HEAD INJURIES Flashcards
impairment of brain function as a result of mechanical force w/ diminished/altered consciousness
TBI
trauma induced alteration of mental status which may or may not involve consciousness; functional disturbance sx, normal imaging
concussion
GCS of mild TBI (majority of head injuries)
14-15
GCS of mod. TBI
9-13
signs of severe TBI
- Fixed or dilated pupils, decorticate (flexion) or decerebrate (extension) posturing, bradycardia, HTN respiratory depression
- periorbital ecchymosis (racoon eyes), battle signs, hemotympanum, CSF otorrhea, CSF rhinorrhea
what GCS do you intubate? what 3 meds can you give for induction?
- < 8 or uncooperative/combative
- Etomidate, propofol for induction & succinylcholine/rocuronium
why do you do aggressive fluid resusicitation?
to prevent hypotension and secondary injury
Single fixed and dilated pupil in unresponsive pt indicates what?
uncal herniation (will be same side lesion)
3 things that Bilateral fixed and dilated pupils suggest
- increased ICP w/ poor perfusion
- bilateral uncal herniation
- drug or severe hypoxia
2 things bilateral pinpoint suggests
- opiate use
- pontine lesion
eye opening for GCS scale
- 1= none
- 2= pain; 3= voice
- 4= spontaneous
verbal response for GCS
- 1= none
- 2= no words, only sounds
- 3= words but not coherent
- 4= disoriented conversation
- 5= normal conversation
motor response for GCS
- 1= none
- 2= deceberate
- 3= decorticate posture
- 4= withdraws to pain
- 5= localized to pain
- 6= normal
“cor”- body clenched; arms, head oriented towards core is what posture? indicates damage to what 3 structures?
- decorticate posture
- thalamus, midbrain, cerebral hemispheres
decerebrate posture indicates what?
- brainstem injury –worse
bleeding into the brain tissue; usually component of cerebral contusion disrupting intraparenchymal capillaries; hyperdense area in brain tissue on CT with surrounding hypodense area (edema)
intracerebral hemorrhage
2x likely to die, remain in persistent vegetative state or experience severe disability; Can be missed on early CT; looks like whispy white lines on CT
SAH
bleeding in epidural space (between skull and dura mater) caused by laceration of meningeal arteries; often associated w/ skull fractures
epidural hemorrhage
hyperdense lens shaped hematoma on CT scan is what kind of hemorrhage
epidural hemorrhage
Classic presentation of LOC then lucid interval w/ subsequent rapid neurologic demise (can lead to herniation w/in hrs)
epidural hemorrhage
why do we say that GCS does not necessarily reflect underlying injury
its based off level of consciousness and patients w/ same level of consciousness per GCS may have very different pathophys
what is the monroe-kelli hypothesis
if theres increase in one compartment of the cranium, ther needs to be compensatory decrease in another otherwise ICP will increase
3 goals of approaching head injuries
- find life threatening injuries
- find treatable mass lesions like bleeding
- prevent more injury by preventing things that will increase metabolic demand
3 goals of approaching head injuries
- find life threatening injuries
- find treatable mass lesions like bleeding
- prevent more injury by preventing things that will increase metabolic demand
labs that would be helpful in determining what is occuring (5)
- CBC
- type & cross-match
- electrolytes
- coags
- consider tox screen, ethanol level, ABG
completely unresponsive, total coma is what GCS
3
patient is confused (dementia, intox, concussion?) is what GCS score
14
patient is talking out of their head (bleed?); whats their GCS score
13
why should you avoid long acting agents with intubation
may mask neurologic changes like seizures
which type of hemorrahage is common in mod-severe TBI
SAH
what hematoma results when this happens
trauma tears cerebral veins bridging the spce between the brain and venous sinuses causing slower venous bleedin ginto subdural space
subdural
blood surrounds brain forming crescent-shaped hyperdense (acute)areas on CT; isodense if subacute
subdural hematoma
which hematoma is comon in elderly and alcoholics, trivial trauma; pt may be asymp. or have progressive focal neuro deficits over days/weeks
subdural hematoma; need to have high suspicion even for near falls or other minor injuries
3 things non-con CT is good for
brain
bone
air
when do you do surgical drainage of epidural hematoma
over 30 ml
when do you do surgical drainage for acute subdural hematomas (3)
over 10 mm thick or shifts over 4mm of midline
GCS decreases 2+ points since admit
ICP over 20 mmHg
when do you do surgical drainage with intracerebral hemorrhage
if evidence of mass effect
other than hemorrhages and hematomas, what two injuries is surgical drainage indicated
- penetrating injury
- depressed skull frature if open or if depressed more than cranial thickness
if surgical drainage is complete, your focus moves to what?
preventing secondary injury & lowering ICP
general things to do when preventing secondary injury (5)
- maintain VS
- frequent neuro checks
- prevent seizures
- monitor ICP
- avoid fever and hypoglycemia
goal PaCO2 and O2 saturation when ventilating
- PaCO2: 35-40 mmHg
- O2 saturation: 95%
goal systolic BP when preventing secondary injury
> 90 mmHg
why do you elevate HOB to 30 degrees when preventing secondary injury
increase CSF outflow from skull base
what medication can be used to lower ICP and helps to maintain cerebral perfusion; immediate plasma expaing; diuretic effects
Mannitol by repetitive boluses
reduces ICP w/in 30 mins and effects last 6-8 hrs
when do you initiate ICP monitoring
pt w/ evidence of increased ICP or GCS <9
normal ICP
< 15 mmHG
battle sign & racoon eyes is associated with what injury
basilar skull fracture
aka midaxillary fracture; affect the midface of the skull and collectively involve a partial or complete separation of the midface from the skull.
Lefort fractures
break of one or more of the bones that surround the eye
blow out fracture
3 ways to tx scalp lacerations
- direct pressure
- lido w/ epi
- clamp or ligate vessel
T/F: torn dura causes otorrhea or rhinorrhea
true
imaging will appear normal for which type of TBI
mild (GCS 14-15)
LOC, vomiting, HA, focal neuro findings, over 65yo, coagulopathy, basilar skull fx, coagulopathy, etc + any alteration in the mental state at the time of event like seing stars, beind dazed/confused
mild TBI
3 ways mild TBI can cause significant morbidity
- neuropsych difficulties– memory, attention, executive functioning, depression
- disrupt relationships & affects ability to resume usual activities
- repeat concussions can cause longer term structural deficits
which imaging is more sensitie in showing small areas of contusion, hemorrhae, axonal injury, or small extra-axial hematoma
MRI
3 populations to get CT on if TBI (not a comprehensive list)
- 2+ episoes of vomitting
- 65+ yo
- amnesia before impact of 30+ mins
according to New orleans critera, get CT if GCS of 15 + (5)
- HA
- vomit
- over 60
- drug/alcohol
- persistent anterograde amnesia
- visible trauma above clavicle
when do you do CT on kids < 2 yo
if theres high risk of intracranial injury or suspected skull fx
signs of high risk sxs that would warrant CT in < 2 yo
focal neuro findings
skull fx
depressed mental status
bulging fontanel
persistent vomit
seizure, prolonged LOC
child abuse
hx of AV malformation or bleeding do
what do you do for intermediate risk where CT isnt indicated
observe for 4-6hrs after injury w/ planto CT for any worsening condition during that time
4 times where you would admit for observation
- GCS < 15
- abnormal CT
- seizures
- abnormal bleeding parameters
