Head Injury And ACS,Stroke And Headache Flashcards

Question

What is the Canadian CT head rule? (DAM SATHAG) Which people does it apply to? What constitutes dangerous mechanism of injury?

Answer 1

Canadian CT Head Rule CT Imaging is only required for patients with minor head injury with any one of the following findings. The criteria apply to patients with minor head injury who present with GCS of 13-15 after witnessed LOC, amnesia or confusion. SATHAG(H means high risk) High Risk for Neurosurgical Intervention: 1.GCS < 15 at two hours after injury 2.Suspected open or depressed skull fracture 3.Any sign of basilar skull fracture (Hemotympanum, Peri-orbital Eccymosis, Otorrhea or Rhinorrhea, Battle sign 4 Two or more episodes of vomiting 5.Age > 65 years (DAM. M means medium risk) Medium risk for Brain Injury: Detection by CT Imaging 1 .Amnesia before impact of 30 or more minutes 2. Dangerous mechanism (E.g. Pedestrican vs. Motor vehicle, Ejection from motor vehicle or fall from an elevation of 3 or more feet or 5 stairs or fall from a place twice your height)

Answer 2

Head CT Clinical Rules- New Orleans Criteria Sensitivity and Specificity of detecting a clinically significant CT finding Sensitivity = 100% Specificity = 24.5 % Estimated to decrease CT imaging by 23% Canadian Head CT Rule Sensitivity and Specificity for need for neurosurgical intervention and clinically significant finding on CT imaging Sensitivity = 100% Specificity = 68% Proposed to reduce CT scanning by 46% Both decision rules have subsequently been validated

Answer 3

Mild Head Injury: Admission Criteria Discharge Criteria Discharge Instructions Return to Play Guidelines Symptomatic treatment and prevention of secondary injury Appropriate management depends on assessment of risk of neurological decompensation and risk factors for intracranial hematoma Risk factors for intracranial hematoma- Coagulopathy, Drug/Alcohol Intoxication, Previous neurosurgical procedures, Pre-trauma epilepsy or older age (> 60 y/o) Low risk features All patients with mild traumatic brain injury should be observed for 24 hours after that injury (either inpatient or outpatient).

Answer 4

Moderate and Severe Head Injury General Principles Airway Management Hemodynamic Assessment Seizure Prophylaxis Operative Management Intracranial Monitoring In summary: Do ABcs Give oxygen Hydrate Elevate head Prevent Coagulopathy Prevent infections Give anti seizure prophylaxis if indicated

Answer 5

Admission Criteria Hospital Admission is required for all patients at higher risk for complications including: GCS < 15 Abnormal CT Scan Seizure Activity Abnormal Bleeding Parameters (Anticoagulation or bleeding diathesis) Unable to be observed at home Discharge Criteria Low risk patients can be discharged home with oral and written discharge instructions Patients can be discharged if: GCS = 15 Normal neurological exam Normal Head CT No predisposition for bleeding

Answer 6

Discharge Instructions Appropriate follow-up instructions should be provided both verbally and written instructions. No need to awaken patient q 2 hours Patients who return to ED due to persistent symptoms should undergo careful repeat neurological evaluation but little data supports repeat CT Scanning Warning signs after discharge: Inability to awaken the patient Decreased/Altered mental status Severe or worsening headache Somnolence or confusion Restlessness, Unsteadiness leizure activity Visual difficulties Change in behavior Vomiting, fever, neck stiffness Urinary or bowel incontinence Weakness or numbness

Answer 7

General Principles All moderate and severe head injured patients should undergo CT imaging Stabilization and prevention of secondary insults is mainstay of treatment Airway Management: Prevention of hypoxia and hypoventilation key to preventing secondary insults Patients with GCS < 9, should have endotracheal airway placed Rapid Sequence Intubation is preferred method of intubation Nasotracheal Intubation contraindicated due to tendency for ICP to increase 2/2 cough/gag Lidocaine for prevention of increased ICP has not been shown to have a benefit Special attention should be paid to maintaining cervical spinal immobilization

