Head Injuries SDL

Question 1

How is consciousness defined?

Answer 1

Consciousness refers to your individual awareness of your unique thoughts, memories, feelings, sensations, and environments.

The Glasgow Coma Scale (GCS) is used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients

Question 2

Can you name one cause of unconsciousness in each of the following categories?

a) traumatic
b) vascular
c) metabolic
d) infective

Answer 2

a) head injury
b) decreased cerebral blood flow due to bilateral carotid artery compression e.g. vascular neck restraint
c) diabetic ketoacidosis
d) encephalitis/meningitis

Question 3

Examples of causes of sudden loss of consciousness?

Answer 3

seizure, stroke, or transient ischaemic attack (TIA)

Question 4

When should the C-spine always be immobilised?

Answer 4

When there is a history of trauma and possible C-spine injury.

Question 5

When should oxygen be given to a patient?

Answer 5

Oxygen should always be given when patients are unconscious, even if they are breathing and their saturations are satisfactory.

An unconscious patient cannot maintain their own airway and so this needs to be supported too.

Question 6

Why is suction necessary in a patient who is unconscious?

Answer 6

Maintain a patent airway and improve oxygenation by removing mucous secretions and foreign material (vomit or gastric secretions) from the mouth and throat (oropharynx)

Question 7

What is first step in treating a patient who is unconscious/has a head injury?

Answer 7

AIRWAY! –> makes sure this is established

Question 8

During head injuries with lots of bleeding, what is needed?

Answer 8

Replace lost blood via drip e.g. with Gelofusine

Gelofusine is a plasma volume substitute; replaces fluid lost from the circulation.

Question 9

Why is bleeding from ears and nose during trauma important?

Answer 9

Can indicate a fractured skull

Question 10

How would a low blood pressure during trauma be dealt with?

Answer 10

intravenous fluid e.g. Hartmanns

Question 11

What are the 3 types of painful stimuli that can be used on a patient to assess the eye opening, verbal and motor response in children who have a decreased level of consciousness?

Answer 11

1. Trapezium squeeze; Using a thumb and two fingers, hold and twist the trapezius muscle of the shoulder
2. Supraorbital pressure; Using a finger or thumbnail, apply pressure in the supraorbital groove.
3. Sternal rub; Using the knuckles of a clenched fist, vertically rub the centre of the sternum

Question 12

What is the GCS?

Answer 12

Glasgow Coms Scale. The GCS is a way of quickly assessing and objectively scoring a person’s level of consciousness

Question 13

What is the highest and lowest score for the GCS?

Answer 13

The highest score possible is GCS 15/15; the lowest is GCS 3/15.

Question 14

There are 3 categories in the Glasgow Coma Scale. What are they, and what is the maximum ‘score’ that any patient can be given in each category?

Answer 14

1. Motor responsiveness; 6 points max
2. Verbal performance; 5 points max
3. Eye opening; 4 points max

Question 15

A score of around 8 or less is particularly significant. What does this mean?

Answer 15

indicates severe injury

Question 16

What is the pupillary light reflex?

Answer 16

The pathway that mediates changes in pupil size depending on light levels is called the pupillary light reflex (it is a reflex; we cannot control it); it is complex and involves several neurological structure

Question 17

What does abnormalities of the pupillary light reflex indicate?

Answer 17

That there is pathology / injury to one (or several) components of the pathway

Question 18

If you have a normal pupillary light reflex, what happens to the right pupil when you shine a light by the side of your right pupil? What is this response called?

Answer 18

Constricts

This is a direct response.

Question 19

What happens to your left pupil when you shine a light by your right pupil again? What is the name for this response in the opposite pupil?

Answer 19

When light is shone into only one eye and not the other, it is normal for both pupils to constrict simultaneously.

The reflex is consensual:

Question 20

In an unconscious patient, how can the airway be supported?

Answer 20

Tracheal intubation

Question 21

What is the purpose of ‘logrolling’ a patient?

Answer 21

The purpose of logrolling is to maintain alignment of the spine while turning and moving the patient who has had spinal surgery or suspected or documented spinal injury.

Question 22

Why is a chest xray often acquired after placement of an endotracheal tube (ET tube)?

Answer 22

To determine the position of the tip

Question 23

What is the first line of imaging in a suspected skull fracture?

Answer 23

CT of the head (NOT an xray)

Question 24

What is a diffuse head injury?

Answer 24

Diffuse axonal injury (DAI) is a form of primary traumatic brain injury. It happens when the brain rapidly shifts inside the skull as an injury is occurring. The axons in the brain are sheared as the brain rapidly accelerates and decelerates inside the hard bone of the skull.

Question 25

If a scan shows the basal systems and/or ventricles being compressed, what does this indicate?

Answer 25

Raised ICP

Question 26

What is white matter?

Answer 26

White matter is tissue in the brain composed of myelinated axons.

Question 27

Can a diffuse head injury be treated?

Answer 27

There is no surgery available to people who have sustained a DAI. If the injury is severe, there is a likelihood of a vegetative state or even death. But if the DAI is mild to moderate, rehabilitation is possible.

Question 28

Typical presentation of extradural haematoma?

Answer 28

The classic picture is of an initial loss of consciousness at the time of injury, followed by a lucid period, before further deterioration (albeit this is present in only around 30% cases). Other symptoms may include headache, nausea or vomiting, or progressive drowsiness.

On examination, patients may have a low conscious level, localising neurological signs, or clinical features of brain herniation or raised intracranial pressure. If left untreated, this can progress to coma and death.

Question 29

How can an extradural haematoma affect pupillary responses?

Answer 29

As blood accumulates, it starts to compress intracranial structures, which may impinge on the third cranial nerve, causing a fixed and dilated pupil on the side of the injury.

Question 30

What is an extradural haemorrhage?

Answer 30

Bleeding into the space between the dura mater and the skull

Question 31

Response to extradural haematoma?

Answer 31

Immediate surgery

Question 32

Why can an extradural haematoma lead to loss of consciousness?

Answer 32

As brainstem is compressed

Question 33

Why can a a fracture of the temporal bone lead to an extradural haematoma?

Answer 33

The pterion is known as the weakest part of the skull. The anterior division of the middle meningeal artery runs underneath the pterion.

Middle meningeal artery has been torn, allowing blood to accumulate under pressure in the epidural space.