Head and Neck

Question 1

Altered Head Injured Patient. Start with trauma primary survey

Answer 1

ABCDE
D=Disability, caused by the injury?
E=Exposure, take the pts cloths off.

Question 2

Pupil eval
Miosis?
one pupil larger then other?
Mydirasis?

Answer 2

Miosis=OPIATES. PONTINE LESION

One pupil bigger then the other?=LEFT HEMATOMA- HERNIATION OR OCULAR GLOBE TRAUMA, commonly stroke, brain or optic tumor, brain aneurysm, MS.

Mydriasis=INCREASED ICP WITH POOR CEREBRAL PERFUSION, DRUG EFFECT, BILATERAL HERNIATION, SEVERE HYPOXIA

Question 3

Evaluation and Management of the Head injured Patient

Answer 3

The Glasgow Coma Scale
Standardized evaluation of neurological status
Reproducible - can be performed by multiple examiners at different levels of care
Predictive of morbidity/mortality

Question 4

Glasgow Coma Scale

Eye opening

Answer 4

4: Spontaneous eye opening.
3: Eye opening in response to speech – that is, any speech or shout.
2: Eye opening in response to pain.
1: No eye opening.

Question 5

GCS continued

Best Verbal Response

Answer 5

5: Oriented - patient knows who and where they are, and why, and the year, season and month.
4: Confused conversation - patient responds in conversational manner, with some disorientation and confusion.
3: Inappropriate speech - random or exclamatory speech, with no conversational exchange.
2: Incomprehensible speech - no words uttered, only moaning.
1: No verbal response.

Question 6

GCS continued

Best Motor Response

Answer 6

6: Carrying out request (‘obeying command’) - patient does simple things you ask.
5: Localising response to pain.
4: Withdrawal to pain - pulls limb away from painful stimulus.
3: Flexor response to pain - pressure on nail bed causes abnormal flexion of limbs (decorticate posture).
2: Extensor posturing to pain - stimulus causes limb extension (decerebrate posture).
1: No response to pain.

Question 7

GCS Interpretation

Answer 7

A.V.P.U.
Alert, or responsive to 
Verbal stimuli, or to
Painfull stimuli, or 
Unresponsive

Question 8

Trauma eval. Secondary survey and AMPLE history

Answer 8

A -> Allergies
M -> Medications (especiallyanticoagulants/anti-platelets)
P -> Past medical history
L -> Last meal (especially if surgery is indicated emergently)
E -> Events (what happened just before..?)
VITALS SIGNS ARE VITAL!!!!

Question 9

Epidural Hematoma=Definition, sx’s

Answer 9

Transient loss of consciousness; lucent interval
Laceration of dural vessels from skull fracture (91%), usually the middle meningeal artery
3rd nerve palsy (sign of cerebral herniation)
Somnolence 24-96 hrs after accident

Question 10

Epidural Hematoma=Etiology

Answer 10

Hematoma expands
Increased ICP, decreased CBF
Herniation, ipsilateral CN-3 dysfunction and contralateral paralysis or posturing

Question 11

Subdural Hematoma

Answer 11

Incidence: 5% of head trauma patients
Age: infants and elderly (large subarachnoid space with freedom to move)
Cause: damage to subdural veins (“bridging veins”)
Acute Subdural Hematoma:
Manifests hours after injury
Hyperdense (<1 week); isodense (1-3 weeks); hypodense (3-4 weeks)
Underlying brain injury (50%)
Worse long term prognosis than epidural hematoma

Question 12

Subdural Hematoma=Etiology

Answer 12

May be acute, like epidural hematoma
May have delayed course, days to weeks
Increased ICP, edema, herniation
ETOH increases cerebral edema by increasing the permeability of the blood brain barrier

Question 13

Subdural Hematoma=different types

Answer 13

Chronic Subdural Hematoma:
Following minor injury, rarely parenchymal injury
Convex configuration

Interhemispheric Subdural Hematoma:
Usually posterior
Most common acute finding in child abuse
(whiplash injury)

Question 14

Sub-Arachnoid Hemorrhage

Answer 14

Bleeding from small vessels at site of coup or contrecoup injury
Bleeding under arachnoid, spreads in CSF
Vasoactive substances in blood contribute to ischemia and altered level of consciousness

Question 15

Sub-Arachnoid Hemorrhage=etiology

Answer 15

Often occurring directly beneath an external injury
Can also occur as a contrecoup injury
Direct rupture of intrinsic cerebral vessels.

