Head injury, syncope + bleeds Flashcards
Management of delirium
Check bloods
Treat conservatively but haloperidol +- lorazepam
S+S SAH
Severe, sudden onset occipital headache - sometimes preceded by sentinel headache
Neck stiffness
N+V
Papilloedema, retinal haemorrhages, focal neurology
Causes of SAH
Bending
Post coital
Berry aneurysm - polycystic kidneys, Ehlers/ Marfans, trauma, tumour
Assessing severity of SAH
Hunt + Hess scale
1: minimal symptoms
2: mod/ severe headache, stiff, no neuro
3: drowsy/ confused
4: stupor, hemiparesis
5: comatose
Investigations for ?SAH
CT - within 48hrs
Lumbar puncture if clear - if blood in CSF, CT angiogram
CSF is bloody early, then yellow after 12 hours
Bloods: clotting screen, U+Es
Management for SAH
Refer to neurosurgery - VP shunt, craniotomy, clipping, endovascular coil - only if cause is aneurysm Treat raised ICP - Mannitol Correct hypotension (IV nitrates, nimlodipine)
Indications for skull x ray following head injury
Amnesia Reduced consciousness N+V Neuro signs CSF/ blood from orifices
Characteristics of extradural haematoma
Dura + skull Acceleration/ deceleration injury Temporal region + middle meningeal Raised ICP Lucid interval
Characteristics of subdural haematoma
Frontal/ parietal lobe
Old age + alcohol are risks
Slow onset of symptoms
What is the management for raised ICP?
IV mannitol
Oedema may require decompressive craniotomy
What is the Monroe Kellie doctrine?
Cranium is incompressible - volume is fixed
Blood, CSF + brain: increase in 1, decreases the others
Cerebral perfusion = mean arterial pressure - ICP
So if ICP increases, perfusion decreases
What is the Cushings response?
Reduced cerebral perfusion due to raised ICP - causes brain hypoxia
Body’s response is to raise BP
What is Cushings triad?
HTN, bradycardia, abnormal respiration
Causes of seizures
Vascular - haemorrhage, thrombosis Trauma Tumours Toxins Metabolites - hypoxia, hypoglycaemia, electrolyte disturbances Infection Inflammation
What is the san francisco syncope rule?
CHESS CCF Haematocrit <30 ECG abnormal SOB Systolic BP
What is the Oseil risk score?
Age >65 History of CV disease Syncope without prodrome Abnormal ECG findings Predicts 12 month mortality after syncope
What is the commonest cause of syncope?
Reflex bradycardia
Peripheral vasodilation from pain, fear, emotion
Investigations for syncope
ECG Neuro exam BP lying + standing Bloods + glucose EEG, echo CT/ MRI
GCS eye response
Open spontaneously: 4
Open to verbal command: 3
Open in response to pain: 2
No response: 1
GCS verbal response
Talking: 5 Confused: 4 Inappropriate words: 3 Incomprehensible sound: 2 No response: 1
GCS motor response
Obeys commands: 6 Localises pain: 5 Withdraws from pain: 4 Abnormal flexion: 3 Extension: 2 No response: 1
Indications for CT head immediately (within 1 hr) post head injury
GCS <13
GCS <15 2 hours after the injury?open fracture
Signs of basal skull fracture: panda eyes, CSF leak, Battle’s sign (bruising over mastoid)
Seizure
Focal neuro deficit
>1 episode vomiting
Indications for CT head within 8 hrs post head injury
Any LOC or amnesia +: >65Hx of bleeding/ clotting Dangerous mechanism of injury >30mins retrograde amnesia Pt on warfarin
Transient loss of consciousness - how to determine urgency
Person has sustained injury
Person not fully recovered consciousness
TLOC secondary due to other condition
