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ER 2 > Head Injuries > Flashcards

Head Injuries Flashcards

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1
Q

Stats

A
  • TBI is 4th leading cuase of death in US, leading cause in people aged 1-44
  • 50% of all trauma deaths are secondary to TBI, 35% of these are dt GSW to head
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2
Q

When does neuro injury occur

A

All neuro damage does not occur at moment of impact (primary injury), often evolves over ensuing minutes, hours, days (secondary brain injury)

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3
Q

Primary vs. secondary head trauma

A
  • Primary injury: irreversible cellular injury dt direct result of injury, only way to avoid is to prevent the event
  • Secondary injury: damage to cells that were not initially injured, occurs hours to weeks after primary injury. Goal: prevent hypoxia and ischemia
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4
Q

Critical steps to head trauma

A
  • Early recognition of TBI by public
  • Early recognition of TBI by EMS
  • Dispatch appropriate EMS
  • Early intervention by EMS
  • Appropriate hospital by EMS
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5
Q

Prehospital treatment of head trauma

A
  • CAB, O2, IVs, C-spine
  • Assess and document pupil size and light reflex
  • Document duration of pupillary dilation and fixation
  • ID hypotension (SBP <90 mmHG)
  • ID hypoxia: O2 sat <90%
  • Evidence shows raising bp in hypotensive pts with severe head injury improves outcome
  • Goal: get pt to hospital that has the right resources in a reasonable amount of time
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6
Q

Monro-Kellie Doctrine

A

If have a brain bleed, body can compensate for a while, as mass expands, start to herniate and ICP increases

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7
Q

Cerebral perfusion pressure

A
  • CPP = MAP – ICP
  • Normal ICP is 10-15 mmHG or less
  • Goal: maintain CPP ≥ 70 mmHG **
  • Maintaining adequate CPP is more important than keeping normal ICP value
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8
Q

Cerebral Blood Flow

A
  • Brain uses 20% of O2 consumed and 15% of resting cardiac output
  • Remains constant over wide range of arterial pressures, if MAP >150, increased cerebral blood flow, if MAP <20 then CBF ceases
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9
Q

Cerebral imaging

A
  • CT scan: NO contrast is gold standard (assume since have TBI prob have c-spine injury so do CT of neck too)
  • Plain films: not used much any more
  • MRI: not used in acute situations unless known spinal cord trauma
  • US: more of a brain death exam, not for acute analysis
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10
Q

Skull fracture

- linear and simple comminuted

A
  • Explore wound
  • Prophylactic abx?
  • Occipital = high incidence other injury
  • If depressed beyond outer table = NS repair
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11
Q

Skull fracture

- Basilar

A
  • Petrous portion of temporal bone
  • Results in dural tear: CSF otorrhea/rhinorrhea, battle sign, raccoon eyes, hemotympanum, vertigo, hearing loss, seventh nerve palsy
  • Do start prophylactic abx (Ceftriaxone)
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12
Q

Brain Lesions

A
  • Caused by increasing amts of acceleration-deceleration or torsional forces
  • MC type of TBI
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13
Q

Brain lesion

- s/sx

A
  • LOC, AMS, amnesia (retrograde or post traumatic), disorientation, sleepiness, abnl coordination or balance, abnl reaction time, poor concentration and comprehension, opposition or other behavior change, diplopia, incontinence
  • On the field: vacant stare, lack of coordination, poor performance, wrong huddle, distracted, inappropriate behavior, slurred speech
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14
Q

Types of brain lesion

A
  • Mild concussion
  • Cerebral concussion
  • Diffuse axonal injury (DAI)
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15
Q

Mild concussion

A
  • Consciousness is preserved
  • Noticeable degree of impaired neuro dysfunction
  • Often go unnoticed
  • Confusion/disorientation with slight anterograde/retrograde amnesia
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16
Q

Cerebral concussion

A
  • LOC + some amnesia
  • Return to full consciousness within 6 hrs of injury
  • Usu no sequelae
  • Some suffer post-concussion syndrome
17
Q

Diffuse axonal injury

A
  • Prolonged posttraumatic coma not dt mass lesion or ischemia, persistent vegetative state
  • Disruption of axons in white matter and brainstem
  • Occurs immediately, is irreversible
  • Common after MVC and shaken baby syndrome
  • Motor posturing and autonomic dysfunction
  • Normal CT initially
  • MRI shows multiple, diffuse abnormalities
18
Q

Tx

- concussion

A
  • Serial neuro evaluations Q2-3 hours
  • Avoid sedating medications: narcotics, alcohol, antihistamines
  • Yes: ICE, Tylenol, light diet
19
Q

