Head Injury and Coma Flashcards
Define Head Injury.
Any trauma to the scalp, skull or brain.
A head injury does not always equal a _____ ________
Brain Injury
Define Acquired Brain Injury.
Damage to the brain which occurs after birth and isn’t related to a congenital or degenerative disease.
___________ is any damage to the head.
____________ is any damage to the brain.
Head Injury
Acquired Brain Injury.
Name the 2 types of acquired brain injury.
Traumatic Brain Injury
Non-traumatic Brain Injury
___________ brain injury leads to normally more focal damage.
Non-traumatic.
list some causes of non-traumatic brain injury.
Stroke Tumour Infection Anoxia (total depletion in oxygen) Toxic or Metabolic causes
What is a traumatic brain injury?
A non-degenerative, non-congenital insult to the brain from an external mechanical force.
What can traumatic brain injury lead to?
Temporary or permanent impairment of cognitive, physical and psychosocial function with an associated diminished or altered state of consciousness.
Traumatic brain injury is a _______ onset which leads to drastic ______ _________.
sudden, life changes
Describe the type of damage you get from traumatic brain injury.
Typically diffuse, generalised damage.
In traumatic brain injury changes can be ________.
hidden.
Name the high risk groups for traumatic brain injury.
Young men Elderly Previous head injury Residents of inner cities Alcohol Drug Abuse Low Income
Name the mechanisms of traumatic brain injury.
Assault Falls Road traffic accidents Sports Work Injuries Over half involve Alcohol
For traumatic injury- what is better than cure?
Prevention is better than cure.
Name some things that have prevented traumatic brain injury.
- seatbelt laws 1983
- drink driving test 1983
- air bags
- helmets on bikes and motorbikes
- Alcohol awareness + violence
Name the 3 types of Head Injuries causing traumatic brain injury.
Closed head injury
Open or penetrating wounds
Crush Injuries
COC
What is the most common type of head injury causing traumatic brain injury?
Closed Head Injury
What is a closed head injury?
A closed head injury is a result of rapid acceleration or deceleration- the head is rocked back and forward or rotated and the brain must follow the movement of the skull.
When the brain follows heads movement in a car accident this is an example of what HI?
Closed Head Injury
When the skull is opened and the brain is exposed and damaged- what injury is this known as?
Open or Penetrating Wound
Give an example of what can cause an open/penetrating wound.
Gunshot.
What is a crush injury?
When the head is caught between two hard objects.
What do crush injuries often damage?
They often damage the base of the skull and nerves of the brain stem rather than the brain itself.
Name-
Damage occurring at the time of impact.
Primary Injury (the event)
Name-
Damage that evolves over time after the initial trauma.
Secondary Injury (body’s response to trauma)
What is the first stage in pre-hospital management?
Resuscitation (if necessary)
Name the 2nd Stage in pre-hospital management?
Primary Survey- using ATLS
What does ATLS stand for?
Advanced
Trauma
Life
Support
Name the steps in Advanced Trauma Life Support (ATLS).
Airway maintenance and cervical spine protection.
Breathing and Ventilation
Circulation and haemorrhage control
Disability- neurological status, GCS, pupils
Exposure- undress patient
After primary survey (and once patient is stable) what is the next step?
Secondary Survey.
What sort of things does a secondary survey include?
Other Injuries History Age Allergies On medication Event related to the injury etc. etc.
What are the 3 things we should include in assessment?
ATLS
GCS
Extent of injury.
What does GCS stand for?
the Glasgow Coma Scale
GCS is _______ monitored.
continually.
What is an SLTs role regarding the GCS?
Any changes you notice must be brought to the team’s attention.
Name the 3 responses that the GCS records.
Eye Opening Response
Best Verbal Response
Best Motor response
Fill in the blanks for eye opening response:
____________________ 4
To __________________ 3
To __________________ 2
_____ ________________ 1
Spontaneously
Speech
Pain
No response
Fill in the blanks for best verbal response:
Orientated to ____, _____ and _______ 5
________________ 4
___________ words 3
Incomprehensible ________________ 2
_________ ____________ 1
Place, person and time Confused Inappropriate Sounds No Response
Fill in the blanks for best motor response:
___________ __________________ 6
moves to localised ___________ 5
____________ withdrawal from pain 4
Abnormal _____________ 3
Abnormal _____________ 2
___ ____________________ 1
Obeys Commands pain flexion flexion extension no response
A GCS score of 15 means…
Minimal- no LOC (level of consciousness)
What GCS score means Mild/brief level of consciousness?
