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Block 8 Week 2 > Head Injury > Flashcards

Head Injury Flashcards

1
Q

How do you classify head injuries?

A
  • mechanism
  • severity
  • morphology
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2
Q

What are the 2 mechanisms to get a head injury?

A
  • closed

- penetration

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3
Q

What are the 3 ways to state severity of head injury?

A
  • mild
  • moderate
  • severe
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4
Q

What are the morphologies of head injury? (whats there and where is it)

A
  • skull fracture

- intracranial lesions

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5
Q

What are the two ways of getting closed injuries?

A 
high velocity (auto accidents)
low velocity (falls, assault)
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6
Q

Do you want contrast in CT of the brain for a head injury?

A

NO!

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7
Q

What are the 2 ways to get a penetrating head injury?

A

gun shot wounds

-other open injuries

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8
Q

What are some common closed head injuries?

A
  • falls
  • auto accidents
  • assaults
  • sports
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9
Q

On the glascow coma scale what does a 14-15 denote?

A

MILD Severity

talking, a little confused

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10
Q

On the glascow coma scale what does a GSC 9-13 denote?

A

moderate severity

-may have neuro defects, may be repetitive or not talking

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11
Q

On the glascow coma scale what does a GSC of 8 or less denote?

A

Severe!

comatose and usually a bad CT

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12
Q

Is a low GCS good or bad?
What is the lowest score you can get?
What is the highest score you can get?

A

low is bad
high is good
3 is lowest
15 is highest

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13
Q

What should you combine with a GCS to establish a neurological baseline?

A

eye/pupil exam

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14
Q

(blank) may be beneficial in head trauma.

A

cooling (only in healthy tissue)

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15
Q

What do you want to keep the intracranial pressure at? How do you idecrease ICP?

A

below 20

mannitol

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16
Q

When should you test the patient with the GCS and eye/pupil exam?

A
  • after BP and O2 normalize

- before sedative meds or paralyzing meds

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17
Q

Why do you want to use the GCS test after a patient’s BP and O2 normalize?

A

Because low BP and low O2 can cause decrease level of consciousness (LOC)

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18
Q

Why do you want to use the GCS test BEFORE sedative medications or paralyzing meds are given?

A

because you cant evaluate a paralyzed patient for head injury

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19
Q

A normal response to cold water in the ear is…?

A

eyes move to same side and have nystagymus to the opposite side

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20
Q

What is a battle sign a sign of (brusingin behind the ears)?

A

a basilar skull fracture or CSF leakage

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21
Q

In basilar skull fracture, if cranial nerve injuries are present, it usually involves CN (blank)

A

7 or 8

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22
Q

What are all the signs of a basilar skull fracture?

A
  • battle sign (brusining behind the ears)
  • Raccoon eyes
  • Hematoympanum (blood behind the ear drum)
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23
Q

(blank) is the presence of air or gas within the cranial cavity.

A

pneumocephalis

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24
Q

(blank) will be lenticulate and lay on top of the dura

A

epidural hemorrhage (between skull and dura)

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25
Q

(blank) will lay on top of the brain and under the dura

A

subdural hemorrhage

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26
Q

What patients on the ASIA score can walk out of the hospital?

A

C,D,E (E is the best)

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27
Q

If you are decerebrate (extensor) you likely have a (blank)

A

brain injury

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28
Q

If a patient is comatose and the CT scan is negative, then you can do what to the patient?

A

take them out of their collar

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29
Q

Who can do a GCS?

A

doctor, nurse, VS in ICU

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30
Q

THe lower the GCS the more likely you will die. What score shows marked increase in survival?

A

6 and up

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31
Q

What are the three components of the GCS?

A 
Eye opening (1-4 pts)
Motor response (1-6 pts)
Verbal response (1-5 pts)
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32
Q

How do you score eye opening?

A

4 points for spontaneous eye opening
3 points for eyes opening in response to speech
2 points for eyes opening in response to pain
1 point if eyes dont open at all

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33
Q

How do you score motor response?

A 
6=if they can obey commands
5= localizes
4= withdraws
3= abnormal flexor response
2= extensor response
1= nil (no response)
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34
Q

How do you score verbal response?

A 
Physician asks what year is this:
5= oriented and state the correct year
4= confused conversation
3= inappropriate words
2= incomprehensible sounds
1= no response
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35
Q

How do you get the max number of points on the GSC?

A
  • opens eyes spontaneously (4)
  • obeys commands (6)
  • oriented (5)
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36
Q

How do you get the worst possible score of GSC?

