Head Emergencies: ICP, Basal skull fractures, Intracranial injury (EDH, SDH, SAH) Flashcards
Basal skull fracture
-presentation
-investigations
-management
High impact trauma => ATLS
-Battle sign, racoon eyes
-ear, nose discharge
-hematoma
-blood behind eardrum
Head CT in 1 hr of A&E presentation
NEUROSURGERY REFERRAL
Supportive - A-E approach
Temporal bone fracture
-presentation
-investigations
-management
Significant blunt trauma
-Battle sign
-VII, VIII damage => sensorineural loss, vertigo, balance, facial paralysis
Head CT
Manage facial nerve injury, hearing and vestibular function, CSF leak
-immediate facial paralysis => surgery
-incomplete facial paralysis => tapered CS
How to calculate cerebral perfusion pressure
-what makes up ICP
CPP = MAP (50-150mmHg) - ICP
ICP
-CSF volume
-blood volume
-brain volume
Epidemiology of head injury
Almost half in children
Risk factors
-alcohol
-extremes of age
Clinical signs of head injury
Head
-bruising
-laceration
-palpable fracture
Basal fracture
-racoon eyes
-Battle signs
-CSF, blood from ear or nose
-CN7, 8 palsy
Neuro signs
How to assess head injury
-what are you looking for
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 => hypoxic brain
-Cushings triad - bradycardia, irregular RR, wide BP
-headache, vomiting, confusion
Pathophysiology of Cushing’s triad
Increased ICP exceeds MAP => brain hypoxia
Triggers SNS => increased HR, BP
Triggers PNS => bradycardia
As pressure in brain rises => brainstem dysfunction leading to irregular respirations
When to admit to hospital
Reduced consciousness
Skull fracture
Persistent neurological symptoms/signs
Difficulty assessing patient - alcohol
Significant medical conditions - coagulopathy
No carer around
Initial management of head injuries
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
When would you do a CT head
1hr of risk being identified
8hr of injury
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
When to refer to neurosurgery
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
When to discharge from ED
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
Extradural hematoma
-pathophysiology, causes
-presentation, signs
-non contrast CT head findings
-management
Arterial bleed between dura and skull - often MMA
-trauma
High ICP
LOC immediately after injury => Lucid interval => progressive LOC
N+V, headache, confusion
UMN signs, sensorimotor deficits of limbs
Lemon
Midline shift
BS herniation
Initial
-stop AC, prophylactic ABx for open skull fractures, anticonvulsants, mannitol
Definitive
-conservative if bleed small with minimal mass effect
-Burr hole craniotomy, hemicraniectomy
Subarachnoid hematoma
-pathophysiology, causes
-presentation, signs
-non contrast CT head findings
-management
Cerebral arterial bleed from trauma/spontaneous rupture
-aneurysm
-AVM
-HTN, smoking, FHx
-ADPKD
Thunderclap headache, N+V, photophobia
Reduced LOC
Neck stiffness, Kernig
Blood in SA space
LP if CT does not show evidence of bleeding/ICP, U12 hours since onset
-xanthochromia
A-E assessment
Refer to neurosurgery
-clipping, coiling
-ventricular drain if hydrocephalus
Nimodipine => reduce cerebral artery spasm and 2ndary cerebral ischemia
Phenytoin
Subdural hematoma
-pathophysiology, causes
-presentation, signs
-non contrast CT head findings
-management
Bridging venous bleed between dura and arachnoid, often around frontal, parietal
-low impact trauma in older adults
-alcohol, AC
-AVM, malignancy
Gradual deterioration
Signs of ICP
Lucid interval but symptoms arise slower than extradural
Banana