14 (sometimes 15)
Moderate score on GCS is between ___________.
9 and 13.
A score of 5-8 on the GCS means __________.
5-8.
What is a critical GCS score?
3-4.
On arrival at the hospital-we assess what?
The extent of the Injury.
How do we asses the extent of the injury?
Using a CT scan.
A ____ scan is the gold standard in suspected brain injury.
CT
Why are CT scans used?
Easy to perform
Quick
Can detect the presence of blood and fractures, which are the most crucial lesions to identify.
If patient needs a CT scan and has a GCS < 15, what should the scanning include?
It should include the cervical spine.
Why is MRI scan not used?
Although it’s v. detailed- it takes too long - time is of the essence here!
A brain injury can either be ______ or ______.
Focal (non traumatic)
Diffuse ( traumatic).
A CT scan can find a _________ __________ ________ .
Diffuse Axonal Injury.
A CT Scan can identify traumatic __________ as well as _________.
Haematoma (bleeding)
Contusion (bruising)
Name this:
An area of localised injury that may cause pressure within the brain.
A Focal Injury.
What are focal injuries sometimes referred to as?
Mass Lesions
Name the 2 most common mass lesions.
Haematomas
Contusions
What is a haematoma?
A haematoma is a blood clot within the brain or on its surface. It can occur anywhere in the brain.
A cerebral _____ is bruising of brain tissue.
contusion.
Name the 3 main types of haematoma associated with HI.
Extradural haematoma
Subdural haematoma
Intracerebral haematoma
What is an extradural haematoma?
The collection of blood between the skull and the dura.
What is a subdural haematoma?
The collection of blood between the dura and arachnoid mater.
Name a type of haemorrhage that’s not normally associated with head injury, but aneurysms can cause this.
Sub-arachnoid haemorrhage.
What is an intracerebral haematoma?
A blood vessel within the brain bursts allowing blood to leak inside the brain.
A sudden increase in pressure in the brain causes what?
Damage to the surrounding brain cells.
Name this:
An area of injured or swollen brain mixed with blood that has leaked out of arteries, veins or capillaries.
Contusion.
What is contusions caused by?
Small blood vessel leaks.
When are contusions usually most evident?
On scans after 24 hours.
Where are contusions most normally seen?
At the base of the front parts of the brain.
What injury occurs under the site of injury (where the bleeding is)?
A coup injury.
What occurs on the side opposite the area that was hit?
A centre- coup injury.
What is a microscopic change that cannot be seen on CT scans and that are scattered throughout the brain?
Diffuse Axonal Injury.
Diffuse Axonal Injuries don’t normally show up on _____ scans, they are usually diagnosed on _____ scans.
Initial
Delayed.
Diffuse Axonal Injuries may occur with or without an associated ________ injury.
Focal.
What is one of the most common types of brain injury and also one of the most devastating?
Diffuse Axonal Injury.
What is diffuse axonal injury a result of?
Its a result of the brain moving back and forward in the skull as a result of acceleration or deceleration.
Explain what happens as a result of diffuse axonal injury.
- Impaired functions and gradual loss of some axons
- If enough axons are injured then the ability of nerve cells to communicate with each other + integrate their function is lost or greatly impaired
- This can lead to severe disability
What does diffuse axonal injury also cause as well as loss of axons?
It causes brain cells to die, which causes swelling in the brain.
Name the 3 bone injuries that a CT scan might find.
Cervical Spine Injury
Skull Fractures
Facial Fractures
With a head injury we presume there is also a ____ ______ injury until proven otherwise.
Cervical Spine
Cervical spine injuries can be _____ or ______.
Minor
Severe
If somebody has a cervical spine injury they may require what?
Spinal Nursing.
Cervical spine can be stabilized by a _____.
collar.
Cervical spine injuries may require _____ management.
surgical.
No treatment is required for most ______ structures or ____ breaks or cracks in the skull.
linear.
simple
When do fractures at the base of the skull become problematic?
They may cause injury to the nerves, arteries or other structures.
If a fracture extends into the sinuses what happens?
