Head Trauma Flashcards
What types of brain injury are there?
1) Primary brain injury
- Focal pathology
- Lesions of the scalp, skull and dura, lacerations
- Surface contusions: coup, contrecoup
- Intracranial haematoma: extradural, intradural (SAH, subdural, intracerebral)
- Diffuse axonal injury (DAI) associated with acceleration-deceleration injuries
- Secondary brain injury
- Raised ICP
- Hypoglycaemia and hyperglycaemia
- Seizures
- Hypoxic damage
- Hypotension
- Hypoxia and hypercarbia
- Anaemia
- Cerebral oedema
Give some examples of symptoms associated with head trauma.
Physical symptoms
- Headache - Vomiting* (continuing vomiting) - Drowsiness/fatigue* (difficulty waking) - Bleeding/discharge from ear or nose* - Fits/seizures/twitching/convulsions* - Blurred/double vision* - Poor coordination/clumsiness/weakness* - Difficulty swallowing, coughing when eating or drinking* - Noise sensitivity
Behavioural and emotional symptoms
- Irritable/frustrated/mood swings - Anxiety/fear - Changed sleep patterns
Cognitive or communication symptoms
- Cognitive fatigue: difficulty concentrating, slower - Memory problems/confusion/loss of orientation* - Slurred speech*
Aside from the GCS, what can you use to assess conscious state of a patient?
- AAlert
- VResponds to voice
- PResponds to pain - use firm supraorbital pressure/jaw thrust as stimulus
- Purposefully
- Non-purposefully
□ Withdrawal/flexor response
□ Extensor response
- UUnresponsive
+ Assess pupil size, equality and reactivity
Secondary survey: what might you look for in the eyes?
○ Pupil size ○ Equality ○ Reactivity ○ Fundoscopy for retinal haemorrhage (may indicate non-accidental injury) ○ Dilated non-reactive pupil
What are some signs of a base of skull fracture?
- Raccoon eyes
- Battle’s sign: bruising behind ear
- Blood behind ear drum
- CSF leak - ears, nose
What does a dilated non-reactive pupil indicate?
3rd nerve palsy from ipsilateral intracranial haematoma until proven otherwise
What are definite indications for a CT brain and C-spine in head trauma?
- Any sign of basal skull fracture on secondary survey
- Focal neurological deficit
- Suspicion of open or depressed skull fracture
- Unresponsive or only responding non-purposefully to pain
- GCS persistently < 8
- Respiratory irregularity/loss of protective laryngeal reflexes
What are relative indications for a CT brain and C-spine in head trauma?
- Loss of consciousness lasting more than 5 minutes (witnessed)
- Amnesia (antegrade or retrograde) lasting more than 5 minutes
- Persistent vomiting
- Clinical suspicion of non-accidental injury
- Post-traumatic seizures (except a brief ( <2 min) convulsion occurring at time of the impact)
- GCS persistently less than 14, or for a baby under 1 year GCS (paediatric) persistently less than 15
- If under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head
- Dangerous mechanism of injury
- high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant,
- fall from a height.
• Known bleeding tendency
Other than imaging, what are some investigations that are always done for head trauma?
- VBG and blood sugar level (especially in small children and in adolescents who have been drinking alcohol)
- ECG (query arrhythmia as cause of fall)
Minor head injury:
- AVPU~GCS?
- Conscious state
- Other features
- AVPU ~ GCS 13-15
- No LOC, stable and alert conscious state
- Up to one episode of vomiting
- May have scalp bruising or laceration
Moderate head injury:
- AVPU~GCS?
- Conscious state
- Other features
- AVPU ~ GCS 9-12
- Brief LOC at time of injury
- Currently alert or responds to voice
- May be drowsy
- Two or more episodes of vomiting
- Persistent headache
- Up to one single brief ( <2min) convulsion occurring immediately after the impact
- May have a large scalp bruise, haematoma or laceration
- Visual disturbance
Severe head injury:
- AVPU~GCS?
- Conscious state
- Other features
- AVPU ~ GCS 3-8
- Decreased conscious state – responsive to pain only or unresponsive
- Localising neurological signs (unequal pupils, lateralising motor weakness)
- has a second seizure, convulsion or fit, other than a single brief one when the injury happened
- Signs of increased intracranial pressure
- Penetrating head injury
- CSF leak from nose or ears
What are some signs of increased ICP?
- Uncal herniation: Ipsilateral dilated non-reactive pupil due to compression of the oculomotor nerve
- Central herniation: Brainstem compression causing bradycardia, hypertension and widened pulse pressure (Cushing’s triad)
- Irregular respirations (Cheynes-Stokes)
- Decorticate: arms flexed, hands clenched into fists, legs extended, feet turned inward
- Decerebrate: head arched back, arms extended by the sides, legs extended, feet turned inward
When do you intubate a trauma patient?
○ Child unresponsive or not responding purposefully to pain
○ GCS persistently <8
○ Loss of protective laryngeal reflexes
○Respiratory irregularity
What kind of feeding tube should you give a head trauma patient?
OGT (NGT to avoid in case it is a base of skull fracture!)