A
  • Does not open eyes (1)
  • Flaccid (1)
  • Doesn’t talk or make sounds (1)
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37
Q

What responses are you looking for when you check someones eyes?

A
  • dilated pupils that are unresponsive to light
  • lost corneal reflex
  • dolls eyes
  • lost oculobestibular reflex (ice water in ear and eyes dont move)
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38
Q

What is a dolls eye response?

A

you move their head but their eyes remain facing straight forward

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39
Q

What is the cold caloric response?

A

you put water into ears an their eyes move to that side and cause nystagmus to the contralateral side.

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40
Q

If you loose the cold caloric response what happen?

A

ice water in ears, eyes move to that side but dont do nystagmus to opposite side.

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41
Q

What are the two types of skull fractures?

A
  • vault

- basilar

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42
Q

What is a vault fracture?

A

over the brain

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43
Q

What is a basilar fracture?

A

under the brain

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44
Q

What are the 2 types of vault fractures?

A
  • linear or stellate

- depressed or non depressed

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45
Q

What are the 2 types of basilar fractures?

A
  • With/without CSF leak

- With/without VII or other cranial nerve palsy

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46
Q

What are the 2 types of intracranial lesions?

A
  • focal

- diffuse

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47
Q

What are the 2 types of focal intracranial lesions?

A
  • subdural

- epidural

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48
Q

What are 2 types of diffuse intracranial lesions?

A
  • concussions

- diffuse axonal injury

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49
Q

What kind of imaging would you use to see a skull fracture?

A

CT scan (x-ray isnt that good)

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50
Q

When describing a skull fracture, you would say it is either (blank) or (blank) or (blank) or (blank)

A

linear or stellate

depressed or non-depressed

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51
Q

What is a skull fracture you often see in newborns?

A

ping-pong ball fracture (depressed fracture)

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52
Q

What does a hematoma feel like?

How do you know its not a depressed skull fracture?

A

soft center and hard edges-> feels like a depressed skull fracture
-need CT to see if there is a fracture present

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53
Q

Up to 25% of head injuries are (blank) skull fractures

A

basilar skull fractures

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54
Q

What are the best ways to see basilar skull fractures?

A

on CT scan (bone windows)

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55
Q

In basilar skull fractures, how often will you have CN injury?
HOw often will you have CSF leak?

A

5%

10%

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56
Q

Where do you often get basilar skull fractures?

A
  • petrous bone
  • anterior cranial fossa and cribiform plate
  • clival fractures (less common)
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57
Q

In a basilar skull fracture, what are the three ways you can fracture it?

A
  • longitudinal
  • transverse
  • anterior fossa
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58
Q

If you get a longitudinal fracture you can have (blank) percent chance of damaging the facial nerve.

A

20%

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59
Q

If you get a transverse fracture you can have a (blank) percent chance of damaging the facial nerve.

A

50%

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60
Q

What are the clinical indications of basilar skull fractures?

A
  • pneumocephalis
  • CSF leak out of nose or ear
  • Cranial nerve damage
  • hemotympanum
  • battle’s sign
  • raccoon eyes
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61
Q

In 10% of basilar skull fractures what can you get?

A

CSF leak

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62
Q

What do you make people with CSF leaks do and how effective is this at treating it?

A

bed rest and head elevation

85% effective

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63
Q

Should you give antibiotics to people with CSF leakage?

A

no! (unless pt develops meningitis)

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64
Q

How do you treat persistent CSF leaks?

A

with lumbar drain

small number require surgical repair

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65
Q

When testing CSF what are you checking for?

A
  • glucose

- beta-2 transferrin ( a protein found almost uniquely in CSF)

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66
Q

What is the most common cause of subarachnoid hemorrhage?

A

trauma

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67
Q

Traumatic SAH have a low risk for (blank) or (blank)

A

deterioration

surgical intervention

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68
Q

What can traumatic SAH lead to?

A

vasopasm (19%-68%)

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69
Q

In traumatic SAH you can get clinical deficits in (blank) percent of patients and the clinical course tends to be milder than vasospasm from (blank)

A

4-16%

aneurysm SAH

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70
Q

What are the four focal lesions (of the intracranial lesions)?

A
  • epidural hematoma
  • subdural hematoma
  • contusions
  • intracerebral hematomas
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71
Q

Epidural hematoma are commonly due to arterial bleeds caused by the (blank) artery and a fracture

A

middle meningeal artery

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72
Q

An epidural hematoma can be due to a artery or (blank)

A

vein or venous sinus

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73
Q

What is the classic presentation of an epidural hematoma patient?

A

alert patient that deteriorates as clot enlarges

74
Q

What shape is an epidural hematoma?

