Head Trauma Flashcards
Ventricles are _____________ filled spaces
CSF it is absorbed over the surface of the brain.
Normal ICP __________
Critical ICP ____________
normal <10
critical > 20
The monroe Kellie doctrine states that the total volume of intracranial contents must remain _____________.
If equal venous blood and CSF out =
once the limit is reached, ICP rapidly
constant.
OK
INCREASES
For airway, what is the worst outcome possible?
You want to avoid bagging in patients who are in _______________ pt gastric dilation can induce vomiting and they can aspirate
hypocarbia because can lead to cerebral vasospasm.
active breathing
Breathing:
Hypercapnia- increased…
Hypocapnia- decreased…
For ALL head trauma you want to give
CXR
morbidity/mortality
cerebral blood flow and decreased cerebral oxygen sat
continuous SPO2%
Circulation:
hypotension = increased M/M
How do you treat shock? what do you want to avoid in the treatment?
WATCH FOR CUSHINGS RESPONSE (bodies response to ICP)
LR, NS or blood avoid HYPOTONIC saline because it could increase the ICP AND HYPERGLYCEMIA- which is detrimental to ICH.
T/F does ICH cause hypotension?
FALSE
What med is part of the secondary survey? What lab do you want to run because of it?
ANTICOAGS, COAGS
A mild TBI has a GCS score of __________.
What is the presentation of these patients?
14>
asymptomatic with mild amnesia
+/- BRIEF loss of consciousness, usually <30 min
Global HA
N/V
The Canadian Head CT Rule is 100% sensitive. It is used in ages _____________ with ______________ head injury.
Obtain CT scan if:
1.
2.
3.
4.
5.
6.
16-64
mild
- GCS <15 at 2 hours post injury
- suspected open/depressed/basilar skull fx
- > 2 episodes of vomiting
- age > 65
- amnesia > 30 min
- mechanism
-ped struck
-ejection
-fall from 3+ feet or 5+ stairs
Moderate TBI is a GCS score of ____________.
9-13
Severe TBI is a GCS score of _____________. You want to ensure to prevent a secondary TBI!!
<8
What is the management of a scalp hematoma/laceration?
wash out and close promptly
-keep hair out of wound
-close up to 12 hours post injury
-sutures/staples out in 7-10 days
An epidural hematoma (more of a lens shape) is a collection between the ____________ and the skull. Arterial bleeding is present from the _______________ arteries. The pupils will be _________________
dura
middle meningeal
fixed/dilated
What are the s/s of an epidural hematoma
initial, brief, LOC-lucid interval(appears alert and conscious) - rapid neuro deterioration
How is an epidrual hematoma managed?
emergent neuro sx
control BP/HR
reverse coagulopathy
consider intubation
likely will need OR emergently
A subdural hematoma is MORE COMMON. A shearing force on _______________ bridging veins between the ____________ and ______________. It is a ______________ hematoma. There are 3 types:
1.
2.
3.
This is more seen in ___________ and _____________ because they have more space in their brains.
venous
dura
arachnoid
concave
1. Acute
2. Chronic
3. Acute/Chronic
elderly, alcoholics
What are the s/s of a subdural hematoma?
MANY ARE ASYMPTOMATIC- NONFOCALLL!!!!!
HA, diziness, N/V, ataxia, lethargy, wax/wane level of consciousness, focal weakness/paresthesia, coma
How does an acute subdural present on imaging? How is it managed?
it will show up as bright white. darker blood= chronic.
You want to correct coagulopathy
control HR/BP/O2
Admit to ICU
neurosurgical eval
frequent neuro check
+/- surgical drainage
Acute on chronic subdural hematoma occurs after ___________________. The patient experiences increased symptoms. How is it managed?
a more recent trauma.
admit to neurosurg
correct coags
control BP
may need evacuation/drainage
How is chronic subdural hematoma managed?
it is more gray on imaging
admit for observation
if symptomatic- may need drainage
PT/OT
When calling neurosurgery for a patient with a hematoma, what do you want to ensure you fill them in on?
time of injury
anticoags?
VS- ESP BP
Neuro exam: GCS, any focal deficits?
