Head Injuries and Hypothermia

Question 1

1.7 million TBIs occur annually in the U.S.

__% are classified as concussion

Answer 1

Over half, 65%

Question 2

Contributes significantly to the death of approximately half of all trauma victims

Answer 2

TBI

Question 3

Leading causes of TBI

Answer 3

MVC

Falls in the elderly

Question 4

Scalp contains the following layers

Answer 4

Skin

Connective tissue

Galea aponeurotica (thick fibrous layer that provides structural support)

Periosteum

Question 5

Skull

Small openings for blood vessels and nerves to pass

Answer 5

Foramina

Question 6

Brain stem and spinal cord passes through

Answer 6

Foramen magnum

Question 7

Provides protection to the brain

Answer 7

Skull/cranium

Question 8

Layers that cover the brain

Answer 8

Meninges

Question 9

Meninges

Inside the skull, tough fibrous layer, epidural space

Answer 9

Dura mater

Question 10

Meninges

Closely adhered to the brain

Answer 10

Pia mater

Question 11

Layered on top of blood vessels adhered to pia

Answer 11

Arachnoid membranes

Question 12

Surrounds the brain, produced in the ventricular system and functions to cushion the brain

Answer 12

CSF (150ml)

Question 13

Exert a pressure within the brain, which is referred to as intracranial pressure (ICP)

Answer 13

Brain tissue, blood, and CSF

Question 14

Portion of dura mater between cerebrum and cerebellum

Answer 14

Tentorium cerebelli

Question 15

Cranial nerves originate from the:

Answer 15

Brain Stem

Question 16

Controls pupillary constriction. Crosses surface of tentorium. Hemorrhage or edema that leads to herniation of the brain will compress the nerve. Leading to pupillary dilation.

Answer 16

CN III (oculomotor)

Question 17

Mean arterial pressure (MAP) =

Answer 17

(systole + diastole x2/3) or diastole + 1/3 pulse pressure

Question 18

Used to characterize pressure driving blood into the brain

Cerebral perfusion pressure (CPP)

Amount of pressure it takes to push blood through cerebral circulation to maintain oxygen, glucose delivery

Answer 18

Mean arterial pressure (MAP)

Question 19

CPP =

Answer 19

MAP - ICP

Question 20

Normal CPP =

Answer 20

70-80 mmHg

Question 21

CPP

Decreased levels of CO2 lead to:

Answer 21

Vasoconstriction

Question 22

CPP

Elevated levels of CO2 =

Answer 22

Dilation

Question 23

Used to lower ICP

Decreases PaCO2 which in turn affects the acid base balance resulting in vasoconstriction

Answer 23

Hyperventilation

Question 24

Direct trauma to the brain

Answer 24

Primary brain injury

Question 25

Refers to ongoing injury processes set in motion from primary injury

Answer 25

Secondary brain injury

Question 26

2-5% of TBI patients have _________ injury which can affect | patient’s ability to properly ventilate

Answer 26

C-spine

Question 27

The hypoxic brain leads to vasoconstriction and subsequent stimulation of the sympathetic nervous system in an effort to raise BP Therefore parasympathetic nervous system causes slowing of the heart rate in response

Answer 27

Cushing's reflex

Question 28

Elevated systolic BP, bradycardia, abnormal respirations (cheyne-stokes)

Answer 28

Cushing's triad

Question 29

Primary assessment includes:

Answer 29

Airway Breathing Circulation Disability

Question 30

Suspected if CSF drainage or delayed (several hours) findings of periorbital ecchymosis or battle signs are seen

Answer 30

Basilar skull fracture

Question 31

- Briefly knock you out (loss of consciousness), OR - May affect your ability to remember information before, during, or after the event (post traumatic amnesia), OR - Makes you feel dazed, like you had your bell rung (alteration of consciousness)

Answer 31

Concussion

Question 32

Also known as a mild traumatic brain injury

Answer 32

Concussion

Question 33

Bleeding between skull and Dura Mater 1-2% of TBI patients Usually low velocity blow to temporal bone Pathognomonic history is patient has head trauma with a brief LOC, regains consciousness (lucid interval), then experiences rapid decline in consciousness

Answer 33

Epidural hematoma

Question 34

Account for 30% of severe brain injuries - Generally results from venous bleed - Bridging veins are torn during blow to the head - Blood collects between Dura and Arachnoid membrane

Answer 34

Subdural hematoma

Question 35

Bleeding that occurs between arachnoid membrane Commonly associated with ruptured cerebral aneurysm and onset of worst headache of life. - Severe HA - Nausea & vomiting - Dizziness - May have meningeal signs - Seizure

Answer 35

Subarachnoid hemorrhage (SAH)

Question 36

All suspected TBI should receive:

Answer 36

O2, maintain SpO2 >95%

Question 37

After mild TBI/concussion there is a ____-hour minimal recovery period

Answer 37

24 hour

Question 38

Steps following suspected Concussion or mild TBI

Answer 38

MACE exam Look for red flags 24-hour mandatory rest period Manage symptoms to facilitate rest and sleep -Acetaminophen every 6 hours, for 48 hours, after 48 hours, may use Naproxen as needed Reevaluate after 24 hours -Neurobehavioral Symptom Inventory (NSI) screening

Question 39

If symptom free during exertional testing and this is their first concussion in the past 12 months then:

Answer 39

Return to duty

Question 40

If symptom free during exertional testing and this is their second concussion in the past 12 months then:

Answer 40

Stay at stage 2 light routine activity for the next 5 days Perform NSI screening questionnaire daily

Question 41

May perform these activities no longer than 30 minutes – walk, stretch, ride a stationary bike at slow pace with low resistance, no light housework, use the computer, play simple games, such as cards.

