Head Trauma Flashcards
What is the definition of head trauma?
Injury to scalp, skull, or brain
What is the definition of a traumatic brain injury (TBI)?
Injury to brain tissue / vessels with any change in mentation, no matter how brief, following head trauma
What mechanism of action (MOI) is the most common cause of TBI?
Falls (28%)
What are the three main components of the Glasgow Coma Scale (GCS)?
Eye Opening, Verbal Response, Motor Response
What is the point breakdown for Eye Opening in the GCS?
4 = Spontaneous 3 = To voice 2 = To pain 1 = None
What is the point breakdown for Verbal Response in the GCS?
5 = Normal conversation
4 = Disoriented conversation
3 = Words, but not coherent ("word salad")
2 = No words, only sounds
1 = NoneWhat is the point breakdown for Motor Response in the GCS?
6 = Normal 5 = Localizes to pain 4 = Withdraws to pain 3 = Decorticate posture 2 = Decerebrate posture 1 = None
Describe Decorticate posture
Flexor, arms like “Cs”, moves toward the “Cord”
Problems with cervical spinal tract or cerebral hemisphere
Describe Decerebrate posture
Extensor, arms like “e”
Problems within midbrain or pons
What is the following patient’s GCS score?
42 y/o M, eyes open after a car accident, slightly confused about events of accident (repetitive questioning), follows commands.
14 (loses point for verbal)
What is the following patient’s GCS score?
Will not open eyes to pain, moaning, when stimulated pulls arms to chest and becomes rigid
6 (1 for eyes, 2 for verbal, 3 decorticate posture = 6 GCS, pt will likely go to trauma center and be intubated, highly likely cerebral hemisphere/cortical spinal tract injury w/ high mortality)
A mild TBI is defined as a GCS of ____-____. Moderate TBI GCS? Severe TBI GCS? What type is the most common?
Mild 13-15 (most common)
Moderate 9-12
Severe 8 or less
What rules or criteria can be followed to determine if a pt requires a CT scan following a mild TBI? (children vs adults)
Canadian CT Head Rule
PECARN Pediatric Criteria
According to the Canadian CT Head Rule, what are the high risk findings that would indicate that a CT head is indicated in a pt with a minor head injury? (hint: 5)
- GCS score < 15 at 2 hours post-injury
- Suspected open or depressed skull fx
- Any sign of basal skull fx
- Vomiting > or = 2 episodes
- Age > or = 65 y/o
According to the Canadian CT Head Rule, what are the medium risk findings that would indicate that a CT head is indicated in a pt with a minor head injury? (hint: 2)
- Amnesia before impact > or = 30 min
2. Dangerous mechanism
What are considered signs of basal skull fx?
Hemotympanum, “raccoon eyes”, CSF otorrhea/rhinorrhea, Battle’s sign
What are examples of “dangerous mechanism”?
Pedestrian struck by vehicle, occupant ejected, fall from >2x height/3ft/or 5 stairs
What is Battle’s sign?
Mastoid ecchymosis
PECARN is the largest study ever done in emergency medicine in children, and there is one rule for kids under ___ y/o and one for kids over ___ y/o
2 y/o
T/F All pts with a moderate or severe TBI get a CT scan performed
True
T/F All pts with a moderate or severe TBI are admitted for observation (why or why not?)
True, high potential for decompensation
Diffuse axonal injury (DAI) occurs most frequently during what type of injury mechanism?
Deceleration injury
What are some examples of impact injuries?
Cerebral or brainstem contusions
Cerebral lacerations
Immediate hematomas
Diffuse axonal injury (DAI)
What are some examples of secondary injuries?
Intracranial hematoma
Edema
Ischemia
What type of imaging study is best for visualizing blood and bone?
CT Scan
Can you visualize a concussion on CT scan?
No, there is no good study for dx of a concussion and the dx is usually clinical
T/F Surgery is not often required even if there is a significant intracranial mass lesion
False, surgery is typically required when there is a significant intracranial mass lesion present
Does an epidural hematoma affect more men or more women? At what ratio?
Men, 4:1
The ____(vessel)____ is responsible for EDH ~85% of the time
Middle meningeal artery
EDH comprise ~___% of head trauma admissions
1%
Mortality ranges from ___-___% with optimal management of EDH
5-10%
What is a lucid interval? With what condition is it associated with?
A period of improvement or wellness (~1 hour)
“Talk then die”
Associated with EDH
A subdural hematoma (SDH) is more or less common than an EDH?
More common by ~2x
What are the common sources of bleeding in a SDH?
Bridging veins and cortical lacerations
What is the mortality of SDH? (%)
50-90%
Is the clinical course of SDH fast or slow?
Slow, with subtle sx, can worsen progressively over weeks
What age population is SDH most common in?
The elderly
What are the “shapes” of EDH and SDH, respectively?
EDH = football SDH = crescentic
Are cerebral contusions often associated with mass effect?
No, they often have little mass effect
T/F Cerebral contusions are not often operative
True
What is the focus on in regards to non operative management of cerebral contusions? What is the goal?
Focus: Reducing pressure and secondary damage
Goal: Goal is maintain Central Perfusion Pressure (>50 is normal) (CCP)
CCP = ___ - ___
CCP = MAP - ICP
ICP increase = (more/less) flow
Less
What are the three components of Cushing’s Reflex?
Systolic BP increase
Bradycardia
Irregular respirations
What is the most important component of nonoperative management in head trauma pts?
FREQUENT neuro checks!
in addition to ICP monitoring
What are possible indications for ICP monitoring?
Loss of neurological examination i.e. due to sedation or general anesthesia
Therapy for Intracranial HTN includes Tier 1 and Tier 2 therapies. What are examples of each?
First tier: Positioning (elevate head of bed) Ventricular drainage Osmotic diuresis (to reduce edema) Hyperventilation
Second tier: Sedation have brain less active to use less glucose Neuromuscular blockade Hypothermia Barbiturate coma
T/F Glucocorticoids are recommended as part of tx of intracranial HTN
False, they are NOT recommended
What are the two major types of potential surgical lesions?
Epidural and Subdural hematomas
In the approach to head injuries, you as a provider should always first perform your exam and assess the patient’s GCS, then determine if their injury is mild / mod / severe (to image or not to image), determine any necessary surgical intervention, and then admit ___ and ___ TBI pts.
Moderate and severe
A palpable radial pulse indicates a systolic BP of at least ____-____ mmHg, which is “good enough” for a mass casualty triage setting
80-90mmHg
