hypoxia

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16
Q

Signs of ICP

A

Headache
Vomiting
Reduced consciousness
Papilloedema

Cushing triad

  • widening pulse pressure
  • low HR
  • irregular breathing
17
Q

Investigations and monitoring

A 
FBC, U&E, LFT, glucose, clotting, cultures - impact on other organs and find cause
Toxicology screen 
CXR - infection?
CT head
LP if safe
18
Q

Management of ICP

A

AIM TO LOWER ICP, AVERT SECONDARY INJURY
Focal cause => neurosurgery
-burr holes, craniotomy

ICP monitoring in GCS3-8 with/without abnormal CT

Holding measures until definitive

  • 45 degree head elevation
  • IV mannitol/furosemide
  • controlled hyperventilation
19
Q

Basal skull fractures

  • pathophysiology
  • causes
  • presentation
  • management
A

Fracture of cranial floor
Often from falls, RTAs, assault

Racoon eyes
CSF from nose and ears
Blood in middle ear
Battle sign - bruise on mastoid
VII, VIII dysfunction => facial paralysis, hearing loss

TBI management
CSF leak management - conservative
-frequent cultures taken for meningitis monitoring

20
Q

Diffuse axonal injury

  • pathophysiology
  • causes
  • presentation
  • management
A

Mechanical shearing following deceleration => tearing of axons

RTAs, child abuse

Diagnosis only suspected when patients do not make a neurological recovery
CT head generally normal

Preventing secondary effects
-poor prognosis

21
Q

Contusion vs concussion

  • pathophysiology
  • causes
  • presentation
  • management
A 
Concussion - forceful injury to the brain 
Contusion - bruised brain
-headache
-LOC
-amnesia
-ICP symptoms, seizures
-confusion, irritability

Concussion - clinical diagnosis
Contusion
-head CT, MRI - assess for hemorrhagic lesions

Both generally resolve with time
-if symptoms do not resolve, complications => neuro management

22
Q

Uncal herniation

-pathophysiology, presentation

A 
Monroe Kelly doctrine
-small ICP => CSF loss 
-when this is no longer possible => ICP increases rapidly and impairs blood flow
-leads to neuronal death
CPP = MAP - ICP

ICP => herniation puts pressure on brain vasculature => ischemia
-corticate or cerebrate positioning

Decrease ICP - craniotomy

23
Q

Basal skull fracture

  • presentation
  • investigations
  • management
A 
Racoon eyes
Battle sign
Oto, rhinorrhea
Hematotympanum
Cranial nerve palsy

Head CT within 1hr

ATLS stabilisation and neurosurgery referral

Trauma and Accident (40 decks)

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