Head Injuries Flashcards

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
Subdural hematoma
``` • Tearing of veins • Sudden acceleration-deceleration injury • Common in elderly and alcoholics • Acute, sub-acute, chronic - Acute < 2 weeks - Chronic >2 weeks ```
26
Traumatic SAH
* MC CT finding in moderate to severe TBI * HA, photophobia, meningismus * Early SAH triples mortality * CT: can see blood inside gyri
27
Four types of brain herniation
* Uncal transtentorial * Central transtentorial * Cerebellotonsillar * Upward posterior fossa
28
How to select a hospital for head trauma care
- Trauma center preferred - Want immediate dx and interventional capabilities and appropriate medical personnel - CT scan and operating room - ICP monitoring capabilities - ICU
29
Reasons to CT
* LOC or persistent AMS * Intoxicated * Other associated injuries * Poor f/u likely
30
Reasons to not CT
* Alert and awake and not confused * Reliable family and transportation * Knowledge and wits to come back if things get worse
31
Tools to use to determine extent of head injury
- Canadian CT head injury/trauma rules for adults | - PECARD and Pediatric NEXUS II Head CT Decision for Blunt Trauma for pediatrics
32
When to admit head trauma
- 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
Prognosis for head trauma
- Poorer as GCS decreases - Inversely proportional to age - Pupillary findings: Bilateral worse than single non-reactive pupil (>4 mm is dilated)
34
Head trauma | - tx
- 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
IV fluid tx
* 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
Treatment for intracranial HTN
No specific tx unless signs of herniation or neuro deterioration
37
head trauma pearls
- 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