A

lenticular shape

75
Q

What is the most common location for an epidural hematoma?

Where do they occasionally occur?

A

temporal fossa

  • sub-frontal region
  • posterior fossa
76
Q

What is the most common location for an epidural hematoma in children?

A

posterior fossa

77
Q

How do you get subdural hematomas?

A

due to tearing of veins or brain lacerations

78
Q

Which is worse, a subdural hemorrhage or a epidural hemorrhage? Why?

A

subdural hemorrhage

-due to the associated brain injury

79
Q

What is the shape of a subdural hematoma?

A

spread out (i.e not lenticular)

80
Q

A chronic subdural hematoma may show up (blank or blank) after head injury

A

weeks or months

81
Q

Do you need a major head injury to cause a subdural hematoma?

A

no it can be a minor head injury

82
Q

Does a subdural hematoma present with?

A
  • headache
  • focal neuro deficits
  • decreased level of conc.
83
Q

What will rotational forces result in?

A

shearing and twisting

84
Q

What will contrecoup result in?

A

contusion, swelling, blood clots

85
Q

What is a cerebral contusion?

A

area of focal injury-deficit depends on area injured

86
Q

How do you typically get cerebral contusions?

A

coupe-contra coup pattern (frontal occipital)

87
Q

20% of cerebral contusions expand into (blank)

A

surgical hematomas

88
Q

If you have a patient with a cerebral contusions what should you do with the patient?

A

observe them in the ICU

89
Q

How long should you monitor the ICP of a cerebral contusion patient?

A

monitor it until the patient becomes conscious and cooperative

90
Q

After a patient has a cerebral contusion you give a CT, when do you repeat this CT? Why?

A

within 24 hours or sooner if deteriorates

91
Q

Are cerebral contusions common?

A

yes 8% of all TBI

and 13-35% of all severe injuries

92
Q

Where do you typically get cerebral contusions?

A

frontal and temporal lobes (but any site possible)

93
Q

What do cerebral contusions look like on a CT?

A

“salt and pepper”

94
Q

You always do a follow up CT with cerebral contusions because they can develop into (blank)

95
Q

What is the treatment for a significant mass effect caused by a intracerebral hematoma?

A

surgical evacuation

96
Q

What is the treatment for a intracerebral hematoma that does have signif mass effect?

A

conservative managmet

97
Q

What should you do with a patient that has an intracerebral hematoma but is alert with no signs of ICP?

A

manage with intensive monitoring and serial imaging

98
Q

What is this:

short loss of consciousness or temporary neurological dysfunction

A

concussion

99
Q

What is this:

loss of consciousness from time of injury beyond 6 hours

A

diffuse axonal injury (may be mild, moderate or severe)

100
Q

What does a severe diffuse axonal injury present as?

A

deeply comatose for prolonged periods of time and often remain severely disabled if they survive

101
Q

Where do most diffuse axonal injuries occur?

How do they happen?

A

at the gray-white matter junction
(injury is greatest in where density difference is greatest)
-extreme acceleration and deceleration

102
Q

Whats wrong with using a CT to detect a diffuse axonal injury?

A

CT can look normal or have small hemorrhages but the exam findings can be worse than explained by CT

103
Q

(blank) percent of head injuries are mild TBI (concussion)

104
Q

What is the GCS of a mild TBI?

105
Q

What are some characteristics of TBI?

A
  • AWAKE but may be amnesic about injury
  • usually make uneventful recovery
  • lingering mild neurologic symptoms
106
Q

3% of mild TBI patients do what unexpectedly?

A

deteriorate :(

107
Q

Concussion (blank and blank) determine the severity of head injury

A

symptoms and duration

108
Q

Concussion may be associated with loss of consciousness in (blank) of patients

A

(minority 10%)

109
Q

What are some symptoms of concussion?

A
  • confusion
  • amnesia
  • dizziness
  • visual disturbance
  • headache
110
Q

How do you manage concussions?

A

a symptoms free waiting period of physical and cognitive rest before returning to subsequent play

111
Q

What is second impact syndrome?

A

2 events-> days, weeks or minutes apart

Athlete has post-concussive symptoms after head injury and then returns later to play and sustains a second head injury.

112
Q

In second impact syndrome you get loss of (blank). What does this result in?

A

autoregulation

-diated blood vessels-> cerebral swelling-> increased ICP-> brain herniation and death

113
Q

Who typically gets second impact syndrome?

A

rare-usually young healthy athletes less than 18 years old

114
Q

What is repetitive head injury syndrome?