There may be leakage of CSF from the nose or ears.
Most CSF leaks from the ears and nose will stop spontaneously but if not, what may be necessary?
A lumbar drain may have to be inserted.
What is a depressed skull fracture?
Where part of the bone presses on or into the brain.
A depressed skull fracture may require ________.
ORIF (Open Reduction Internal Fixation)
What is Open Reduction Internal Fixation (ORIF)?
surgery to fix the severe bone fracture.
What 2 things does damage depend on?
- The location in the brain
- Co-existence of other injury
Why cant a skull or facial fracture be immediately repaired?
Need to wait for swelling to reduce or patient to stabilize.
Sometimes people go immediately into ______ but some don’t and are monitored in _______ (__________________ ______________).
Surgery/ neurosurgery
ICU (conservative management)
When are people normally taken straight into surgery?
To remove a large haematoma or contusion that is significantly compressing the brain or raising pressure within the skull.
After surgery the patient is ____ and ______ in ICU.
observed and monitored
Give an example of neurosurgery.
removing a haematoma by drilling a hole in the skull.
Name 2 reasons why people don’t go into surgery straight away.
the patient must be stable
the haematoma may not have been discovered initially
What is one of the main goals of ICU monitoring/management?
To prevent secondary insults.
Name 4 secondary insults.
Hypoxia (not enough oxygen)
Hypotension (low blood pressure)
Mass lesions
Herniation (really high ICP).
What does ICP stand for?
Intracranial Pressure.
Name some secondary brain injuries.
Increased tissue pressure Increased intracerebral pressure (ICP) Reduced Cerebral Perfusion Pressure (CPP) - controls cerebral blood flow Reduced CSF (cerebrospinal fluid) Increased Ischaemia (no O2) Increased Oedema (swelling)
Name this:
When there is a build up of CSF inside the skull that leads to brain swelling.
Hydrocephalus.
The build up of CSF does what?
It puts pressure on the brain, pushing the brain up against the skull and damaging brain tissue.
When can hydrocephalus occur?
- The flow of CSF is blocked
- The fluid isn’t properly absorbed into the blood
- overproduction of the fluid
How is hydrocephalus treated?
- The blockage can be surgically removed
- The fluid can be drained.
What can cause high intracranial pressure?
- Build up of CSF
- Swelling of brain (mass)
- haemorrhage
- cerebral oedema
Elevated ICP is directly correlated with ____ _______.
poor outcome.
Explain the Monro-Kellie hypothesis.
-Cranial compartment is incompressible
- Cranium (blood, brain tissue, CSF) is a fixed volume
- Any increase in volume of one of the constituents must be compensated by a decrease in volume of another.
High ICP can cause _______ shift.
Midline.
How can raised ICP be managed?
Sedation
Drainage of CSF/fluid
Removal of CO2
If need be- decompressive craniectomy
Name this:
A treatment that allows the temporary drainage of CSF from the ventricles of the brain.
External Ventricular Drain.
The external ventricular drainage helps to do what?
Relieve raised intracranial pressure.
The external ventricular drain is inserted in ________ under general anaesthetic.
theatre.
Aswell as relieving ICP, what else is a External Ventricular Drain used for?
To divert infected CSF
To divert bloodstained CSF following neurosurgery/haemorrhage
To divert the flow of CSF
A device in the EVD can directly measure ______.
ICP
Name the 3 common types of surgical management.
Burr Holes
Craniotomy
Craniectomy
What is a burr hole surgery?
A small hole is drilled in the skull and a tube is inserted to drain the haematoma and relieve pressure.
Name this:
- Operation where a disc of bone is removed from the skull to allow access to the underlying brain.
- After the surgery the bone is replaced.
Craniotomy
What is a craniectomy?
- Operation where a disc of bone is removed from the skull to allow access to the underlying brain.
- The bone isn’t replaced until swelling goes down (few weeks) , sometimes not replaced :)
Name some examples of neurological deterioration.
- Development of agitated or abnormal behaviour
- decrease in one point in motor/verbal response GCS
- decrease in 2 points in the eye opening response GCS
- development of severe or increasing headache or persisting vomitting.
- new neurological symptoms eg. pupil inequality, asymmetry of limb or facial movement.
Head injury is the leading cause of death in people aged ___ to _____ years old.
1 to 40 years old.
