Head Injury Flashcards
1
Q
ABCDEs of obtunded/altered head injured patient
A
- Airway,
- Breathing,
- Circulation, and…….
- C-spine: You must evaluate, or protect the cervical spine
- Disability, your neuro exam
- Exposure, complete secondary survey
2
Q
pupil evaluation
A
3
Q
Evaluation and management of head injured patient
A
- The Glasgow coma scale
- *Standardized evaluation of neurological status
- *Reproducible - can be performed by multiple examiners at different levels of care
- *Predictive of morbidity/mortality
- Eye opening:
- 4: Spontaneous eye opening.
- 3: Eye opening in response to speech - that is, any speech or shout.
- 2: Eye opening in response to pain.
- 1: No eye opening.
- Best verbal response
- 5: Oriented - patient knows who and where they are, and why, and the year, season and month.
- 4: Confused conversation - patient responds in conversational manner, with some disorientation and confusion.
- 3: Inappropriate speech - random or exclamatory speech, with no conversational exchange.
- 2: Incomprehensible speech - no words uttered, only moaning.
- 1: No verbal response.
- Best motor response
- 6: Carrying out request (‘obeying command’) - patient does simple things you ask.
- 5: Localising response to pain.
- 4: Withdrawal to pain - pulls limb away from painful stimulus.
- 3: Flexor response to pain - pressure on nail bed causes abnormal flexion of limbs (decorticate posture).
- 2: Extensor posturing to pain - stimulus causes limb extension (decerebrate posture).
- 1: No response to pain.
- •GCS 13-15: Mild Head Injury
- •GCS 9-12: Moderate Head Injury
- •GCS 3-8: Severe Head Injury
- A.V.P.U.
- Alert, or responsive to
- Verbal stimuli, or to
- Painfull stimuli, or
- Unresponsive
4
Q
Trauma eval. Secondary survey and AMPLE history
A
- A -> Allergies
- M -> Medications (especially anticoagulants/anti-platelets)
- Meds we are worried about are anticoagulants (warfarin, coumadin)
- P -> Past medical history
- L -> Last meal (especially if surgery is indicated emergently)
- E -> Events (what happened just before..?)
- ●Vital Signs
- −Bradycardia+ hypertension+ irregular respiration= Cushing’s Triad
- −Increased ICP and impending Herniation
- ●Pupilary response to light
- −Mydriasis ipsilateral to site of 3rd nerve injury in herniation events
- ●Motor deficits usually contralateral to the sight of injury
- ●Heent exam
- −Battle sign, Racoon eyes, hematotympanum
- ●CT without contrast
5
Q
immediate actions
A
- ●IV, Labs: cbc, electrolytes, stat glucose, coags, tox screen, ETOH level
- ●Monitor, HR, O2 sat,BP
- ●Oxygenate, ventilate, intubate if indicated
- − (GCS<8), hypoxia, hypoventilation,need to sedate for trip to the scanner
- ●Treat presumpively for increased ICP if:
- −(GCS<8), fixed and dilated pupil(s),decorticate or decerebrate posturing, bradycardia, hypertension or respiratory depression
- −Initial treatment is HOB up 30degrees and Manitol 1g/kg iv
- ●Non-contrast Head CT
6
Q
epidural hematoma
A
- *2% of all serious head injuries
- *Uncommon in infants
- *Associated with skull fracture in 40-85%
- *Laceration of dural vessels from skull fracture (91%), usually the middle meningeal artery
- *Avulsion of venous vessels from points of calvarial perforations
- *Disruption of dural sinuses (major cause in kids)
- *Transient loss of consciousness; lucent interval
- *3rd nerve palsy (sign of cerebral herniation)
- *Somnolence 24-96 hrs after accident
- *Hematoma expands
- *Increased ICP, decreased CBF
- *Herniation, ipsilateral CN-3 dysfunction and contralateral paralysis or posturing
7
Q
subdural hematoma
A
- * Incidence: 5% of head trauma patients
- * Age: infants and elderly (large subarachnoid space with freedom to move)
- * Cause: damage to subdural veins (“bridging veins”)
- Acute Subdural Hematoma:
- Manifests hours after injury
- Hyperdense (<1 week); isodense (1-3 weeks); hypodense (3-4 weeks)
- Underlying brain injury (50%)
- Worse long term prognosis than epidural hematoma
- *May be acute, like epidural hematoma
- *May have delayed course, days to weeks
- *Increased ICP, edema, herniation
- *ETOH increases cerebral edema by increasing the permeability of the blood brain barrier
- Chronic Subdural Hematoma:
- Following minor injury, rarely parenchymal injury
- Convex configuration
- Interhemispheric Subdural Hematoma:
- Usually posterior
- Most common acute finding in child abuse
- (whiplash injury)
8
Q
Sub-arachnoid hemorrhage
A
- *Bleeding from small vessels at site of coup or contrecoup injury
- *Bleeding under arachnoid, spreads in CSF
- *Vasoactive substances in blood contribute to ischemia and altered level of consciousness
- *Often occurring directly beneath an external injury
- *Can also occur as a contrecoup injury
- *Direct rupture of intrinsic cerebral vessels.
