Head/Spinal Injuries & Raised ICP

Question 1

What are the two main types of traumatic brain injury?

Answer 1

Primary - as a result of brain trauma
Secondary - develop later as a result of complications 
   -hypoxia
   -ischaemia
   -haematomas

Question 2

What are the common types of primary brain injuries?

Answer 2

Concussion
Diffuse axonal injury
Focal brain injuries

Question 3

What is concussion?

Answer 3

Transient loss of consciousness w/ no persistent neurological signs
May be signs of neurological injury on CT

Question 4

What are they key management features of diffuse axonal injury?

Answer 4

Visible on high res CT
Does not cause raised ICP
Treatment supportive
Can cause deficiencies in higher funcn

Question 5

What are focal brain injuries?

Answer 5

Gross damage to localised areas of brain, visible on CT

These act as space-occupying lesions

Question 6

What are the three types of focal brain injury?

Answer 6

Coup - beneath site of impact
Contre-coup - on opposite side of brain
Haemorrhage/haematoma

Question 7

What is post-concussion syndrome?

Answer 7

Long term disability affecting 50% of those w/ a head injury

Question 8

What are the sx of a post-concussion syndrome?

Answer 8

Dizziness
Headache
Poor concentration/memory
Inability to work
Difficulties w/ self care

Question 9

What are the key components of assessing a pt w/ head injury?

Answer 9

C-spine precautions
ABCDE resus
Record GCS
Hx/exam
Imaging - CT head, C-spine radiography

Question 10

What are the key signs of neurological deterioration?

Answer 10

Falling GCS (most important size)
Changing pupillary size/responsiveness
Focal neurological signs
Changing resp rate
Cushing's reflex

Question 11

What is Cushing’s reflex?

Answer 11

Late sign of neurological deterioration, due to pressure on medulla
Falling pulse, rising BP

Question 12

What pupillary changes are signs of neurological deterioration?

Answer 12

Initial progressive dilation on side of lesion and sluggish response to light
Due to pressure on oculmotor nn as ICP rises
If bilateral is pre-terminal

Question 13

What is the effect of hypercapnia in head injury?

Answer 13

Cerebral vasodilation
Raises ICP
May need hyperventilation on ICU

Question 14

What is the effect of hypoxaemia in head injury?

Answer 14

Cerebral vasodilation

Rapid lactic acidosis –> cerebral damage

Question 15

What is the effect of hypotension in head injury?

Answer 15

Loss of autoregulation
Cerebral blood flow relies on SBP
Resus vital to maintain SBP

Question 16

Which pts should have a head CT w/i 1hr of arrival?

Answer 16

GCS <13 at any time OR <15 2hrs post injury
Focal neurological deficit
Signs of increasing ICP
Suspected skull fracture
Post-traumatic seizure
Vomiting >1 times

Question 17

Which pts should have a head CT w/i 8hrs of arrival?

Answer 17

Anticoagulated pts
Loss of consciousness AND
   -age >65
   -dangerous mechanism of injury
   -retrograde amnesia >30mins

Question 18

Which pts should be admitted following head injury?

Answer 18

If imaging shows pathology
GCS <15 (monitory every 30mins)
Continuing worrying signs/sources of concern

Question 19

What is normal ICP?

Answer 19

0-10mmHg

Question 20

What are the causes of increased ICP?

Answer 20

Vasogenic (tumour, trauma, ischaemia, infection)
Cytotoxic
Interstitial (obstructive hydrocephalus)

Question 21

What are the sx of increasing ICP?

Answer 21

Headache - dull, persistent, worse on lying, present on waking, worse w/ coughing/straining
Vomiting
Seizures
Irritability

Question 22

What are the signs of increasing ICP?

Answer 22

GCS deterioration
Progressive dilation of pupil on affected side
Cushing’s reflex
Cheyne-Stokes respiration

Question 23

What is the management of raised ICP?

Answer 23

ABCDE
Elevate head of bed to 30-40o
Hyperventilate (reduce PaCO2)
Mannitol (0.2g/kg 20% IV over 15 mins)
Corticosteroids
Fluid restriction
Controlled hypothermia, CSF drainage, barbiturates

Question 24

How long does Papilloedema take to develop?

Answer 24

Weeks

Question 25

What is the general approach to investigating spinal cord injuries?

Answer 25

ABCDE
Determine MOI
Examination
Imaging - AP/lat/C2 XR, CT C-spine, whole spinal XR

Question 26

What additional measures are required for unconscious pts?

Answer 26

C-spine stabilisation if traumatic
Urgent CT head if signs of deterioration
Cervical/Thoracic/Lumbar XR

Question 27

What five factors in a conscious pt suggest that the C-spine has not been damaged?

Answer 27

Simple rear-end RTA
Sitting position in ED
Walking at any time
Delayed onset of neck pain
Absence of C-spine tenderness

Question 28

How can the C-spine be assessed if it seems likely there has been no damage?

Answer 28

Pt asked to rotate neck 45o to left/right

Question 29

What should be done if there is any uncertainty about damage to the C-spine?

Answer 29

Get radiological input