Head Trauma

Question 1

Criteria for a “Present Airway”

Answer 1

Patient is conscious and speaking in a normal tone of voice.

Question 2

Criteria for Needing an Airway

Answer 2

• Expanding Hematoma
• Emphysema in the Neck
• Unconscious
• Breathing Noisily or Gurgly
• Severe Inhalation Injury

Question 3

Most Common Method of Maintaining Secured Airway

Answer 3

Orotracheal Intubation

Question 4

How do you intubate orotracheally?

Answer 4

• Direct Vision with Laryngoscope

- Monitor Pulse Oximetry

Question 5

T/F: If there is a possible cervical spinal injury and needing airway securement, you should deal with the cervical spinal injury to avoid paralysis in the patient.

Answer 5

False, you’ll stabilize the head, but airway clearance is first!

Question 6

Second Line Intubation Technique

Answer 6

Nasopharyngeal Inutbation

Question 7

Third Line Intubation Technique

Answer 7

Fiber Optic Bronchoscope

Question 8

When is third line intubation (Fiber Optic Bronchoscope) mandatory to use?

Answer 8

• Subcutaneous Emphysema (major sign of traumatic dirutpion in the tracheobronchial tree).

Question 9

In the setting where we need an airway, but cannot intubate, what should we do?

Answer 9

Cricothyroidotomy

Question 10

What would cause an inability to intubate?

Answer 10

• Laryngospams
• Severe Maxillofacial Injuries
• Impacted Foreign Body

Question 11

Clinical Signs of Shock

Answer 11

• Low BP
• Fast Feeble Pulse
• Low Urinary Output (under 0.5 mL/kg/h)
• Pale, Cold, Shivering, Sweating, Thirsty, Apprehensive

Question 12

What can cause shock in trauma case?

Answer 12

• Bleeding (Hypovolemic-hemorrhagic)
• Pericardial Tamponade
• Tension Pneumothorax

Question 13

Physical Findings of Pericardial Tamponade

Answer 13

• Blunt or Penetrating Chest Trauma
• High CVP
• No Resp. Distress

Question 14

Physical Findings of Tension Pneumothorax

Answer 14

• Blunt or Penetrating Chest Trauma
• High CVP
• Severe Resp. Distress
• No Breath Sounds, Hyperresonant on one side
• Mediastinum is displaced to opposite side.

Question 15

Treatment of Hemorrhagic Shock with Big Trauma Center Nearby

Answer 15

First, Surgical removal of source

Then, Volume replacement

Question 16

Treatment of Hemorrhagic Shock without Big Trauma Center Nearby

Answer 16

First, Volume Replacement (2L LR -> PRBC until Urine Output 0.5-2.0 mL/kg/h)
* Watch for CVP! Do not want above 15 mmHg

Question 17

Management of Pericardial Tamponade

Answer 17

!Prompt Evacuation of Pericardial Sac, via;

• Pericardiocentesis
• Tube
• Pericadial Window
• Open Thoracotomy

*IV Fluids and Blood also helpful simultaneously.

Question 18

Management of Tension Pneumothorax

Answer 18

Start with Big Needle or Big IV Catheter into the Pleural Space
- Follow with Chest Tube with Underwater Seal

Question 19

This type of head trauma requires surgical intervention and repair of the damage. It involves piercing the skin/skull

Answer 19

Penetrating Head Trauma

Question 20

This type of skull fracture via head trauma does not require intervention if there is a closed wound. However, if there is an open wound, you can just close it and let it heal.

Answer 20

Linear Skull Fractures

Question 21

This type of skull fracture via head trauma requires surgical intervention.

Answer 21

• Comminuted Fractures

- Depressed Fractures

Question 22

An unconscious patient comes in with head trauma, what do you do? Why?

Answer 22

CT!!!

• Possible intracranial hematoma

Question 23

When a patient comes in with head trauma, CT is negative, and they are neurologically intact. When can they be discharged?

Answer 23

After 24 hours observation to make sure a coma doesn’t happen.

Question 24

Signs of Basilar Skull Fracture

Answer 24

• Racoon Eyes
• Rhinorrhea
• Otorrhea
• Ecchymosis behind ear

Question 25

Management of Basilar Skull Fracture

Answer 25

• Expectant Management
• Evaluate the Cervical Spine (CT Scan)

AVOID NASOPHARYNGEAL INTUBATION

Question 26

This type of hematoma occurs with modest trauma to the side of the head and has classic sequence of trauma.

Answer 26

Acute Epidural Hematoma

Question 27

Sequence of Head Trauma

Answer 27

• Unconsciousness
• Lucid interval
• Gradual lapsing into coma again
• Fixed dilated pupil (Usually on affected side)
• Contralateral hemiparesis with decerebrate posture.

Question 28

CT Scan Results of Acute Epidural Hematoma

Answer 28

• Biconvex, lens hematoma

Question 29

Treatment of Acute Epidural Hematoma

Answer 29

Emergency Craniotomy

Question 30

This type of hematoma appears as a more advanced version of an Acute Epidural Hematoma; appears sicker, more neurologic damage.

Answer 30

Acute Subdural Hematoma

Question 31

CT Scan Results of Acute Subdural Hematoma

Answer 31

Semilunar, crescent-shaped Hematoma

Question 32

Management of Acute Subdural Hematoma with midline deviation.

Answer 32

Craniotomy, but poor prognosis

Question 33

Management of Acute Subdural Hematoma without midline deviation.

Answer 33

Therapy to prevent further damage and increasing ICP.

• ICP Monitoring
• Elevate Head
• Hyperventilate
• Avoid Fluid Overload
• Mannitol or Furosemide (don’t diurese below systemic arterial pressure)

Question 34

What is it called when the CT Scan shows diffuse blurring of the gray-white matter interface and multiple small punctate hemorrhages.

Answer 34

Diffuse Axonal Injury.

Consistent with severe trauma.

Question 35

T/F: Without hematoma, there is no role for surgery.

Answer 35

True. Therapy would be to prevent further damage and monitor ICP.

Question 36

This type of hematoma occurs in the very old or in severe alcoholics. It is caused by a shrunken brain that is rattled around the head by minor trauma, tearing venous sinuses. After several days, mental function deteriorates as the hematoma forms.

Answer 36

Chronic Subdural Hematoma

Question 37

T/F: If a patient appears to be in hypovolemic shock with acute head trauma and the CT scan reveals a cranial hematoma, then this is the cause of the shock.

Answer 37

False. There is not enough space in the cranium to house enough blood to create shock.