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Neurology Yr2 > Head Injury and Coma > Flashcards

Head Injury and Coma Flashcards

1
Q

Define Head Injury.

A

Any trauma to the scalp, skull or brain.

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2
Q

A head injury does not always equal a _____ ________

A

Brain Injury

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3
Q

Define Acquired Brain Injury.

A

Damage to the brain which occurs after birth and isn’t related to a congenital or degenerative disease.

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4
Q

___________ is any damage to the head.

____________ is any damage to the brain.

A

Head Injury

Acquired Brain Injury.

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5
Q

Name the 2 types of acquired brain injury.

A

Traumatic Brain Injury

Non-traumatic Brain Injury

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6
Q

___________ brain injury leads to normally more focal damage.

A

Non-traumatic.

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7
Q

list some causes of non-traumatic brain injury.

A 
Stroke
Tumour
Infection 
Anoxia (total depletion in oxygen)
Toxic or Metabolic causes
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8
Q

What is a traumatic brain injury?

A

A non-degenerative, non-congenital insult to the brain from an external mechanical force.

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9
Q

What can traumatic brain injury lead to?

A

Temporary or permanent impairment of cognitive, physical and psychosocial function with an associated diminished or altered state of consciousness.

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10
Q

Traumatic brain injury is a _______ onset which leads to drastic ______ _________.

A

sudden, life changes

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11
Q

Describe the type of damage you get from traumatic brain injury.

A

Typically diffuse, generalised damage.

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12
Q

In traumatic brain injury changes can be ________.

A

hidden.

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13
Q

Name the high risk groups for traumatic brain injury.

A 
Young men
Elderly
Previous head injury
Residents of inner cities
Alcohol
Drug Abuse
Low Income
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14
Q

Name the mechanisms of traumatic brain injury.

A 
Assault
Falls
Road traffic accidents
Sports
Work Injuries
Over half involve Alcohol
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15
Q

For traumatic injury- what is better than cure?

A

Prevention is better than cure.

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16
Q

Name some things that have prevented traumatic brain injury.

A
  • seatbelt laws 1983
  • drink driving test 1983
  • air bags
  • helmets on bikes and motorbikes
  • Alcohol awareness + violence
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17
Q

Name the 3 types of Head Injuries causing traumatic brain injury.

A

Closed head injury
Open or penetrating wounds
Crush Injuries

COC

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18
Q

What is the most common type of head injury causing traumatic brain injury?

A

Closed Head Injury

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19
Q

What is a closed head injury?

A

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.

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20
Q

When the brain follows heads movement in a car accident this is an example of what HI?

A

Closed Head Injury

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21
Q

When the skull is opened and the brain is exposed and damaged- what injury is this known as?

A

Open or Penetrating Wound

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22
Q

Give an example of what can cause an open/penetrating wound.

A

Gunshot.

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23
Q

What is a crush injury?

A

When the head is caught between two hard objects.

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24
Q

What do crush injuries often damage?

A

They often damage the base of the skull and nerves of the brain stem rather than the brain itself.

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25
Q

Name-

Damage occurring at the time of impact.

A

Primary Injury (the event)

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26
Q

Name-

Damage that evolves over time after the initial trauma.

A

Secondary Injury (body’s response to trauma)

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27
Q

What is the first stage in pre-hospital management?

A

Resuscitation (if necessary)

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28
Q

Name the 2nd Stage in pre-hospital management?

A

Primary Survey- using ATLS

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29
Q

What does ATLS stand for?

A

Advanced
Trauma
Life
Support

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30
Q

Name the steps in Advanced Trauma Life Support (ATLS).

A

Airway maintenance and cervical spine protection.
Breathing and Ventilation
Circulation and haemorrhage control
Disability- neurological status, GCS, pupils
Exposure- undress patient

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31
Q

After primary survey (and once patient is stable) what is the next step?

A

Secondary Survey.

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32
Q

What sort of things does a secondary survey include?

A 
Other Injuries
History
Age
Allergies
On medication
Event related to the injury etc. etc.
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33
Q

What are the 3 things we should include in assessment?

A

ATLS
GCS
Extent of injury.

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34
Q

What does GCS stand for?

A

the Glasgow Coma Scale

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35
Q

GCS is _______ monitored.

A

continually.

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36
Q

What is an SLTs role regarding the GCS?

A

Any changes you notice must be brought to the team’s attention.

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37
Q

Name the 3 responses that the GCS records.