A

(AKA punch-drunk syndrome: its like boxers)

->repeatedly get hit in the head and you get a slow delcine in cognitive abilities, Chronic traumatic encephalopathy

115
Q

Helmet accelerometers show high school and college athletes in contact sports sustain (blank) head impacts per season

A

several 100 to over 1000

116
Q

What are subconcussions?

A
  • asymptomatic (no outward or visible signs or syptoms of neurological dysfunction)
  • functional impairment found on neuropsychological testing and MRI
  • axonal injury (even though asymptomatic)
117
Q

T or F
athletes without history of concussions have pathology consistent with traumatic encephalopathy
What do we call this?

A

T

subconcussion

118
Q

What are the three choices to be made with a TBI?

A
  • street em-> send them home
  • keep em-> admit for 24 hour observation
  • ship em’-> transfer to neuro trauma center
119
Q

What is a category 0 TBI?

A 
GCS=15
alert
no LOC (loss of consciousness)
no PTA (post traumatic amnesia)
(no risk factors)
120
Q

What do you do with a category 0 TBI?

A

send the patient home

121
Q

What is a category 1 TBI?

A

GCS= 15
LOC < 30 min
PTA < 60 min
(no risk factosr)

122
Q

What do you do with a category 1 TBI?

A

CT scan recommended

123
Q

What do you do with a patient who is a category I TBI with a normal CT scan?

A
  • discharge home with head injury warning instructions

- admit if coagulation or other disoders (multi trauma) present

124
Q

What do you do with a patient who is a category I TBI with a abnormal CT scan?

A

-no indication for surgery
(observe for 24 hours, consult neurotrauma center, repeat CT scan before discharge)
-indication for surgery
(transfer to neurotrauma center)

125
Q

What is a category 2 TBI?

A

GCS=15 (alert) with risk factors

126
Q

What are the risk factors associated with a category 2 TBI?

A 
AMBIGUOUS ACCIDENT HISTORY
 HEADACHE
 VOMITING
 FOCAL NEUORLOGICAL DEFICIT
 SEIZURE
 AGE YOUNGER THAN 2 YEARS OR OLDER THAN 60 YEARS
 COAGULATION DISORDER OR ON ANTICOAGULANTS
 HIGH-ENERGY (SPEED) ACCIDENT
127
Q

What is a category 3 TBI?

A

CGS=13-14 (with or without risk factors)

128
Q

What do you do with a category 3 TBI?

A
  • CT scan mandatory

- admit

129
Q

What do you do with a category 3 TBI that has a normal CT?

A

observe for 24 hours
consult neurotrauma center
repeat CT scan before discharge

130
Q

What do you do with a category 3 TBI that has an abnormal CT and there is no indication for surgery?

A
  • Observe for 24 hours or until normal
  • consult neurotrauma center
  • repeat CT scan before discharge
131
Q

What do you do with a category 3 TBI that has an abnormal CT and there is indication for surgery?

A

admit to neurotrauma center

132
Q

10% of head injury patients seen in ER have (blank) TBIs

133
Q

What GSC level are moderate TBI patients?

134
Q

What are the symptoms of moderate TBI?

A

confused or somnolent, can follow simple commands, may have focal neuro deficits

135
Q

(blank) percent of moderate TBIs will deteriorate and result in a coma

136
Q

What is the death rate of moderate TBIs?

A

9% death reate

137
Q

With moderate TBI patients you should assure (blank) stability

A

cardiopulmonary

138
Q

When you CT scan the head with moderate TBIs, how often will you see abnormalities and what percent require surgery?

139
Q

What is a severe TBI?

A

GSC=8 or less

-cannot follow simple commands

140
Q

(blank) percent of severe TBI patients have a major systemic injury

141
Q

(blank) percent of severe TBI patients will die

142
Q

In severe TBI, you should make sure to prevent/correct hypotension and hypoxia?

A

because 35% of patients arrive hypotensive

-systolic BP less than 90mm increases mortality rate from 27% to 50%

143
Q

In severe TBI, how should you treat this?

A
  • Establish airway, breathing and circulation.
  • Establish a venous access
  • volume replacement
144
Q

T or F, hypotension is rarely caused by the brain injury

145
Q

What is the cause of hypotension?

A
  • may be severe blood loss
  • spinal cord injury
  • cardiac contusion or tamponade
  • tension pneumothorax
146
Q

THe patient’s neurological exam is (blank) when hypotensive

A

meaningless

cuz you can go from unresponsive to near normal after BP is restored

147
Q

If you have a severe TBI with a normal CT, what three factors are associated with a poor outcome?

A
  • hypotension on admission
  • age over 40
  • motor posturing (decerebrate)
148
Q

What is a severe TBI workup?

