Head and spinal injury Flashcards
Which type of head injury is most common?
Blunt trauma (as opposed to penetrating)
Common causes of head injury
- RTAs
- Falls
- Assaults
- Sports
- Workplace injuries
Primary vs secondary brain injury
Primary: occurs at time of injury, axonal shearing and disrutpion with associated areas of haemorrhage
Widespread: diffuse axonal injury
Localised injury: coup-contre-coup
>>The only cure for this would be to prevent accidents/ damage limitation e.g. helmets<<
Secondary: occurs later, due to various problems that commonly occur e.g. hypoxia, hypovolemia, intracranial haematoma and raised ICP, epileptic fits, infection
>>The aim of managament in ED is to prevent secondary traumatic brain injury<<
How do we calculate CPP?
MAP - ICP
MAP = systolic BP + diastolic BP + diastolic BP
Following head injury, what are the indications for referral to hospital?
- Impaired consciousness at any time
- Amnesia
- Neuro symptoms: vomiting, severe headache, seizures
- Skull fracture: CSF leak, peri-orbital haematoma
- Significant extracranial injuries
- Worrying mechanism e.g. high energy/ NAI
- Comorbidity e.g. anticoagulant use/ alcohol
- Adverse social factors e.g. home alone
Simple method of assessing the severity of a head injury
AVPU
Patient unresponsive/ only responding to pain - call for senior help + ICU/ anaesthetist as patient will need expert airway care and IPPV
Monitoring of patients following head injury
Every head-injured patient must receive regularneurological obs - early identification of complications e.g. intracranial haematoma, fits and hypovolaemia is esstntial in order for early treatment
Any deterioration in GCS is an emergency - re-examine and correct problems + call for senior help
Important to know about when taking a head injury hx
Mechanism: allows for impression of the forces involved and risk of complications
Time of injury
Loss of consciousness/ amnesia: unconsciousness suggests at least moderate severity, 30mins+ amnesia warrants head CT
Subsequent symptoms: headache, N&V, weakness, sensory loss, visual disturbance, rhinorrhoea, otorrhoea
PMHx: anything that could have caused the injury/ make it worse e.g. epilepsy, cardiac arrhythmias, DM, coagulopathy, thrombocytopenic
Drug hx: drugs/ alcohol, antigoagulants, patients on clopidogrel may be at higher risk of intracranial haemorrhage following head injury so low CT threshold
Social: is there someone at home/ someone they can stay the night with
Discuss the GCS score
Scored from 3-15 assessing eye response, verbal response and motor response
Unconsciousness is taken to mean no eye response and GCS =<8
Simple blood test essential in all patients presenting to a&e following head injury/ confused
BLOOD GLUCOSE
DONT EVER FORGET GLUCOSE
Areas to cover in examination following head injury
C-spine
GCS
Vital signs/ obs
Blood glucose
Alcohol: never assume low GCS is due to alcohol
Eye signs: pupils
Scalp, face, head: cranial nerves
Limbs: neuro exam
Other injuries: intra-abdominal injuries often co-exist with serious head injuries
Signs of base of skull fracture
Often a clinical diagnosis
- Bilateral orbital bruising confined to orbital margin: panda eyes
- Subconjunctival haemorrhage
- Bleeding from ears/ blood behind typanum
- CSF otorrhoea and rhinorrhoea: separates into double ring when dropped on blotting paper
- Battle’s sign: brusing behind ears without local direct trauma - occurs due topetrous temporal bone facture - takes a few days to appear
Clinical features pointing towards an intracranial haematoma
Emergence of focal neurological signs
Deteriorating GCS
Indications for CT scan following head injury
GCS <13 on initial assessment
GCS <15 after 2hrs
Suspected skull fracture/ basal skull fracture
Post injury seizure
Focal neurological deficit Vomiting
Amnesia >30mins
LOC
Dangerous mechanism
Most requests will be urgent - scan interpreted within 1hr
Initial management of a head injury
ABCDE dont ever forget GLUCOSE
2x IV large bore cannula
Bloods: FBC, clotting screen, U&E, glucose
If GCS =<8: rapid sequence induction + intubation
Arrange CT
Give IV antibiotics for compound skull fracture
Liaise w/neurosurgery early
Urinary catheter
Treating complications of head injury
Diminishing consciousness likely to reflect intracranial pathology leading to rise in ICP
Liaise w/ neurosurgeon: they may advise use of mannitol to decrease ICP as a time buying measure
Hypertonic saline acts as an osmotic agent and can dcrease ICP whilst increasing intravascular volume
What medical therapy is used to reduce ICP to buy time?
Mannitol - bolus IV
Hypertonic saline
Investigations and management of patient with seizure
Check glucose and ABG
Give IV lorazepam - repeat once if it doesn’t work
IVI phenytoin with ECG monitoring (can cause bradycardia when given IV)
Levetiracetam is an alternative to phenytoin
Seizure >10-15mins - senior help, RSI, intubation and IPPV
Golden rules for managing head injury
- Never attribute low GCS to alcohol alone
- Never discharge a head-injured patient to go home alone
- Consider admitting patients with head injury who have a coagulopathy/ anticoagulants
Head injury warning instructions
Adults
- Ensure eye is kept on patient for 24hrs
- Rest 24hr
- Pain killers
- No alcohol for 24hrs
- Do not take sleeping tablets
- Any of the following, come back: persistent headache, vomiting, visual changes, balance problems, fits, unrousable
Children
- Child may be more tired than usual
- Allow them to sleep
- Pain killers
- Any of the following come back: persistent headache, vomiting, visual changes, balance problems, fits, unrousable
Post-concussion symptoms
Frequent: headache, dizziness, lethargy, depression, inability to concentrate
~30% patients have headaches for 2months
Migraine may become more frequent after head injury
Diagnosis of exclusion
Subdural haematoma: consider in alcoholics/ elderly and those on anticoagulants - low threshold for CT
How are post concussion symptoms managed?
Reassure + explain that they are likely to resolve gradually
Arrange appropriate follow up with GP
Concussion advice for those who play sport and high-level sport
Rest initially, especially when symptomatic
Take advice from those within their sport about when it is safe to return
Pulsatile tinnitus/ whooshing sound in one ear following head injury
Consider carotid/ vertebral artery dissection
What evidence might there be on the bedsheet of a patient with a CSF leak?
Blood surrounded by a halo of pale fluid
Assessing for maxillofacial injuries
Palpate facial bones systematically
Dish face, flattening of cheek, assymetry, nasal deviation, uneven pupil levels (orbital floor fracture)
Loose/ lost teeth: may have been aspirated
Which airway adjunct should not be used in patients with facial fractures
NP - can go into brain
What is silver trauma?
Trauma in the elderly
Most common cause of serious injury in those 60+ is a fall from standing
Why is it so important to immobilise the neck
It is the most common site of cord injury
Important to note that ventilation can be impaired due to cord oedema so keep a regular eye on diaphragmatic breathing and use pulse oximetry and regular ABGs to confirm adequate oxygenation
Indicators of spinal injruy in patients with loss/ decrease in consciousness
Flaccid arreflexia
Decreased anal tone
Diaphragmatic breathing
Able to flex C5/C6 but not extenf C6/C7
Response to pain above the clavicle but not below
Hypotension + bradycardia
Priapism