A

Eye Opening Response
Best Verbal Response
Best Motor response

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38
Q

Fill in the blanks for eye opening response:

____________________ 4
To __________________ 3
To __________________ 2
_____ ________________ 1

A

Spontaneously
Speech
Pain
No response

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39
Q

Fill in the blanks for best verbal response:

Orientated to ____, _____ and _______ 5
________________ 4
___________ words 3
Incomprehensible ________________ 2
_________ ____________ 1

A 
Place, person and time
Confused
Inappropriate
Sounds
No Response
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40
Q

Fill in the blanks for best motor response:

___________ __________________ 6
moves to localised ___________ 5
____________ withdrawal from pain 4
Abnormal _____________ 3
Abnormal _____________ 2
___ ____________________ 1

A 
Obeys Commands
pain
flexion
flexion
extension 
no response
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41
Q

A GCS score of 15 means…

A

Minimal- no LOC (level of consciousness)

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42
Q

What GCS score means Mild/brief level of consciousness?

A

14 (sometimes 15)

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43
Q

Moderate score on GCS is between ___________.

A

9 and 13.

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44
Q

A score of 5-8 on the GCS means __________.

A

5-8.

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45
Q

What is a critical GCS score?

A

3-4.

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46
Q

On arrival at the hospital-we assess what?

A

The extent of the Injury.

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47
Q

How do we asses the extent of the injury?

A

Using a CT scan.

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48
Q

A ____ scan is the gold standard in suspected brain injury.

A

CT

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49
Q

Why are CT scans used?

A

Easy to perform
Quick
Can detect the presence of blood and fractures, which are the most crucial lesions to identify.

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50
Q

If patient needs a CT scan and has a GCS < 15, what should the scanning include?

A

It should include the cervical spine.

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51
Q

Why is MRI scan not used?

A

Although it’s v. detailed- it takes too long - time is of the essence here!

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52
Q

A brain injury can either be ______ or ______.

A

Focal (non traumatic)

Diffuse ( traumatic).

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53
Q

A CT scan can find a _________ __________ ________ .

A

Diffuse Axonal Injury.

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54
Q

A CT Scan can identify traumatic __________ as well as _________.

A

Haematoma (bleeding)

Contusion (bruising)

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55
Q

Name this:

An area of localised injury that may cause pressure within the brain.

A

A Focal Injury.

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56
Q

What are focal injuries sometimes referred to as?

A

Mass Lesions

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57
Q

Name the 2 most common mass lesions.

A

Haematomas

Contusions

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58
Q

What is a haematoma?

A

A haematoma is a blood clot within the brain or on its surface. It can occur anywhere in the brain.

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59
Q

A cerebral _____ is bruising of brain tissue.

A

contusion.

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60
Q

Name the 3 main types of haematoma associated with HI.

A

Extradural haematoma
Subdural haematoma
Intracerebral haematoma

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61
Q

What is an extradural haematoma?

A

The collection of blood between the skull and the dura.

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62
Q

What is a subdural haematoma?

A

The collection of blood between the dura and arachnoid mater.

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63
Q

Name a type of haemorrhage that’s not normally associated with head injury, but aneurysms can cause this.

A

Sub-arachnoid haemorrhage.

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64
Q

What is an intracerebral haematoma?

A

A blood vessel within the brain bursts allowing blood to leak inside the brain.

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65
Q

A sudden increase in pressure in the brain causes what?

A

Damage to the surrounding brain cells.

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66
Q

Name this:

An area of injured or swollen brain mixed with blood that has leaked out of arteries, veins or capillaries.

A

Contusion.

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67
Q

What is contusions caused by?

A

Small blood vessel leaks.

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68
Q

When are contusions usually most evident?

A

On scans after 24 hours.

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69
Q

Where are contusions most normally seen?

A

At the base of the front parts of the brain.

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70
Q

What injury occurs under the site of injury (where the bleeding is)?

A

A coup injury.

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71
Q

What occurs on the side opposite the area that was hit?

A

A centre- coup injury.

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72
Q

What is a microscopic change that cannot be seen on CT scans and that are scattered throughout the brain?

A

Diffuse Axonal Injury.

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73
Q

Diffuse Axonal Injuries don’t normally show up on _____ scans, they are usually diagnosed on _____ scans.

A

Initial

Delayed.

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74
Q

Diffuse Axonal Injuries may occur with or without an associated ________ injury.

A

Focal.

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75
Q

What is one of the most common types of brain injury and also one of the most devastating?

A

Diffuse Axonal Injury.

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76
Q

What is diffuse axonal injury a result of?

A

Its a result of the brain moving back and forward in the skull as a result of acceleration or deceleration.

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77
Q

Explain what happens as a result of diffuse axonal injury.

A
  • 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
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78
Q

What does diffuse axonal injury also cause as well as loss of axons?