A
  • intubation (ventilator)
  • IV access
  • Foley catheter (look for hematuria)
  • NG tube (beware of frontal floor fx)
  • CT brain
  • Cervical spine films or a CT scan (better!)
  • chest film
  • KUB abdominal film
  • pelvic film
  • Better: CT scan of head, neck, chest, abdomen and pelvis (after eval and stabilization)
149
Q

What do you use a computed tomography angiography (CTA) for?

A

pts with skull base fx, cervical fx through transverse foramen at risk for artery dissection

150
Q

When do you use an MRI?

A
  • help with dx in those w/ non specific CT
  • contraindicated unless absolutely certain patient has no incompatible device, implant, or foreign body
  • usually done late if needed
151
Q

When do you use ICP monitoring?

A

-if pt isnt following simple commands (cant be monitored clinically)

152
Q

What is the normal ICP in relaxed patients?

A

10 mmg hg

10-20 is ok

153
Q

It useful to follow (blank) rather than ICP

A

CPP (cerebral perfusion pressure)

154
Q

What is cerebral perfusion pressure (CPP)?

A

mean arterial bp minus the ICP

155
Q

What should the minimum CPP be?

156
Q

Where do you put the transducer for ICP monitoring?

A

at the level of the foramen of monro

157
Q

What are the different methods for monitoring ICP?

A
  • epidural
  • subdural
  • subarachnoid
  • intra parenchymal
  • ventricular
158
Q

What should you do if your ICP is increased (greater than 20 mm or CPP greater than 70 mm Hg)?

A

make sure its for real:

  • check neck is in neutral position (veins)
  • check calibration of system
  • make sure transducer is at level of foramen of Monro
159
Q

How do you conservatively treat increased ICP?

A
  • sedation or chemical paralysis (esp. if patient restless or fighting ventilator)
  • head of bed elevated 30 degrees
  • euthermia
  • make sure pCO2 not elevated
  • mild hyperventilation
160
Q

What happens if you treat the elevated ICP but it wont lower?

A

Repeat CT to rule out mass leasion that should be removed

161
Q

What are the three methods for treating increased ICP?

A
  • ventricular drainage
  • hyperventilation
  • hyperosmolar therapy
162
Q

How does ventricular drainage work?

A

remove CSF if ventr. catheter

163
Q

Why do you utilize hyperventilation to treat increased ICP?

A

reduces IC blood flow and volume through vasoconstriction

-if prolonged can cause ischemia

164
Q

What is hyperosmolar therapy ?

A 
mannitol-> 48-72 hours
hypertonic saline-> longer (monitor blood chem)
loop diuretics (furosemide) adjunct to mannitol
165
Q

What is a decompressive hemicraniectomy?

A

a “robust craniotomy” from frontal to occipital lobe including the temporal lobe and opening the dura (patch graft)

166
Q

What is a barbituate coma?

A

last resort management of ICP

-lowers cerebral metabolism and reduces cerebral blood flow

167
Q

Whats the downside of barbituate coma?

A

-can cause hypotension requiring vasopressors and can cause hypotension

168
Q

Do you use steroids to improve ICP?

169
Q

What do you use to improve ICP?

A

anti seizure meds:

Dilantin and Keppra (levetiracetam)

170
Q

What is this:

  • head compressed between two forces
  • may cause failure of cranium
171
Q

What is this:

recently added after experience with IED devices in recent combat situations

172
Q

How long is mannitol effective for?

How much do you give?

A

48-72 hours

0.25 g to 1 g/kg at 4-6 hours

173
Q

What is a hypertonic saline made up of and how do you give it?

A

23.4 % NaCl 30 cc boluses, central line over 15 minutes

174
Q

How do hypertonic saline solutssions work?

A

they creat osmotic gradients

175
Q

Mannitol has a reflective coefficient less than 1, what does this mean?

A

it will slowly leak into the interstitial fluid/brain parenchyma

176
Q

Hypertonic saline has a coefficient of 1, what does this mean?

A

it will not accumulate in interstitial space/brain parenchyma if bbb is intact

177
Q

(blank) with mannitol-has a synergistic effect

A

furosemide

178
Q

Furosemide with mannitol works primarily on the (Blank) and is not dependent on intact (blank). This may reduce CSF production.

179
Q

The (blank) in semipermeable membranes relates to how such a membrane can reflect solute particles from passing through.

A

reflection coefficient

180
Q

A reflection coefficient of zero results in a (blank) particles passing through

181
Q

A reflection coefficient of 1 results in (blank) particles that can pass.

Block 8 Week 2 (8 decks)

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