Head and C spine injury Flashcards

1
Q

What is normal ICP?

A

5-15 mmHg

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2
Q

What is the equation for cerebral perfusion pressure?

A

CPP = mean arterial pressure - ICP

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3
Q

What are signs of basilar skull fracture?

A

Blood in ear canal, hemotympanum, rhinorrhea, otorrhea, ‘battle’s sign’ (retro-auricular hematoma), ‘raccoon eye’ (periorbital ecchymoses)

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4
Q

What is a basilar skull fracture?

A

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

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5
Q

What tests can be used to assess brainstem function?

A

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)

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6
Q

What are the components of the GCS score?

A

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

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7
Q

How is a head injury classified as mild, mod or severe based on GCS?

A

Mild: 14-15
Moderate: 9-13
Severe: 8 or less

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8
Q

Which head injury patients are EXCLUDED from the CT head rules? (7)

A

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

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9
Q

Which pt population do the CT head rule guidelines apply to?

A

pts with ‘minor head injury’: Amnesia, LOC, disorientation, GC 13-15 as a result of HI in the past 24 hrs

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10
Q

What are the ‘high risk’ (5) and ‘medium risk’ (2) criteria in the CT head rules?

A

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).

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11
Q

What is the sens and sp of the CT head rules?

A

for high risk criteria: sens 100%, sp 69%.

For all 7 factors: sens 98%, sp 50%

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12
Q

What is a concussion?

A

Characterized by transient cognitive change or neurologic function with no CT findings.

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13
Q

What symptoms may suggest concussion?

A

confusion, amnesia, disorientation, LOC, restlessness, lethargy, irritability, brief seizure immediately after insult.

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14
Q

What is the SCAT2?

A

Sport cognitive assessment tool 2 which can be used for concussion assessment.

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15
Q

When discharging a pt with a concussion, what symptoms should they return to the ED for?

A

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

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16
Q

Describe stepwise return to play instructions

A

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:

  1. rest until asymptomatic (physical and mental rest including no screens). Goal is recovery.
  2. light aerobic exercise (e.g. stationary cycle, walking). Goal is to increase HR.
  3. sport-specific exercise (e.g. running soccer, skating in ice hockey)
  4. non-contact training drills (start light resistance training)
  5. full contact training after medical clearance
  6. return to competition (game play)
17
Q

What measures can be taken to prevent secondary brain injury that may occur as a result of primary moderate-severe head injury?

A

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).

18
Q

What are signs of elevated ICP?

A

Aniscoria (unequal pupil sizes), labile BP, cushings reflex (HTN, brady, resp depression).

19
Q

What steps should be taken to intervene with impending herniation secondary raised ICP?

A

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).

20
Q

What are secondary therapies for refractory raised ICP?

A

Barbiturates or propofol to control elevated ICP.
HTN therapy.
Moderate hyperventilation (PCO2 C30).
Decompressive craniectomy.

21
Q

what are the 3 standard views for C spine radiographs?

A

AP, lateral, odontoid views. Consider flexion/extension views to look for ligamentous injuries after bony injuries are ruled out on standard 3 view.

22
Q

Which vertebrae should be visible on lateral C spine XR?

A

Should include C1-T1

23
Q

How should ‘A’ be assessed in the ABCS assessment of C spine radiographs?

A

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

24
Q

How should ‘B’ be assessed in the ABCS assessment of C spine radiographs?

A

Bone.

Follow bony contours of vertebrae looking for breaks in cortex.

25
Q

How should ‘C’ be assessed in the ABCS assessment of C spine radiographs?

A

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*.

26
Q

How should ‘S’ be assessed in the ABCS assessment of C spine radiographs?

A

Soft tissue. Look at the retropharyngeal. C1/2, <7mm, Widens at C4.

27
Q

When should you consider intubating someone for a c spine injury?

A

If the injury is at or above C5.

28
Q

What are the components of the Canadian C spine rules?

A

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.

29
Q

what groups should the canadian C spine rules NOT be used for?

A

Non-trauma cases, GCS <15, unstable vitals, age <16, acute paralysis, known vertebral disease, prior C spine injury.

30
Q

What is considered a ‘dangerous mxn’ in the canadian c spine rules?

A

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.

31
Q

What are low risk factors on the Canadian spine rules that would allow you to assess neck ROM?

A

simple rearend MVC, sitting position in ED, ambulatory any time, delayed onset neck pain.