A

It causes brain cells to die, which causes swelling in the brain.

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79
Q

Name the 3 bone injuries that a CT scan might find.

A

Cervical Spine Injury
Skull Fractures
Facial Fractures

80
Q

With a head injury we presume there is also a ____ ______ injury until proven otherwise.

A

Cervical Spine

81
Q

Cervical spine injuries can be _____ or ______.

A

Minor

Severe

82
Q

If somebody has a cervical spine injury they may require what?

A

Spinal Nursing.

83
Q

Cervical spine can be stabilized by a _____.

A

collar.

84
Q

Cervical spine injuries may require _____ management.

A

surgical.

85
Q

No treatment is required for most ______ structures or ____ breaks or cracks in the skull.

A

linear.

simple

86
Q

When do fractures at the base of the skull become problematic?

A

They may cause injury to the nerves, arteries or other structures.

87
Q

If a fracture extends into the sinuses what happens?

A

There may be leakage of CSF from the nose or ears.

88
Q

Most CSF leaks from the ears and nose will stop spontaneously but if not, what may be necessary?

A

A lumbar drain may have to be inserted.

89
Q

What is a depressed skull fracture?

A

Where part of the bone presses on or into the brain.

90
Q

A depressed skull fracture may require ________.

A

ORIF (Open Reduction Internal Fixation)

91
Q

What is Open Reduction Internal Fixation (ORIF)?

A

surgery to fix the severe bone fracture.

92
Q

What 2 things does damage depend on?

A
  • The location in the brain

- Co-existence of other injury

93
Q

Why cant a skull or facial fracture be immediately repaired?

A

Need to wait for swelling to reduce or patient to stabilize.

94
Q

Sometimes people go immediately into ______ but some don’t and are monitored in _______ (__________________ ______________).

A

Surgery/ neurosurgery

ICU (conservative management)

95
Q

When are people normally taken straight into surgery?

A

To remove a large haematoma or contusion that is significantly compressing the brain or raising pressure within the skull.

96
Q

After surgery the patient is ____ and ______ in ICU.

A

observed and monitored

97
Q

Give an example of neurosurgery.

A

removing a haematoma by drilling a hole in the skull.

98
Q

Name 2 reasons why people don’t go into surgery straight away.

A

the patient must be stable

the haematoma may not have been discovered initially

99
Q

What is one of the main goals of ICU monitoring/management?

A

To prevent secondary insults.

100
Q

Name 4 secondary insults.

A

Hypoxia (not enough oxygen)
Hypotension (low blood pressure)
Mass lesions
Herniation (really high ICP).

101
Q

What does ICP stand for?

A

Intracranial Pressure.

102
Q

Name some secondary brain injuries.

A 
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)
103
Q

Name this:

When there is a build up of CSF inside the skull that leads to brain swelling.

A

Hydrocephalus.

104
Q

The build up of CSF does what?

A

It puts pressure on the brain, pushing the brain up against the skull and damaging brain tissue.

105
Q

When can hydrocephalus occur?

A
  • The flow of CSF is blocked
  • The fluid isn’t properly absorbed into the blood
  • overproduction of the fluid
106
Q

How is hydrocephalus treated?

A
  • The blockage can be surgically removed

- The fluid can be drained.

107
Q

What can cause high intracranial pressure?

A
  • Build up of CSF
  • Swelling of brain (mass)
  • haemorrhage
  • cerebral oedema
108
Q

Elevated ICP is directly correlated with ____ _______.

A

poor outcome.

109
Q

Explain the Monro-Kellie hypothesis.

A

-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.
110
Q

High ICP can cause _______ shift.

A

Midline.

111
Q

How can raised ICP be managed?

A

Sedation
Drainage of CSF/fluid
Removal of CO2
If need be- decompressive craniectomy

112
Q

Name this:

A treatment that allows the temporary drainage of CSF from the ventricles of the brain.

A

External Ventricular Drain.

113
Q

The external ventricular drainage helps to do what?

A

Relieve raised intracranial pressure.

114
Q

The external ventricular drain is inserted in ________ under general anaesthetic.

A

theatre.

115
Q

Aswell as relieving ICP, what else is a External Ventricular Drain used for?

A

To divert infected CSF
To divert bloodstained CSF following neurosurgery/haemorrhage
To divert the flow of CSF

116
Q

A device in the EVD can directly measure ______.

A

ICP

117
Q

Name the 3 common types of surgical management.

A

Burr Holes
Craniotomy
Craniectomy

118
Q

What is a burr hole surgery?

A

A small hole is drilled in the skull and a tube is inserted to drain the haematoma and relieve pressure.