Post concussive sx

A
  • At 3 months post injury, 20-40% have post concussive syndrome
  • Neuropsychiatric impairments: attention, concentration
  • Somatic complaints: HA, fatigue, dizzy
  • Affect: depression or anxiety
20
Q

Secondary Impact syndrome

A

If receive second injury after first injury has healed, lose ability to regulate pressure in brain and can herniate and die

21
Q

Return to play after concussion

A
  • No sports for 5-7 days
  • Should f/u with PCP or neurologist before RTP
  • Must be asx for a week before RTP
22
Q

Impact program for concussions

A
  • Computer test that can be administered by coach, trainer, medical provider to measure baseline and post injury performance.
  • Measures attention, memory, processing speed, reaction time
  • Measures cognitive function: attention span, working memory, sustained and selective working time, response variability, non-verbal problem solving, reaction time
  • Post-concussion testing within 24-72 hours of injury
23
Q

Focal brain lesions (4)

A
  1. epidermal hematoma
  2. Subdural hematoma
  3. traumatic SAH
  4. Contusion
24
Q

Epidural hematoma

A
  • Blunt trauma to temporoparietal region
  • 80% associated with skull fracture
  • Usu middle meningeal artery under the temporal bone
  • May experience a “lucid interval” and then crump
  • Tx: acute craniotomy with sx drainage
25
Q

Subdural hematoma

A 
• Tearing of veins
• Sudden acceleration-deceleration injury
• Common in elderly and alcoholics
• Acute, sub-acute, chronic
- Acute < 2 weeks
- Chronic >2 weeks
26
Q

Traumatic SAH

A
  • MC CT finding in moderate to severe TBI
  • HA, photophobia, meningismus
  • Early SAH triples mortality
  • CT: can see blood inside gyri
27
Q

Four types of brain herniation

A
  • Uncal transtentorial
  • Central transtentorial
  • Cerebellotonsillar
  • Upward posterior fossa
28
Q

How to select a hospital for head trauma care

A
  • Trauma center preferred
  • Want immediate dx and interventional capabilities and appropriate medical personnel
  • CT scan and operating room
  • ICP monitoring capabilities
  • ICU
29
Q

Reasons to CT

A
  • LOC or persistent AMS
  • Intoxicated
  • Other associated injuries
  • Poor f/u likely
30
Q

Reasons to not CT

A
  • Alert and awake and not confused
  • Reliable family and transportation
  • Knowledge and wits to come back if things get worse
31
Q

Tools to use to determine extent of head injury

A
  • Canadian CT head injury/trauma rules for adults

- PECARD and Pediatric NEXUS II Head CT Decision for Blunt Trauma for pediatrics

32
Q

When to admit head trauma

A
  • GCS < 14 or
  • Not CT available or abnl CT
  • Penetrating in jury
  • LOC or fluctuating LOC
  • Severe HA
  • Intoxicated
  • Skull fx
  • Sig associated injuries
  • No reliable caretaker
  • Not able to promptly return to ED
  • Sig amnesia
    CSF leak
33
Q

Prognosis for head trauma

A
  • Poorer as GCS decreases
  • Inversely proportional to age
  • Pupillary findings:
    Bilateral worse than single non-reactive pupil (>4 mm is dilated)
34
Q

Head trauma

- tx

A
  • Aggressive patient resuscitation
  • Blood pressure control
  • O2
  • IV fluids
    Goal is euvolemia
  • Patient positioning: elevate head to dec ICP
  • Sedation: brain injuries cause irritation. Also if have shunt
  • Mannitol and Lasix – diuretics, can be used together
  • NO STEROIDS
  • Anticonvulsants: Keppra MC. Phenytoin or carbamazepine may also be used. (Acute control via diazepam or lorazepam)
  • Neuromuscular blockade: paralysis
    CSF reduction: ICP monitoring device, release CSF based on ICP
35
Q

IV fluid tx

A
  • Goal is euvolemia
  • Isotonic fluids to avoid hyperglycemia
  • Non-dextrose containing fluids: dextrose crosses bbb and can cause edema
  • Watch for hyponatremia
  • Monitor I&Os
  • Foley catheter
36
Q

Treatment for intracranial HTN

A

No specific tx unless signs of herniation or neuro deterioration

37
Q

head trauma pearls

A
  • Scan all elderly heads if any possibility of head injury
  • Scan all pts on ASA, Coumadin, Plavix if any possibility of head injury
  • Repeat neuro exams (inc pupil exams)
  • Don’t hesitate to intubate in a controlled setting if at all worried will lose airway

ER 2 (10 decks)

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