What happens to a patient after they leave the hospital?
Normally they undergo rehab.
TBI causes numerous ________ disabilities.
hidden.
Give some examples of hidden disabilities.
changes to…
personality
thinking
memory
What can frontal lobe damage result in?
Behavioural problems, such as loss of insight and self restraint.
Name the 4 categories that brain injury can cause issues with.
Physical
Sensory
Cognitive
Behavioural
____ and _____ changes can be as a result of TBI.
Mood, personality
Name some other consequences of TBI.
Agression
Depression
Seizures
A TBI can impair a person’s ability to live _____________.
Independently.
What can TBI affect in a person’s life?
Relationships
Jobs
Previous Lifestyle eg. hobbies
Give a few examples of physical changes as a result of brain injury.
changes to... Balance Fine and gross motor skills problems walking coordination quality of speech swallowing endurance (eg. fatique easier)
What category do these changes come under: Information Processing Memory Communication problem Social skills planning and organising Attention and concentration.
Cognitive changes.
Name some emotional changes people with TBI can experience.
Depression Aggression Anxiety Mood swings Apathy Changes in drives (hunger, sex, temper)
What category do these changes come under? Inappropriate behaviour Difficulty reading social cues Isolation Difficulty maintaining relationships Change in roles
Social Changes
Rehab Team:
_________ __________ - support for emotional consequences
_______ ______________- help them return to an activity that supports their emotional well being
_____________ - assessment and rehab of strength, co-ordination, transfers, balance and mobility.
_________________- communication and swallowing
____________ ___________- provide social, financial and support to family and individual.
__________ ___________- support therapists to carry out rehab programmes
Clinical Psychologist
Occupational Psychologist
Physiotherapy
SLT
Social Worker
rehabilitation assistants.
______ problems after brain injury are very common.
Communication.
Often the _____ and _______ impairments have more significance than the physical changes.
cognitive, communicative.
People with TBI ________ better than they _______.
talk, communicate
talks lots but nothing makes sense
name some areas that SLT are involved in when it comes to TBI patients.
Aphasia
Dysarthria (slurred/unintelligible)
Apraxia (order of words or sounds)
Dysphagia
Name 4 cognitive difficulties that impact on communication.
Memory Impairment
Attention Difficulties
Poor social skills
fatigue
When it comes to dysphagia, SLTs plan ________ _______, support resumption of ____ and regaining functional ______ _______.
Alternate Feeding
diet
swallowing skills
What things can impact feeding?
Impulsivity
Behavioral changes
attention
fatigue
CHOKING HAZARDS ARE HUGE
What are the causes of a coma?
A coma can be the complication of:
- Head Injury
- Alcohol/drugs/medication
- other neurological disease
- metabolic disturbance
Coma comes from the Greek “Koma” meaning….
deep sleep
If you are in a coma what must be your score on the GCS?
GCS 8 or less.
If you are in a coma, what do you have the inability to do?
Inability to eye open, verbalise and obey.
In a coma you have no _____/______ cycle.
sleep/wake
In a coma you have no _______ ________.
voluntary movements
Name the 2 systems that regulate and control our consciousness.
Cerebral Cortex and reticular activating system.
What is the cerebral cortex composed of?
It is composed of grey and white matter.
Name some functions of the cerebral cortex.
Perception Sensation (via thalamus) Movement Vision Thought
What is the reticular activating system?
It is a brain stem structure.
It is a diffuse network of nerve pathways in the brainstem connecting the spinal cord, cerebrum and cerebellum.
What does the reticular activating system mediate?
It mediates the overall level of consciousness.
What does the reticular activating system control?
Arousal
Sleep
Wakening
Th brainstem controls all _______ functions and relays nerve signals between the _________ and ______ ______.
autonomic
brain
spinal cord
Name the 3 parts of the brainstem.
Midbrain
Pons
Medulla.
Midbrain is associated with _____ , ______, motor control, sleep/wake, ________ and _______ regulation.
Vision
Hearing
Alertness
Temperature.
What nuclei does the pons contain?
- nuclei that relay signals from the forebrain to the cerebellum
- Nuclei that deal primarily with sleep, respiration, swallowing, taste, eye movement, facial expression & sensation and posture etc.
What is the medulla?
