Head and C spine injury Flashcards
What is normal ICP?
5-15 mmHg
What is the equation for cerebral perfusion pressure?
CPP = mean arterial pressure - ICP
What are signs of basilar skull fracture?
Blood in ear canal, hemotympanum, rhinorrhea, otorrhea, ‘battle’s sign’ (retro-auricular hematoma), ‘raccoon eye’ (periorbital ecchymoses)
What is a basilar skull fracture?
basilar skull fractures include breaks in the posterior skull base or anterior skull base. The former involve the occipital bone, temporal bone, and portions of the sphenoid bone; the latter, superior portions of the sphenoid and ethmoid bones. The temporal bone fracture is encountered in 75% of all basilar skull fractures
What tests can be used to assess brainstem function?
Look at respiratory pattern, pupil size and reactivity and eye function including the corneal reflex, Doll’s eye reflex (oculocephalic reflex), caloric test (oculovestibular test)
What are the components of the GCS score?
E: 4 open, 3 open to command, 2 pain, 1 closed.
V: 5 normal, 4 confused, 3 wrong words, 2 incomprehensible, 1 nothing
M: 6 command, 5 localizes to pain, 4 withdraws pain, 3 decorticate, 2 decerebrate, 1 limp
How is a head injury classified as mild, mod or severe based on GCS?
Mild: 14-15
Moderate: 9-13
Severe: 8 or less
Which head injury patients are EXCLUDED from the CT head rules? (7)
1) penetrating trauma, 2) obvious depressed skull #, 3) acute neuro deficit, 4) seizure, 5) bleeding d/o or on anticoagulation, 6) pregnant pts, 7) <16 yrs
Which pt population do the CT head rule guidelines apply to?
pts with ‘minor head injury’: Amnesia, LOC, disorientation, GC 13-15 as a result of HI in the past 24 hrs
What are the ‘high risk’ (5) and ‘medium risk’ (2) criteria in the CT head rules?
High risk: GCS <15 2 hrs after injury, suspected open or depressed skull #, signs basilar skull #, vomiting >2x, Age >65.
Medium risk: amnesia >30 min, dangerous mxn (pedestrian struck by vehicle, occupant ejected, fall >3ft or 5 stairs).
What is the sens and sp of the CT head rules?
for high risk criteria: sens 100%, sp 69%.
For all 7 factors: sens 98%, sp 50%
What is a concussion?
Characterized by transient cognitive change or neurologic function with no CT findings.
What symptoms may suggest concussion?
confusion, amnesia, disorientation, LOC, restlessness, lethargy, irritability, brief seizure immediately after insult.
What is the SCAT2?
Sport cognitive assessment tool 2 which can be used for concussion assessment.
When discharging a pt with a concussion, what symptoms should they return to the ED for?
Problems could arise over the first 24-48 hours. You should not be left alone and must go to a hospital at once if you:
• Have a headache that gets worse
• Are very drowsy or can’t be awakened (woken up)
• Can’t recognize people or places
• Have repeated vomiting
• Behave unusually or seem confused; are very irritable
• Have seizures (arms and legs jerk uncontrollably)
• Have weak or numb arms or legs
• Are unsteady on your feet; have slurred speech
Describe stepwise return to play instructions
Athletes should not be returned to play the same day of injury. When returning athletes to play, they should follow a stepwise symptom-limited program, with stages of progression. For example:
- rest until asymptomatic (physical and mental rest including no screens). Goal is recovery.
- light aerobic exercise (e.g. stationary cycle, walking). Goal is to increase HR.
- sport-specific exercise (e.g. running soccer, skating in ice hockey)
- non-contact training drills (start light resistance training)
- full contact training after medical clearance
- return to competition (game play)
What measures can be taken to prevent secondary brain injury that may occur as a result of primary moderate-severe head injury?
Prevention of hypotension (sBP>90), hypoxia, anemia, glycemic extremes, hyperthermia. Reverse anticoagulations. Call interventionalists for evacuation of hematomas, burr holes or ICP monitoring. Prophylactic anti-seizure medications may reduce the incidence of early post-traumatic seizures (within 7d).
What are signs of elevated ICP?
Aniscoria (unequal pupil sizes), labile BP, cushings reflex (HTN, brady, resp depression).
What steps should be taken to intervene with impending herniation secondary raised ICP?
Elevated head, keep head midline, provide sedation, avoid unnecessary stimuli, provide analgesia, hypertonic saline or mannitol if deteriorating despite measures, neuromuscular blockade, mild hyperventilation (pCO2 30-35 mmHg).
What are secondary therapies for refractory raised ICP?
Barbiturates or propofol to control elevated ICP.
HTN therapy.
Moderate hyperventilation (PCO2 C30).
Decompressive craniectomy.
what are the 3 standard views for C spine radiographs?
AP, lateral, odontoid views. Consider flexion/extension views to look for ligamentous injuries after bony injuries are ruled out on standard 3 view.
Which vertebrae should be visible on lateral C spine XR?
Should include C1-T1
How should ‘A’ be assessed in the ABCS assessment of C spine radiographs?
A = alignment.
Follow the anterior and posterior contour lines. Translation of one vertebrae over another of >3.5 mm and an angulation of >11* is considered significant. The diameter between the posterior cortex and the spinolaminar line should be >18mm
How should ‘B’ be assessed in the ABCS assessment of C spine radiographs?
Bone.
Follow bony contours of vertebrae looking for breaks in cortex.
How should ‘C’ be assessed in the ABCS assessment of C spine radiographs?
Cartilage.
Look at disk spaces to ensure they are equal length throughout. Pre-dental space should be <3mm. Distance from lowest part of occiput base and dense <12 mm. Facet joints should be at 45*.
How should ‘S’ be assessed in the ABCS assessment of C spine radiographs?
Soft tissue. Look at the retropharyngeal. C1/2, <7mm, Widens at C4.
When should you consider intubating someone for a c spine injury?
If the injury is at or above C5.
What are the components of the Canadian C spine rules?
Population: Alert (GCS 15) stable pts where cervical spine injury is a concern.
1) determine if high risk factors mandating radiography including either: age >65, dangerous mxn. if yes, radiograph.
2) determine if pt has low-risk factors that allow you to assess safe ROM, IF you can safely assess, ROM then if not able to actively rotate neck >45* L/R, then radiograph.
what groups should the canadian C spine rules NOT be used for?
Non-trauma cases, GCS <15, unstable vitals, age <16, acute paralysis, known vertebral disease, prior C spine injury.
What is considered a ‘dangerous mxn’ in the canadian c spine rules?
fall >3ft or 5 stairs, axial load to head, MVC high speed (>100km), roll over or ejection, motorized recreational vehicle, bicycle struck or collision.
MVCs that include rollover, large truck/bus, hit by high speed vehicle.
What are low risk factors on the Canadian spine rules that would allow you to assess neck ROM?
simple rearend MVC, sitting position in ED, ambulatory any time, delayed onset neck pain.