- *Traumatic SAH diagnosed without LP. Consider LP if “Trival Trauma”
9
Q
Basal skull fracture
A
- *Caused by deceleration injury or occipital trauma
- *4% of serious head injuries
- *Seldom fatal (except for race car drivers)
- *Separation of suture between temporal and occipital bones
- *May involve orbits or sphenoid bone, or fracture near foramen magnum
- *Damage to Cranial nerves III, VII or
- *CSF otorrhea, CSF rhinorrhea (danger of meningitis!)
- *Battle’s sign
- *Racoon eyes
- *Hematotympanum
10
Q
treatment of seriously head injured pt
A
- *Seizure prevention: IV Phenytoin
- *Prevent fever
- *Control bleeding, transfuse to HCT>30
- *Antibiotics for penetrating injury or basal skull fracture
- *Early neurosurgical consultation: ventriculostomy, craniotomy
- •Treat hypotension, resucitate to MAP>90 (SBP 120-140 with NS. Pressors as needed. N.B. isolated head injury is unlikely to be hypotensive on initial presentation, so look for other injuries!
- •Control excessive hypertension.
- Labetolol to reduce BP 20-30%
- •Treat hypoxia, intubate and ventilate (increased CO2 dilates vessels and lowers cpp)
- •Sedate if needed (not ketamine)
- *Treat increased ICP (target <20, cpp70- 80)
- *Raise head of bed to 30 degrees
- *IV mannitol boluses once euvolemic
- (serum osmolality 280-300)
- *Hyperventilate PCO2 to 26-30? Consider only if other measures ineffective
- *Steroids not proven to have benefit in head trauma
11
Q
cerebral perfusion pressure
A
12
Q
head injury, disposition
A
- ●GCS of 15 with resolved symptoms:, dispo to home with vigilant family members and return preacautions
- ● GCS of 14-15 (ie: “mild” injuries)
- −Admit for observation. Neurological exams every 1-4 four hours. IV fluids, analgesia, anti-emetics.
- −Repeat head CT if worsening pain, vomiting or adverse change in level of consciousness
- ●GCS of 9-13 (ie: “moderate” injuries)
- −Admit to ICU. Neurological exams every 1-2 hours.
- −NPO
- −Repeat head CT six hours after admission or promptly if pt worsens
- −If pt is immobile, DVT prevention may be warranted.
- ∙GCS of 8 or less (ie: “severe” injuries)
- ∙Admit to ICU with hourly neurological exams.
- ∙NPO.
- ∙intracranial pressure monitor
- ∙Analgesia and sedation.
- ∙Tight control of BP and intracranial pressure
- ∙Seizure prophylaxis
- ∙DVT prevention
- ∙Expanding Hematoma or signs of imminent herniation
- ∙To OR for craniotomy
- ∙Admit to ICU
13
Q
evaluation of the mild/moderate head injured patient
A
- ●History
- −Mechanism of Injury
- −LOC? How long? Observed by?
- −Amnesia?
- −Pain
- ●Exam
- −Complete neuro and mental status exam, repeat as needed
- −Head,ENT ,Neck
- ●Consider non contrast head CT
14
Q
indications for CT scan
A
- Protocol: Canadian CT Head Rule (for mild Head Injury)
- *High risk indications for Head CT
- •Glasgow Coma Scale <15 at 2 hours after injury
- •Open or depressed skull fracture
- •Vomiting (Two or more episodes)
- •Age 65 years or over (other studies suggest age 60)
- •Basal skull fracture signs:
- –Hemotympanum Periorbital Bruising (Raccoon Eyes)
- –Mastoid process Ecchymosis (Battle’s Sign)
- –Cerebrospinal fluid leakage from ear or nose
- *High risk indications for Head CT
- *Moderate risk indications for Head CT
- •Pre-trauma amnesia lasting longer than 30 minutes
- •High risk mechanism of injury
- •Pedestrian in motor vehicle accident
- •Passenger ejected from vehicle
- •Fall from height over 3 feet or 5 stairs
15
Q
ACEP clinical policy indications for head CT
A
- LOC or Amnesia+any of:
- * Headache
- * Vomiting
- * Age>60
- * Drug/alcohol intoxication
- * Short-term memory deficits
- * Evidence of trauma above the clavicles
- * Posttraumatic seizure
- * GCS<15
- * Focal neurological deficit
- * Coagulopathy
- No LOC or amnesia
- * Severe headache
- * Vomiting
- * Age>65
- * GCS<15
- * Physical signs of a basilar skull fracture
- * Focal neurological deficit
- * Coagulopathy
- * Dangerous Mechanism
- •ejection from a motor vehicle, pedestrian struck, a fall >3 feet or 5 stairs
26
Q
Spinal cord injury without radiographic abnormality
A