119
Q

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.
A

Craniotomy

120
Q

What is a craniectomy?

A
  • 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 :)
121
Q

Name some examples of neurological deterioration.

A
  • 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.
122
Q

Head injury is the leading cause of death in people aged ___ to _____ years old.

A

1 to 40 years old.

123
Q

What happens to a patient after they leave the hospital?

A

Normally they undergo rehab.

124
Q

TBI causes numerous ________ disabilities.

A

hidden.

125
Q

Give some examples of hidden disabilities.

A

changes to…
personality
thinking
memory

126
Q

What can frontal lobe damage result in?

A

Behavioural problems, such as loss of insight and self restraint.

127
Q

Name the 4 categories that brain injury can cause issues with.

A

Physical
Sensory
Cognitive
Behavioural

128
Q

____ and _____ changes can be as a result of TBI.

A

Mood, personality

129
Q

Name some other consequences of TBI.

A

Agression
Depression
Seizures

130
Q

A TBI can impair a person’s ability to live _____________.

A

Independently.

131
Q

What can TBI affect in a person’s life?

A

Relationships
Jobs
Previous Lifestyle eg. hobbies

132
Q

Give a few examples of physical changes as a result of brain injury.

A 
changes to...
Balance
Fine and gross motor skills
problems walking
coordination
quality of speech
swallowing
endurance (eg. fatique easier)
133
Q 
What category do these changes come under:
Information Processing
Memory
Communication problem
Social skills
planning and organising
Attention and concentration.
A

Cognitive changes.

134
Q

Name some emotional changes people with TBI can experience.

A 
Depression
Aggression
Anxiety
Mood swings
Apathy
Changes in drives (hunger, sex, temper)
135
Q 
What category do these changes come under?
Inappropriate behaviour
Difficulty reading social cues
Isolation
Difficulty maintaining relationships
Change in roles
A

Social Changes

136
Q

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

A

Clinical Psychologist

Occupational Psychologist

Physiotherapy

SLT

Social Worker

rehabilitation assistants.

137
Q

______ problems after brain injury are very common.

A

Communication.

138
Q

Often the _____ and _______ impairments have more significance than the physical changes.

A

cognitive, communicative.

139
Q

People with TBI ________ better than they _______.

A

talk, communicate

talks lots but nothing makes sense

140
Q

name some areas that SLT are involved in when it comes to TBI patients.

A

Aphasia
Dysarthria (slurred/unintelligible)
Apraxia (order of words or sounds)
Dysphagia

141
Q

Name 4 cognitive difficulties that impact on communication.

A

Memory Impairment
Attention Difficulties
Poor social skills
fatigue

142
Q

When it comes to dysphagia, SLTs plan ________ _______, support resumption of ____ and regaining functional ______ _______.

A

Alternate Feeding
diet
swallowing skills

143
Q

What things can impact feeding?

A

Impulsivity
Behavioral changes
attention
fatigue

CHOKING HAZARDS ARE HUGE

144
Q

What are the causes of a coma?

A

A coma can be the complication of:

  • Head Injury
  • Alcohol/drugs/medication
  • other neurological disease
  • metabolic disturbance
145
Q

Coma comes from the Greek “Koma” meaning….

A

deep sleep

146
Q

If you are in a coma what must be your score on the GCS?

A

GCS 8 or less.

147
Q

If you are in a coma, what do you have the inability to do?

A

Inability to eye open, verbalise and obey.

148
Q

In a coma you have no _____/______ cycle.

A

sleep/wake

149
Q

In a coma you have no _______ ________.

A

voluntary movements

150
Q

Name the 2 systems that regulate and control our consciousness.

A

Cerebral Cortex and reticular activating system.

151
Q

What is the cerebral cortex composed of?

A

It is composed of grey and white matter.

152
Q

Name some functions of the cerebral cortex.

A 
Perception
Sensation (via thalamus)
Movement
Vision
Thought
153
Q

What is the reticular activating system?

A

It is a brain stem structure.

It is a diffuse network of nerve pathways in the brainstem connecting the spinal cord, cerebrum and cerebellum.

154
Q

What does the reticular activating system mediate?

A

It mediates the overall level of consciousness.

155
Q

What does the reticular activating system control?

A

Arousal
Sleep
Wakening

156
Q

Th brainstem controls all _______ functions and relays nerve signals between the _________ and ______ ______.

A

autonomic
brain
spinal cord

157
Q

Name the 3 parts of the brainstem.

A

Midbrain
Pons
Medulla.

158
Q

Midbrain is associated with _____ , ______, motor control, sleep/wake, ________ and _______ regulation.

A

Vision
Hearing
Alertness
Temperature.

