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Head/Spine/Cord injuries Flashcards

1
Q

 Mild brain injury

A

GCS 13-15
 Acute alteration in brain function caused by blunt external trauma
 LOC and/or confusion and disorientation shorter than 30 min
 Duration of posttraumatic amnesia < 24 hrs
 Deficits in cognition and memory usually resolve at 1 month
 Post-concussive sxs may persist for 3 months or longer
 CT scans normal

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2
Q

 Moderate brain injury

A

GCS 9-12
 30-50% have abnormal CT scans
 20-90% chance of good functional recovery

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3
Q

 Severe brain injury

A

GCS 3-8
 60-90% have abnormal CT scans
 <20% chance of good functional recovery

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4
Q

 Monroe-Kellie Principle

A

 Volume of rigid skull is equal to sum of brain, CSF, and blood, and is altered by pathological processes that increase normal quantities of these compartments (hydrocephalus) or add new compartments (tumor)

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5
Q

 Cushing’s Triad (result of Cushing reflex in head injuries)

A

 Widened pulse pressure
 Irregular respirations
 Bradycardia

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6
Q

 GCS < 8 =

A

severe head injury and Requires definite airway intervention!!

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7
Q

A depressed level of consciousness is considered to be intracranial pathology until

A

proven otherwise

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8
Q

 Mild dilation and sluggish response =

A

early sign of herniation

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9
Q

 B/l dilated and nonreactive pupils =

A

inadequate brain perfusion or b/l CN III palsy

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10
Q

 Pupil that does not react to light but reacts to light in the other eye =

A

optic nerve injury

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11
Q

 B/l small pupils =

A

drugs (esp. opiates), metabolic encephalopathy, or pons lesion

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12
Q

 Who gets CT scans?

A

 Trauma pts with LOC
 Pts with focal neuro deficits
 Pts on anticoagulant therapy
 Pts demonstrating HA, altered behavior, or seizures

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13
Q

 CT scans can be used to:

A

 To identify intracranial lesions that may need surgical correction
 To identify CSF obstruction (hydrocephalus)
 To appreciate severity of cerebral edema or presence of brain shift
 To evaluate prognosis

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14
Q

 “Vault” fractures

A

 Linear skull fractures; depressed vs. non-depressed

- - - - Fragments depressed more than thickness of skull require surgical reduction

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15
Q

 Basilar skull fractures

A

 Fx of bones that make up base of skull

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16
Q

s/s of Basilar skull fractures

A

 Raccoon eyes (periorbital ecchymosis)
 Battle’s signs (retroauricular ecchymosis)
 CSF leaks possible (think about infection)
 Hemotympanum
 CN VII palsy

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17
Q

Epidural Hemorrhage (cause and vignette)

A

 Bleeding between dura mater and internal surface of skull
 Middle meningeal artery most commonly affected
 Lucid interval  So they look good then they go out!
 Often in conjunction with skull fx (Temporal bone most likely)

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18
Q

Epidural Hemorrhage (3 other important points, the last being the CT imaging)

A

 Get a Neurosurgeon ASAP!!
 Might even have Pneumocephalus (if there is a laceration above the temporal fx)
 CONVEXITY on CT

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19
Q

Subdural Hemorrhage

Patho, often associated with, can be a/c

A

 Tear in the bridging veins between dura mater and underlying membranes that cover the brain
 Often see associated with direct damage to brain
 Can be acute or chronic

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20
Q

Subdural Hemorrhage (3 other facts and CT presentation)

A

 Chronic more common in elderly b/c veins are brittle
 Bridging Veins!
 CONCAVE on CT

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21
Q

Subarachnoid Hemorrhage

A

 Bleeding into space between the pia mater and arachnoid mater
 80% of non-traumatic SAHs are from ruptured aneurysms
 Circle of Willis

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22
Q

Nickname for SAH HA.

A

 “THUNDERCLAP HEADACHE”
 Traumatic SAH can lead to hydrocephalus (same process)
 If you see blood in the ventricles, you should think SAH