Severe TBI initial management:
For a SEVERE TBI, ensure _______________.
GCS ____________
Prevent ___________
Immobilize the C spine AT ALL TIMES!!!!!!
Neuro checks every __________
IMMEDIATE RAPID SEQUENCE INTUBATION
<8
hypoxia
hour
Severe TBI initial management:
In a TBI, you want to ensure blood pressure control.
- AVOID HYPOTENSION
-decreased cerebral perfusion pressure
-IV crystalloids, consider blood products
**SBP goal is 140-160 or 120-140
***MAP >65 (80-90 if SCI) - HTN
10% reduction of BP
IV bolus vs Gtt
Labetolol or hydralazine - Caution with maintenance IVF
Use NS generally
NO HYPOTONIC/GLUCOSE CONTANING!!!!!!!
Severe TBI initial management:
You want to elevate the HOB _______________
Consider _____________ or 3% normal saline.
PaCo2 _________________
-avoid hyperventilation
Seizure tx/prophylaxis:
1.
2.
3.
30-45 degrees
mannitol
30-35 mmHg
1. keppra
2. phenytoin
3. treat seizures with benzos
What is the surgical management of severe TBI?
- intracranial pressure monitor “bolt”
- Burr Hole
- craniotomy
- craniectomy
Cerebral contusions(bruising type pattern that will worsen before it gets better) commonly affects the ____________ and ____________ lobes. May have surrounding edema and +/- ____________. The patient will have neurologic dysfunction such as
1.
2.
3.
____________ usually appear when large
contusion >
frontal, temporal
SAH
- confusion
- obtundation
- coma
focal deficits
hematoma
How is a contusion managed?
admit for observation
neurosurg
correct coagulopathy
serial CTs
May go onto require ICP monitor
seizure prophylaxis
Traumatic subarachnoid (TSAH) may increase ICP it blocks out __________________________. If its isolated, you want to consider ________________ cause
3-4th ventricle
aneurysmal
What is the management of traumatic subarachnoid?
admit for observation
neuro c/s
serial CT
seizure prophylaxis
if asymptomatic- may D/C home with stable repeat CT and normal exam
AMS/Focal exam- ICP monitor
Diffuse axonal injury (DAI) mechanism is _______________. The person has INSTANT __________________. It is a frequent cause of ________________.
Degree of injury > ______________
80% of them is _________________
The patient may have relatively normal head CT but severely diminished GCS. You want to confirm with _____________________
shearing forces (high speed MVA)
LOC
post traumatic coma
imaging
nonhemorrhagic
MRI
A concussion is trauma induced alteration in mental status which may or may not include a ________________. Many symptoms present such as _______________ and _______________.
retrograde or anterograde. There are no objective CT findings and no timeline for recovery.
You want to avoid _______________
LOC
confusion and amnesia
NARCOTICS
What are the symptoms of post concussive syndrome?
prolonged HA
dizziness
memory impairment
When do you admit a patient that had a concussion?
- persistent amnesia
- persistent AMS
- inotxication
- safe place to be observed
- any CT abnormality
In peds with head trauma, you want to follow the _____________ rule for low risk head trauma. IF ANY ARE PRESENT (5)
if none are present then D/C
PECARN
1. mental status GCS <14
2. LOC > 5 seconds
3. severe mechanism of injury
4. fall >3 feet <2 years old ORRRRRRR > 5ft > 2 years old
5. Physical exam findings consistent with a skull fracture
What would be the reason for a kid that had a head trauma to return to the ED?
AMS
persistent N/V
numbness/tingling/weakness
severe HA
visual changes
What are the two most common areas of basilar fractures?
It can be linear/nondisplaced vs depressed. there is concern for disruption of the ______________ or ______________.
- petrous portion of temporal bone
- occipital condyle
middle meningeal artery, dural sinus
What are the s/s of a basilar skull fracture?
What will the CT scan show?
What antibiotic do you want to consider if open?
Closed, nondisplaced fractures > extended observation especially without underlying ICH
Open/displaced > admit
hemotympanum
CSF otorrhea/rhinorrhea
racoon eyes
battle sign
CT- pneumocephalus
IV Ancef
