Head Injury

Question 1

How to manage rising ICP in head injuries (2)

Answer 1

• Where there is life-threatening rising ICP such as in extradural haematoma and whilst theatre is prepared or transfer arranged use of IV mannitol/ frusemide
• Diffuse cerebral oedema → decompressive craniotomy

Question 2

How do we manage depressed skull fractures ?

Answer 2

Depressed skull fractures

• open → formal surgical reduction and debridement
• closed → managed nonoperatively if there is minimal displacement

Question 3

When do we consider ICP monitoring (in case of head injury)?

Answer 3

• ICP monitoring is appropriate in those who have GCS 3-8 and normal CT scan
• ICP monitoring is mandatory in those who have GCS 3-8 and abnormal CT scan

Question 4

Why can we see hyponatraemia in head injury?

Answer 4

Hyponatraemia is most likely to be due to the syndrome of inappropriate ADH secretion

Question 5

What’s minimal cerebral perfusion pressure in:

• adults
• children

Answer 5

• Minimum of cerebral perfusion pressure of 70mmHg in adults
• Minimum cerebral perfusion pressure of between 40 and 70 mmHg in children

Question 6

Interpret these pupillary findings

(in the background of HI)

Answer 6

3rd nerve compression secondary to tentorial herniation

Question 7

Interpret these pupillary findings

(in the background of HI)

Answer 7

• Poor CNS perfusion
• Bilateral 3rd nerve palsy

Question 8

Interpret these pupillary findings

(in the background of HI)

Answer 8

Optic nerve injury

Question 9

Interpret these pupillary findings

(in the background of HI)

Answer 9

• Opiates
• Pontine lesions
• Metabolic encephalopathy

Question 10

Interpret these pupillary findings

(in the background of HI)

Answer 10

Sympathetic pathway disruption

Question 11

Classification of primary brain injury (2)

Answer 11

primary brain injury may be:

• focal (contusion/haematoma)
• diffuse (diffuse axonal injury)

Question 12

Types of secondary brain injuries

Answer 12

secondary brain injury occurs when:

• cerebral oedema
• ischaemia
• infection
• tonsillar or tentorial herniation

The normal cerebral auto regulatory processes are disrupted following trauma rendering the brain more susceptible to blood flow changes and hypoxia

Question 13

What’s Cushing’s reflex

Answer 13

Cushings reflex (hypertension and bradycardia) often occurs late and is usually a preterminal event

Question 14

Indications for immediate head CT scan (HI)

Answer 14

CT head immediately

• GCS < 13 on initial assessment
• GCS < 15 at 2 hours post-injury
• suspected open or depressed skull fracture
• any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
• post-traumatic seizure
• focal neurological deficit
• more than 1 episode of vomiting

Question 15

Signs of basal skull fracture (4)

Answer 15

• haemotympanum
• ‘panda’ eyes
• cerebrospinal fluid leakage from the ear or nose
• Battle’s sign

Question 16

Indications for head CT scan within 8 hours (HI)

Answer 16

CT head scan within 8 hours of the head injury - for adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury:

• age 65 years or older
• any history of bleeding or clotting disorders
• dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs)
• more than 30 minutes’ retrograde amnesia of events immediately before the head injury

Question 17

Do we do CT head in a patient who is on Warfarin and sustained a HI?

Answer 17

If a patient is on warfarin who have sustained a head injury with no other indications for a CT head scan, perform a CT head scan within 8 hours of the injury