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23
Q

If you see blood in the ventricles, you should think…

A

SAH

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24
Q

Management of mild head injury

A

May discharge with competent adult if not impaired

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25
Management of head injuries summary
 ABC’s  Intubate if GCS <8  Maintain spinal immobilization  Recognize need for higher lvl of care  Avoid secondary neurological insult (hypotension, hypoxemia, hyperthermia, hypoglycemia, seizures)  Control pain  DO NOT GIVE STEROIDS OR DEXTROSE SOLUTIONS
26
in head injuries do not give dextrose solution b/c...
it will decrease osmolality of blood resulting in increased H2O content of brain
27
In a serious head injury, anticonvulsants are given for.....days
7 days to prevent seizures (dilantin/keppra)
28
in Head injuries ** Avoid fever b/c
fever decreases seizure threshold and increases metabolic demand & makes your brain work harder
29
 High glucose increases cerebral
lactic acidosis
30
``` ICP Tx:  Mannitol -Do NOT give to... -Initial response is a ... -Action: ```
...to a person with hypoT or Renal Failure ...expansion of plasma volume and decrease in blood viscosity (therefore increase in cerebral blood flow) :.:.: 15-30 min - draws water from cerebral tissue to decrease edema
31
 Hypertonic saline (3% or 7.5% Saline)
 Decreases ICP without adversely affecting hemodynamic status  Monitor serum osmolarity and serum sodium
32
 Barbiturate:
 Decreases ICP by decreasing the cerebral metabolic rate for oxygen  Used when patients are refractory to all other treatment
33
 Any injury above the clavicle
should prompt a search for a cervical spine injury.
34
 Maintain c-spine immobilization until
able to properly clear spine → be suspicious
35
``` NEXUS CRITERIA "if dam!" 1 i 2 f 3 d 4 a 5 m ```
1- Assess signs of INTOXICATION in the patient 2-Assess for the presence of FOCAL NEUROlogical DEFICITS 3-Assessment for the presence of painful DISTRACTING INJURIES 4-Assess whether the pt has a NORMAL level of ALERTNESS 5-Presence of POSTERIOR MIDLINE TTP
36
In clearing a C-Spine with the Nexus Criteria,  If no painful response is elicited and the patient has met all prior criteria
the C-collar can be removed and C-spine imaging is not needed
37
During the nexus criteria testing always perform slow...
ROM
38
In diagnostic imaging with 3 plain view films (xray)
_-_Anteroposterior (to assess spinous processes) _-_LATERAL 85-90% of fx seen here!!! (essential to see base of occiput to C7-T1 junction) _-_Open mouth odontoid view - assess lateral masses of C1 and entire odontoid
39
CT is the gold standard for
Neck/spinal fx
40
 Jefferson Fracture
 Fracture of C1 ring from axial loading  Unilateral or bilateral fx of anterior and posterior arches of C1  ***This is an unstable fracture!!!***
41
 C2 Fractures: (epidemiology, 60% are..., others)
 1/3rd of cervical spine fractures at C2  60% of C2 fractures are odontoid fractures  Others are Hangman’s fracture (extends through pedicles of C2)  Odontoid fractures
42
C2 Fxs • Type I -- • Type II -- • Type III --
* Type I -- Avulsion of the tip of dens * Type II -- Base of dens, most common! * Type III -- Fx line extends into body of axis
43
½ of fractures occur @ C6-C7; most common subluxation is at
C5-C6
44
Anterior Wedge Fracture
Loss of body height at anterior portion of body
45
Burst Fracture
Compression fracture extending to posterior third of vertebral body
46
 Chance Fx (Posterior)
splitting injury which begins posterior and proceeds inferiorly through the vertebral body; --seat belt injury--
47
 Fracture - Dislocation
Uncommon but usually cause complete deficits due to narrow canal
48
Tx of Cervical Spine Fxs
 TLSO Brace Thoraciclumbosacro orthotic  LSO Brace Lumbarsacroorthotic  Surgery
49
 Sacral sparing-
preservation of some sensory perception in perianal region and/or voluntary contraction of rectal sphincter
50
Spinal Shock
 State of transient physiological reflex depression of cord function below level of injury with associated loss of sensorimotor function  Duration is variable
51
Neurogenic Shock
 Results from impairment of descending sympathetic efferent pathways in the spinal cord causing loss of vasomotor tone and sympathetic innervation of heart
52
Neuro shock presentation and tx
 Causing vasodilation of visceral & LE vessels, pooling of blood (Hypotension)  Loss of cardiac sympathetic tone (bradycardia)  Vasopressors are often needed to restore blood pressure ***TRIAD: Hypotension, bradycardia, hypothermia
53
 Spinal Cord Management
 Have high index of suspicion  Immobilize - but no need for long spinal board  No Steroids  Consult Neurosurgery
54
Warning! with spinal cord injuries**...
 **Hypotension is not always caused by hypovolemia In trauma patients  Skin is warm, flushed, and dry (this is not the case in hypovolemic shock)
55
 Corticospinal Tract
in posterolateral segment of cord; controls ipsilateral mvmt
56
 Spinothalamic Tract
in anterolateral aspect of cord; transmits pain and temp sensation from OPPOSITE side of body
57
 Posterior Columns
carry proprioception, vibration sense on same side of body
58
 Central Cord Syndrome
 Disproportionately greater power loss in upper extremities than in lower extremities  More pronounced in distal aspect of extremity  Damage to corticospinal tract • Usually assoc/ w. hyperextension (esp in pts w/ spondylosis or congenital stenosis)
59
 Anterior Cord Syndrome
 Complete motor paralysis with loss of pain/temperature (proprioception/vibration preserved)  Often associated with burst fx’s with fragment retropulsion into canal
60
Anterior Cord Syndrome cause
 Caused by compression of anterior spinal artery resulting in anterior cord ischemia or direct compression of anterior cord  You will still have proprioception and vibration!!!
61
 Brown-Sequard Syndrome
 Hemisection of cord -------  Ipsilateral motor loss (corticospinal tract)  Loss of position sense (posterior column)  Contralateral sensory loss of pain & temperature  Begins 1-2 levels below the level of injury
62
 SCIWORA
 Spinal Cord Injury with Out Radiologic Abnormality
63
 SCIWORA is unique in.... | also, Cause, Prognosis, and length of External immobilization, Advised to avoid...wut
 Unique in children  Elastic ligaments and spinal cord stretch leading to neuronal injury  Usually good prognosis  External immobilization for up to 12 weeks  Pts advised to avoid increased risk activities for 6 months after Dx to prevent acute exacerbations of sxs and reduce risk for further injury
64
Maxillofacial Fractures |  ----Mandible Fractures
 2nd most common next to nasal bone |  All mandible fxs, even slightly displaced, are considered open fxs, but use of Abx is controversial
65
 Maxilla Types of Fxs
 Le Fort I -- Transverse fx immediately above the level of the teeth  Le Fort II -- Configuration of pyramid with the apex being across the nasal bridge  Le Fort III -- Separates the craniofacial complex
66
 Blow Out Fractures
 Fractures of the orbital floor without involvement of the orbital rim  Check EOM on exam – Look for entrapment  Get ophthalmological consult

Neurology (2 decks)

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