Question 16

Whats the Battle sign?

Answer 16

Ecchymiosis behind the ear.

Its a late sign

Question 17

Whats Hemotympanum?

Answer 17

Blood behind the tympanic membrane.

Question 18

What are Raccoon eyes?

Answer 18

Blood behind the eye lids?

Question 19

Basal Skull Fracture

Answer 19

Caused by deceleration injury or occipital trauma
4% of serious head injuries
Seldom fatal (except for race car drivers)
Separation of suture between temporal and occipital bones
May involve orbits or sphenoid bone, or fracture near foramen magnum

Question 20

Basal Skull Fracture

Answer 20

Damage to Cranial nerves III, VII or 	
CSF otorrhea, CSF rhinorrhea 				(danger of meningitis!)		
Battle’s sign
Racoon eyes
Hematotympanum

Question 21

Treatment of the seriously head injured patient

Answer 21

Seizure prevention: IV Phenytoin
Prevent fever
Control bleeding, transfuse to HCT>30
Antibiotics for penetrating injury or basal skull fracture
Early neurosurgical consultation: ventriculostomy, craniotomy

Question 22

Treatment of the seriously head injured patient

Answer 22

Treat hypotension, resucitate to MAP>90 (SBP 120-140 with NS. Pressors as needed. N.B. isolated head injury is unlikely to be hypotensive on initial presentation, so look for other injuries!
Control excessive hypertension. Labetolol to reduce BP 20-30%
Treat hypoxia, intubate and ventilate (increased CO2 dilates vessels and lowers cpp)
Sedate if needed (not ketamine)

Question 23

Treatment of the seriously head injured patient

Answer 23

Treat increased ICP (target <20, cpp70- 80)‏
Raise head of bed to 30 degrees
IV mannitol boluses once euvolemic
(serum osmolality 280-300)‏
Hyperventilate PCO2 to 26-30? Consider only if other measures ineffective
Steroids not proven to have benefit in head trauma

Question 24

Head injury, Disposition

Answer 24

GCS of 15 with resolved symptoms:, dispo to home with vigilant family members and return preacautions

GCS of 14-15 (ie: “mild” injuries)
Admit for observation. Neurological exams every 1-4 four hours. IV fluids, analgesia, anti-emetics.
Repeat head CT if worsening pain, vomiting or adverse change in level of consciousness

GCS of 9-13 (ie: “moderate” injuries)
Admit to ICU. Neurological exams every 1-2 hours.
NPO
Repeat head CT six hours after admission or promptly if pt worsens
If pt is immobile, DVT prevention may be warranted.

Question 25

Head injury, Disposition

GCS of 8 or less (ie: “severe” injuries)

Answer 25

Admit to ICU with hourly neurological exams.
NPO.
intracranial pressure monitor
Analgesia and sedation.
Tight control of BP and intracranial pressure

Seizure prophylaxis
DVT prevention

Expanding Hematoma or signs of imminent herniation
To OR for craniotomy
Admit to ICU

Question 26

Evaluation of the Mild/Moderate Head Injured Patient

Think concussion

Answer 26

History
Mechanism of Injury
LOC? How long? Observed by?
Amnesia?
Pain
Exam
Complete neuro and mental status exam, repeat as needed
Head,ENT ,Neck
Consider non contrast head CT

Question 27

Indications For CT Scan

Answer 27

High risk indications for Head CT
Glasgow Coma Scale s Sign)
Cerebrospinal fluid leakage from ear or nose

Question 28

Indications For CT Scan, cont.

