Head Trauma Flashcards
Physical exam for a patient presenting with head trauma would include ______
examination of the nose, scalp & cranium
When examining the nose, scalp and cranium of a patient who presents with head trauma, you are looking for _______ (3)
- lacerations
- hematoma
- deformity
What are the A-B-C-Ds in trauma?
- Airway
- Breathing
- Circulation
- Disability (GCS)
What are the GCS scores that correlate with a severe TBI? Moderate? Mild?
- 3-8
- 9-13
- 14-15
4 Limitations of GCS
- confounded by drugs, alcohol
- intended to measure deterioration overtime, not a snapshot
- does not distinguish between different injuries
- measures behavior, not underlying pathophysiology
Types of brain herniation (4)
- uncal transtentorial (MC)
- central transtentorial
- upward transtentorial
- cerebellotonsillarr
Sx/s of increrased cranial pressure (8)
- severe headache
- vision change
- numbness
- focal weakness
- AMS
- hypertension
- bradycardia
- agonal breathing
What would you suspect in a patient who presents with ipsilateral fixed & dilated pupil?
uncal herniattion (unopposed sympathetic tone)
Which herniation syndrome can lead to sudden death?
cerebellotonsillar
(also demonstrates pinpoint pupils & flaccid paralysis)
Which herniation syndrome presents with myosis, conjugate downward gaze & absence of vertical eye movement?
upward transtentorial
Which herniation syndrome presents with bilateral myosis, b/l babinski sign and increased muscle tone?
central transtentorial
What 4 signs would you expect in a patient who has an impending herniation?
- motor posturing
- hemiparesis
- progressive neuro deterioration
- pupil changes
categories of skull fx (3)
- location (basilar)
- open/closed
- pattern (compression/linear)
complications of skull fx (5)
- dural lacerations
- infection
- hearing loss
- vertigo
- CN dysfunction
What makes a basilar fx unique?
- does not have localizing sx
- causes battle sign and/or raccoon eyes
What must you AVOID if a cribriform plate fx is suspected
placing an NG tube
How do you manage skull fx (4)
- CT
- admit
- abx
- surgery (neuro or otolaryngologist consult)
What is the difference in the causes of brain contusion vs. diffuse axonal injury (concussion)?
- contusion is due to an impact & acceleration/deceleration
- concussion is due to a shearing of axons
Appearance of diffuse axonal injury on CT
blurring of the white and gray matter
____ is the most important cause of persistent disability after brain injury
diffuse axonal injury
Cerebral contusions are often associated with ________.
subarachnoid hemorrhage
contusions of the temporal lobe often present with ______ (2)
- aggression
- delirium
When do you order serial CTs?
brain contusion with mental mental status change & coagulopathy
Traumatic subarachnoid hemorrhage is due to disruption of the ______ and ______.
- parenchyma
- subarachnoid vessels
subarachnoid hemorrhage may lead to ______
increase ICP → blocking CSF outflow from 3rd & 4th ventricles
Subarachnoid hemorrhage sx (3)
- blood in CSF
- photophobia
- meningeal signs
_________ is the most common CT abnormality in TBI patients (moderate-severe)
subarachnoid hemorrhage
Best time to image for SAH?
8 hours post-injury (otherwise you may miss it)
IF you suspect SAH and they develop an altered level of consciousness or neuro findings, ________.
monitor via ICP in critical care setting
Epideral hematoma is located _______-
between the skull and dura mater
epideral hematoma is caused by ______.
blunt force to the side of the head
(middle meningeal artery)
_________ usually have a lucid period before deterioration
epidural hematoma
Epidural hematomas are ______ -shaped on CT ; subdural hematomas are ______- shaped.
- biconvex (football shaped) mass in temporal region
- crescent (cross suture lines)
Epidural hematomas typically do NOT have underlying brain parenchyma injury, but typically the injury leads to ________.
brain herniation
(w/in hours due to rapid expansion; if evacuation occurs before neuro deficits → good outcome)
epidural hematoma w/mass effect (slight midline shift)
Subdural hematoma forms ______ (location)
between the dura mater and arachnoid
(venous origin)
Subdural hematomas usually occur via ________
acceleration-decceleration injury → tearing of bringing dural veins
Structure damaged with subdural hematoma
bridging veins
(mostly patients w/underlying parenchymal damage)
Benign falls can cause ______ in elderly and children < 2 y.o.
subdural hematoma
(no recollection of injury)
subacute subdural hematomas are _______ on CT; chronic are ______ on CT.
- isodense (difficult to ID)
- hypodense (dark)
_______ (acute/subacute) subdural hematomas more likely require surgical repair
acute
(all require neurosurgery eval)
subdural hematoma R fronto temporal
Penetrating trauma > 8 GCS and reactive pupils mortality?
< 5 GCS mortality?
- 25%
- 100%
(as bullet passes through brain can create cavity 3-4 x larger than diameter)
Penetrating trauma to the brain treatment (3)
- intubate
- abx (vancomycin or ceftriaxone)
- surgery
Mild traumatic brain injury (mTBI) s/sx (9)
- N/V
- balance issues
- dizzy
- diplopia
- photophobia
- phonophobia
- confusion
- behavior changes
- sleep difficulty
mTBI w/amnesia indicates
more serious injury
What is included in the concussion specific neuro exam (5)?
- awareness/alertness
- cognition
- C-spine
- oculomotor
- balance
mTBI leading to significant brain injury are evident by ______ (amt of time).
4 hours
mTBI home instructions (3)
- avoid reading, texting, tv
- monitored by friend/family 24 hrs
- return if: HA, AMS, N/V
most mTBI symptoms resolve w/in _____ (time frame)
7-10 days
mTBI should be referred to ______ (2) if symptoms persist
- neuro
- sports med
(specialist in head injuries)
Postconcussive syndrome is when _____ becomes chronic.
symptoms of mTBI
post-concussion syndrome should be referred to _______.
- neuropsych
- mTBI clinic
_____ (#) recurrent concussions pose a risk for long-term sequale.
3 or more
Second impact before the brain has healed leads to loss of _______ → ______→ _______.
auto-regulation → ion imbalance → rapid cerebral edema
Signs of intracranial HTN on CT (3)
- compressed lateral ventricles
- attenuation of the sulci & gyri
- poor white/gray matter distinction
Indication for poor outcomes of TBI in the Er (4)
- SBP <90 mmHg
- PaO2 < 60 mmHg
- fever
- hyperglycemia
patients in the ER w/GCS<8 require
intubation
CPP = ______ - ______
MAP - ICP
(cerebral perfusion pressure)
_______ (2) can lower ICP
mannitol & hypertonic saline