Answer 41

Stage 2 light routine activity

Question 42

May perform the following activities for no longer than 60 minutes: lift and carry objects less than 20 lbs, take a brisk walk, ride in care and look around, use an elliptical machine or stair climber, perform light military tasks such as cleaning equipment May perform these activities no longer than 30 minutes: shop for one item at the store, talk to someone as you walk, gently increase your exposure to light and noise, perform a maintenance check on a vehicle

Answer 42

Stage 3 light occupation-oriented activity

Question 43

You may perform the following activities for no longer than 90minutes: take a brisk walk, do light resistance training, participate in non-contact sports, perform moderate job-related tasks, climb, crawl, or jog You may perform these activities for no longer than 40 minutes: play video games, foosball, putting and ping-pong, play strategy games such as chess or Sudoku, shop for groceries, perform target practice, drive in a simulator

Answer 43

Stage 4 Moderate activity

Question 44

Resume normal routine and exercise, participate in normal military, training and social activities, use night vision goggles, take part in simulations, or be exposed to bright light, start driving again, do heavy job-related tasks, such as digging, communicate by signals during patrol duty or use radio communication

Answer 44

Stage 5 Intensive activity

Question 45

If 3 or more documented concussions and/or TBI in the past 12 months then:

Answer 45

Stage 1 rest and refer to Neurology for a comprehensive work-up with imaging and assessment.

Question 46

Tool that assists providers in the assessment and diagnosis of a concussion Most effective when used as close in timing to the time of the incident

Answer 46

Military Acute Concussion Evaluation Exam 2 (MACE2 exam)

Question 47

MACE2 exam __ Steps __ minutes to complete

Answer 47

17 steps 15 minutes

Question 48

Defined as a core temperature below 95ºF.

Answer 48

Hypothermia

Question 49

Body temp: 90-95

Answer 49

Mild hypothermia

Question 50

Moderate hypothermia

Answer 50

82-90 F

Question 51

Severe hypothermia

Answer 51

<82 F

Question 52

Normal mental status with shivering Functioning normally Able to care for self Estimated core temperature 35 to 37°C (95 to 98.6°F)

Answer 52

Cold stressed

Question 53

Alert, but mental status may be altered Shivering present Not functioning normally Not able to care for self Estimated core temperature 32 to 35°C (90 to 95°F)

Answer 53

Mild hypothermia

Question 54

Decreased level of consciousness Conscious or unconscious, with or without shivering Estimated core temperature 28 to 32°C (82 to 90°F)

Answer 54

Moderate hypothermia

Question 55

Unconscious Not shivering Estimated core temperature <28°C (<82°C)

Answer 55

Severe/Profound hypothermia

Question 56

Reflects the balance between heat production and heat loss.

Answer 56

Body temperature

Question 57

Vaporization of water through both insensible losses and sweat

Answer 57

Evaporation

Question 58

Emission of infrared electromagnetic energy

Answer 58

Radiation

Question 59

Direct transfer of heat to an adjacent, cooler object

Answer 59

Conduction

Question 60

Direct transfer of heat to convective currents of air or water

Answer 60

Convection

Question 61

Demonstrates tachypnea, tachycardia, initial hyperventilation, ataxia, dysarthria, impaired judgment, shivering, and so-called "cold diuresis"

Answer 61

Mild hypothermia

Question 62

CNS depression, drop in heart rate and cardiac output, hypoventilation, and hyporeflexia At lower ends of temp, loss of shivering, dysrhythmias (A fib), and dilated pupils below 29ºC

Answer 62

Moderate hypothermia

Question 63

Pulmonary edema, oliguria, hypotension, bradycardia, ventricular dysrhythmias. (V fib/tach/asystole) Loss of oculocephalic reflexes

Answer 63

Severe hypothermia

Question 64

Hypothermic patients are extremely sensitive movement and prone to which arrhythmia?

Answer 64

V Fib

Question 65

Lab studies for hypothermic patients

Answer 65

Fingerstick glucose Electrocardiogram (ECG): Osborne Waves

Question 66

Mild hypothermia is treated with:

Answer 66

Passive external rewarming

Question 67

Moderate and refractory mild hypothermia are treated with:

Answer 67

Active External rewarming

Question 68

Severe (and some cases of refractory moderate) hypothermia is treated with:

Answer 68

Active internal rewarming and possibly extracorporeal rewarming

Question 69

Prevent the head injured patient from going into: This will lead to hypo-perfusion for the brain.

Answer 69

Hypotension