Answer 28

Moderate risk indications for Head CT 
Pre-trauma amnesia lasting longer than 30 minutes 
High risk mechanism of injury 
Pedestrian in motor vehicle accident 
Passenger ejected from vehicle 
Fall from height over 3 feet or 5 stairs

Question 29

Additional Head CT Indications

Answer 29

Drug or alcohol intoxication 
Physical findings of trauma above clavicle 
Seizure 
Coagulopathy 
Focal neurologic deficit

Question 30

Indications for Head CT in awake, alert pediatric patients.

Answer 30

CT of head indicated for all high risk patients
 Age under 3 months 
 Skull fracture, less than 24 hrs old 
		(intracranial injury in 15-30%) 
 Scalp hematoma predicts skull fracture - 80% sensitive
 Basal skull signs, scalp depression
 Depressed mental status 
 Focal neurologic deficits 
 Bulging fontanelle 
 Irritability after head injury

Question 31

Anybody on Coumadin?

Answer 31

Scan them.

Question 32

Concussion: Grading scale

Grade 1 Concussion

Grade 2 Concussion

Answer 32

Grade 1 Concussion
Transient confusion without amnesia.
No loss of consciousness
Mental status abnormalities resolve within 15 minutes
Most common

Grade 2 Concussion
Transient confusion or amnesia lasting greater than 15 minutes.
No loss of consciousness
Patient may have retrograde amnesia of events preceding the injury

Question 33

Postconcussion Syndrome

Answer 33

Physical findings: nystagmus, cranial nerve abnormalities, asymmetric muscle reflexes, abnormal plantar reflexes, asymmetric hearing loss, electroencephalographic abnormalities.
Exertion and stress can aggravate the symptoms.
Treatment is analgesia and outpatient neurology or primary care. No modality of treatment clearly shown to alter course.

Question 34

Postconcussion Syndrome

Answer 34

Onset one day to weeks after injury
Headache, dizziness, irritability, insomnia, anxiety, impaired attention, impaired memory, and sound sensitivity
Vertigo, tinnitus, decreased hearing, blurred vision, diplopia, photophobia, reduced taste and smell, depression, change in personality, fatigue, sleep disturbances, reduced libido, decreased appetite, decreased attention, and increased information-processing time

Question 35

Concussion: Grading scale

Grade 3 Concussion

Answer 35

Grade 3 Concussion
Loss of consciousness for any amount of time
Mental status change and/or amnesia is not included in the definition

Question 36

Treatment of Minor Head Injury

Answer 36

Discharge for home observation
Diminished LOC is predictive of more serious injury
Waking patient Q2 hours not proven, poor compliance
Analgesics

Question 37

Second Impact Syndrome

Answer 37

An acute, usually fatal swelling of the brain that occurs when a second impact concussion occurs before the symptoms of a previous concussion have fully cleared.
Symptoms can include paralysis, mental disabilities and epilepsy.
Death occurs in over 50% of cases.
Controversial

Question 38

Gradual return-to-play protocol

Answer 38

Day 1: light aerobic exercise (walking, swimming , or stationary cycling) keeping exercise heart rate less than 70% of maximum predicted heart rate. No resistance training

Day 2: sport-specific exercise, any activities that incorporate sport-specific skills. No head impact activities.
Day 3: non-contact training drills
Day 4: full contact practice, participate in normal practice activities
Day 5: return to competition
If any concussion symptoms return during any of the above activities, the athlete should return to the previous level, after resting for 24 hours.

Question 39

Evaluating the neck injured patient

Answer 39

ABCDE
Look for neurological impairment before directly examining the neck
Maintain inline stabilization of the neck as you remove pt from back board. Protect the C-spine until done evaluating it.

Risk factors for more severe injury
MVC, higher speeds, air bag deployment, intrusion into vehicle or car totaled
Sports: diving, horseback riding, football, gymnastics, skiing, hang gliding
Age over 65, arthritis, osteoporosis

Question 40

NEXUS Criteria

Answer 40

1.No posterior midline cervical ?

Question 41

ED treatment of cervical injury

Answer 41

Protect from further injury
IV steroids
Traction for unstable fractures
Treat shock

Question 42

Inhead injury do steroids help?

Answer 42

NO.