159
Q

What nuclei does the pons contain?

A
  • 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.
160
Q

What is the medulla?

A

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.

161
Q

If you have a HI and GCS score less than 8- you have a very _____ _________.

A

prognosis.

162
Q

If you have a coma due to ________ _______, there is a good prognosis with appropriate treatment.

A

drug overdose

163
Q

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?

A

10%

164
Q

Coma due to _____ or ischaemia < 10% chance of recovery

A

Hypoxia

165
Q

You have < 5% chance of recovery if your coma is due to _______ _____________ or _______.

A

Subarachnoid haemorrhage

stroke

166
Q

If you have a coma for around 24 hours you have _____% chance of recovery.

A

10

167
Q

If you have absent _______ ______ for 24 hours then you have very little chance of recovery.

A

brainstem reflexes.

168
Q

If you have had a coma for over ____ days then you have a 3% chance of survival.

A

7.

169
Q

After 7 days of being in a coma, what is their a high incidence of?

A

Death/persistent vegetative state.

170
Q

Describe brain death coma in terms of arousal and awareness.

A

Low arousal

Low awareness

171
Q

Describe vegetative state in terms of arousal and awareness.

A

High arousal

Low awareness.

172
Q

Describe minimally conscious state in terms of minimally conscious state.

A

High arousal

Aware to an extent

173
Q

Describe locked in syndrome in terms of arousal and awareness.

A

High Arousal
High Awareness

Just cant move- stuck or locked in body

174
Q

What is brain stem death?

A

When there is no longer any brain stem functions, there’s permanent loss of the potential for consciousnesses and the capacity to breathe.

175
Q

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 _________.

A

Brain Dead

176
Q

Before Confirming brain death, what must doctors do?

A

Rule out everything else eg. overdose of illegal drugs, hypothermia, severe under activity of thyroid gland etc.

177
Q

What are the rules regarding confirming somebody is brain dead?

A
  • Diagnosis must be made by 2 senior doctors
  • Both doctors must agree
  • Tests are carried out twice to minimise error
178
Q

A series of tests are performed to test for brain stem death. Name all 6 areas they test.

A 
Pupil Response
Corneal Reflex
Motor Response
Vestibulo-ocular reflex
Gag reflex
No respiration.
179
Q

How is the pupil response tested?

A

A torch is shone into both eyes to see if they react to the light.

180
Q

The cornea is stroked with a ______ to see if the eye reacts.

A

tissue/piece of cotton wool

181
Q

How is the motor response tested?

A

pressure applied to forehead and nose is pinched to see if there’s any movement.

182
Q

Ice cold water is inserted into the ears which normall cause the eyes to move, what does this test?

A

this tests the vestibulo-ocular reflex

183
Q

What is a problem with poking thin plastic tube down trachea to see if it provokes gagging or coughing?

A

Not everyone has a gag reflex.

184
Q

How is respiration tested?

A

They are disconnected from the ventilator for a short time to see if they can breathe on their own.

185
Q

When in a vegetative state, what continues?

A

The basic functions of breathing spontaneously, maintaining heartbeat, blood pressure, digesting food and producing urine all continue.

186
Q

In a vegetative state there may still be a _______ and ___________________.

A

sleep/wake cycle

spontaneous eye opening.

187
Q

What do people who are in a vegetative state not have?

A

They don’t have evidence of consciousness in any meaningful sense
They have no response to what is going on in the environment.

188
Q

How long is a persistent vegetative state?

A

4 weeks.

189
Q

How long is a permanent vegetative state?

A

1 year.

190
Q

Why is minimally conscious state different from vegetative state?

A

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).

191
Q

Name the state:
Deliberate movements relates to cognition
Track Visually
Inconsistent, erratic responsiveness

A

Minimally Conscious Sate

192
Q

What is very rare and is caused by damage to the ventral pons?

A

Locked in syndrome

193
Q

How can Locked-In syndrome be caused?

A
  • Stroke
  • Head Injury
  • MS
  • Overdose/sodium problems
194
Q

What does Locked in syndrome result in?

A

Total paralysis with intact consciousness.

195
Q

What is the difference between locked in syndrome and total locked in syndrome?

A

LIS= intact eye movement

Total LIS= loss of eye movement

196
Q

In locked in syndrome where might the SLT have a role?

A

To implement a means a non-verbal way of communication. eg. using eye movement etc.

197
Q

Name the main challenges in coma.

A
  • nursing/positioning to prevent bed sores
  • swallowing and nutrition
  • clearance of urine etc.
  • Maintaining the airway (making sure it’s clean air- not infected)

Neurology Yr2 (9 decks)

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