Answer 8

Hemodynamic Assessment Hypotension (SBP < 90) should be aggressively treated as significant cause of worse outcome Rarely, hypotension is due to head injury itself and other traumatic injuries should be investigated Treatment of hypotension is directed at maintenance of cerebral perfusion Hypotonic fluids are contraindicated Typically isotonic fluids are used (NS) Sedatives, Analgesia and Neuromuscular Blockade: Agitation is common finding and may result from pain, delirium or difficulties with oxygenation and ventilation Minimizing agitation should be goal to limit increases in ICP or inabilities to oxygenate and ventilate Typically, short acting opiates and benzodiazepines are utilized to decrease agitation Long term sedation should be accompanied by sedation holidays to evaluate neurological exam (Diprovan, Midazolam) Barbiturates are not typically used in the emergency department but do have a limited role in long term management of patients with increased ICP who require sedation and have failed other medical and surgical treatments for increased ICP. Neuromuscular blockade is indicated for airway control with RSI but long acting blocking agents should be avoided because they limit serial examinations

Answer 9

Seizure Prophylaxis Post-traumatic seizures = Seizures occurring in less than 7 days post-injury Risk factors = GCS < 10, Cerebral Contusion, Depressed Skull Fracture, EDH, SDH,Intracerebral bleeding, Penetrating head injury or seizure activity within 24 hours of injury Brain Injury Foundation recommends anti-epileptic medications be administered to high risk patients for first 7 days post-injury Acute management of seizure activity is managed with benzodiazepines and other typical anti-epileptic agents No proven benefit to administration of anti-epileptic meds after 7 days to decreasing post-traumatic epilepsy Phenytoin is the anti seizure medication of choice Elevate the head by 30 degrees then You give mannitol for the first 24 hours then you switch to a hypertonic saline???(check)

Answer 10

Most frequent cause of death and disability after severe head injury - raise ICP Identified in any patient with clinical signs of impending herniation, Cushing triad or rising ICP as identified by intracranial monitoring techniques Recommended ICP < 20 mmHg with CPP > 60 mmHg Initial First line treatment of increased ICP HOB – 30 degrees Subsequent first line treatment measures Short term hyperventilation Osmotic diuretic administration (i.e. Mannitol, Hypertonic saline) Second Line Treatments High dose barbiturates Severe hyperventilation Mild/moderate hypothermia Decompressive craniotomy

Answer 11

Second Impact Syndrome Rare, Controversial entity Athlete who has sustained a mild concussion who subsequently suffers a second head injury before the symptoms from the first have resolved Patients subsequently develop rapid diffuse cerebral edema (within 2 min), increased ICP and eventual herniation, coma and death The first head injury is postulated to cause a disruption of the normal cerebral vascular autoregulation that causes increased cerebral blood flow, making the brain vulnerable to the second impact, when the rapid malignant swelling occurs Return to play guidelines have been developed to prevent this type of secondary injury

Answer 12

Post Concussive Syndrome: Constellation of symptoms that develops within 4 weeks of the injury and may persist for months (90% at 1 month, 25% at 1 year) Treatment is with analgesia, anti-depressents and anti-emetics Post-traumatic Epilepsy: Seizure activity > 7 days from traumatic injury Head trauma is cause of long term epilepsy in 3% of patients with epilepsy Incidence is highest in patients with compound skull fracture, intracranial hemorrhage or presence of early acute symptomatic seizure (presence of all 3 factors increases risk by 50-80%) Cannot be prevented with prophylactic use of antiepileptics Persistent Vegetative State: Rare complication of severe head injury, first described in 1972 by Jennett and Plum Disruption of cerebral cognitive function with sparing of brainstem function No awareness of themselves or environment and cannot interact with others but will maintain normal sleep-wake cycle Recovery is rare if symptoms persist for > 3 months, no recovery documented after 12 months of symptoms

Answer 13

Alarm symptoms include GI bleeding, weight loss, early satiety, dysphagia or odynophagia, family history of upper GI malignancy, iron deficiency anemia or new upper GI symptoms in patients older than 55.