The lower half of the brainstem
It contains the cardiac, respiratory, vomiting centres
It regulates autonomic, involuntary functions such as breathing, hear rate and blood pressure.
If you have a HI and GCS score less than 8- you have a very _____ _________.
prognosis.
If you have a coma due to ________ _______, there is a good prognosis with appropriate treatment.
drug overdose
If you have a coma not due to HI or drug overdose and it lats longer than 6 hours, what are you chances of survival?
10%
Coma due to _____ or ischaemia < 10% chance of recovery
Hypoxia
You have < 5% chance of recovery if your coma is due to _______ _____________ or _______.
Subarachnoid haemorrhage
stroke
If you have a coma for around 24 hours you have _____% chance of recovery.
10
If you have absent _______ ______ for 24 hours then you have very little chance of recovery.
brainstem reflexes.
If you have had a coma for over ____ days then you have a 3% chance of survival.
7.
After 7 days of being in a coma, what is their a high incidence of?
Death/persistent vegetative state.
Describe brain death coma in terms of arousal and awareness.
Low arousal
Low awareness
Describe vegetative state in terms of arousal and awareness.
High arousal
Low awareness.
Describe minimally conscious state in terms of minimally conscious state.
High arousal
Aware to an extent
Describe locked in syndrome in terms of arousal and awareness.
High Arousal
High Awareness
Just cant move- stuck or locked in body
What is brain stem death?
When there is no longer any brain stem functions, there’s permanent loss of the potential for consciousnesses and the capacity to breathe.
If a patient is-
- Unconscious and has no response to outside stimulation
- their heartbeat and breathing can only be maintained using a ventilator
- they have serious brain damage and it can’t be cured
we can start the process of diagnosing them as _________.
Brain Dead
Before Confirming brain death, what must doctors do?
Rule out everything else eg. overdose of illegal drugs, hypothermia, severe under activity of thyroid gland etc.
What are the rules regarding confirming somebody is brain dead?
- Diagnosis must be made by 2 senior doctors
- Both doctors must agree
- Tests are carried out twice to minimise error
A series of tests are performed to test for brain stem death. Name all 6 areas they test.
Pupil Response Corneal Reflex Motor Response Vestibulo-ocular reflex Gag reflex No respiration.
How is the pupil response tested?
A torch is shone into both eyes to see if they react to the light.
The cornea is stroked with a ______ to see if the eye reacts.
tissue/piece of cotton wool
How is the motor response tested?
pressure applied to forehead and nose is pinched to see if there’s any movement.
Ice cold water is inserted into the ears which normall cause the eyes to move, what does this test?
this tests the vestibulo-ocular reflex
What is a problem with poking thin plastic tube down trachea to see if it provokes gagging or coughing?
Not everyone has a gag reflex.
How is respiration tested?
They are disconnected from the ventilator for a short time to see if they can breathe on their own.
When in a vegetative state, what continues?
The basic functions of breathing spontaneously, maintaining heartbeat, blood pressure, digesting food and producing urine all continue.
In a vegetative state there may still be a _______ and ___________________.
sleep/wake cycle
spontaneous eye opening.
What do people who are in a vegetative state not have?
They don’t have evidence of consciousness in any meaningful sense
They have no response to what is going on in the environment.
How long is a persistent vegetative state?
4 weeks.
How long is a permanent vegetative state?
1 year.
Why is minimally conscious state different from vegetative state?
Because in minimally conscious state there is definite evidence of some limited self-awareness or awareness of the surroundings (but PVS aren’t aware at all).
Name the state:
Deliberate movements relates to cognition
Track Visually
Inconsistent, erratic responsiveness
Minimally Conscious Sate
What is very rare and is caused by damage to the ventral pons?
Locked in syndrome
How can Locked-In syndrome be caused?
- Stroke
- Head Injury
- MS
- Overdose/sodium problems
What does Locked in syndrome result in?
Total paralysis with intact consciousness.
What is the difference between locked in syndrome and total locked in syndrome?
LIS= intact eye movement
Total LIS= loss of eye movement
In locked in syndrome where might the SLT have a role?
To implement a means a non-verbal way of communication. eg. using eye movement etc.
Name the main challenges in coma.
- nursing/positioning to prevent bed sores
- swallowing and nutrition
- clearance of urine etc.
- Maintaining the airway (making sure it’s clean air- not infected)
