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Block 3 > Head Trauma > Flashcards

Head Trauma Flashcards

1
Q

What are the different levels of the Glasgow Outcome Score?

A
  1. Dead
  2. Vegetative state: sleep/wake cycle but not sentient
  3. Severely disabled: conscious but dependent
  4. Moderately disabled: independent but disabled
  5. Good recovery: may have minor sequelae
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2
Q

How quickly do head trauma patients reach their final outcome?

A

2/3 reach it within 3 months and 90% within 1 year

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3
Q

What are the common findings of head trauma patients in hospital facilities?

A

70% have raised ICP

60% have an intracranial haematoma

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4
Q

Why is Advanced Trauma Life Support (ATLS) (ABDCE response) so important with head injury?

A

Further damage occurs due to ischaemic damage from hypoxia or hypotension and death is often a/w extracranial complications (1/3 patients post-fall or RTA)

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5
Q

How can you manage uncomplicated head injuries?

A

ABC (especially A is unconscious) following ATLS guidelines

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6
Q

What questions should we ask ourselves with a uncomplicated head injury?

A
  • Is the injury diffuse or local?
  • Is there a skull fracture? - present in 2% of trauma attendees (can be good as takes away some ICP)
  • Is the patient improving or deteriorating?
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7
Q

How do you know if a coma state is due to the injury or alcohol?

A

Detectable mental confusion from alcohol abuse occurs when blood alcohol exceeds 200mg/100mls which falls to 10-15mg/hr thus, a coma lasting > few hours should not be ascribed to alcohol alone until other causes have been excluded

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8
Q

How should you manage unconscious patients?

A

Aim to prevent secondary brain damage from impaired cerebral oxygenation by avoiding hypoxia (AB) and hypotension (C)

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9
Q

How is a skull fracture significant?

A

Much higher risk of acute haematoma occurring than if the patient does not have a skull fracture

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10
Q

What is a lucid interval?

A

If a patient gets a head injury, skull fracture and then bleed there is a period where they feel generally okay afterwards - some patients go home and die in their sleep instead of going to hospital

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11
Q

What should you look for in a normal CT head scan?

A

Symmetry
Ventricles
Basal cistern

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12
Q

What options are there to remove raised intracranial pressure (ICP)?

A
  1. Leave bleed if GCS is good and if bleed is most likely not chronic (e.g. subdural bleeds)
  2. Lumbar puncture to remove CSF
  3. Decompress using a EVD drain
  4. Craniectomy if ICP too high - take side of skull off, put it in abdomen for 6 weeks to keep alive and replace
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13
Q

When should a haematoma be drained?

A

If there is a significant midline shift and ventricles/basal cistern are not visible

Clinical situation e.g. very low GCS

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14
Q

What is a contusion?

A

Swollen ischaemic brain with some bleeding into it - can swell after a few days causing problems so keep patient in hospital for up to 2 weeks

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15
Q

How do you treat a contusion if the brain keeps swelling?

A
  1. Decompression craniectomy

2. Suck out that part of the brain

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16
Q

What is a diffuse axonal injury?

A

Head injury in which scattered lesions in white matter tracts as well as gray matter occur at interface over a widespread area - also called Axon Shear (post-concussion syndrome) caused by trauma that causes axons to twist and tear resulting in permanent death of brain cells

17
Q

Why might a diffuse axonal injury look better but have a worst outcome than other head injuries?

A

Little contusions around grey-white matter interface can indicate widespread damage taking out connections in brain so it does not function properly

18
Q

If a head injury has affected the centre of the brain, what does this tell you?

A

Massive rotatory force has been applied to affect the centre of the brain e.g. in brainstem

19
Q

Cerebrospinal Fluid (CSF) is constantly produced so why does the intracranial pressure (ICP) not increase?

A

Excessive CSF is displaced through the spinal canal particularly in the lumbar system meaning the cranial vault usually has a fixed volume (eventually this displacement will reach maximum capacity if something goes wrong e.g. bleed)

20
Q

What can increase in the brain to raise intracranial pressure (ICP)?

A

Brain
Blood
CSF
Mass lesion

21
Q

How is intracranial pressure (ICP) monitored?

A

ICP monitor in skull

22
Q

How should patients with raised intracranial pressure (ICP) be treated?

A
  • ICP monitoring in comatose patients with severe head injury
  • Should treat when >20/25mmHg
  • Maintain cerebral perfusion pressure (CPP = MAP-ICP) to reduce mortality In severe head injury
23
Q

What is the normal intracranial pressure (ICP)?

A

0-10mmHg

24
Q

What time of patients would a slightly raised intracranial pressure (ICP) harm significantly?

A

Hypotensive patients as they have to reserve and need blood perfusing the brain

25
Q

What are 2 significant ways to decrease mortality in critical care management of severely brain injured patients?

A

ICP monitoring

ICP control

26
Q

Why do you want to keep lower levels of CO2 in head injury patients?

A

High levels of PaCO2 (>4.5kPa) will mean arterials will dilate everywhere including the brain and this will be detrimental if there is already raised ICP - can happen if patient is not breathing so check AB

27
Q

What fluid management do you want to give to a head injury patient?

A

NORMOVOLAEMIC - do not keep dry as there is risk of hypotensive episodes causing a fall in cerebral perfusion and SIRS/MOF leading to failure of oxygenation and ventilation

28
Q

How can you prevent a primary head injury becoming a secondary injury?

A

By looking after O2, CO2 etc.

29
Q

What types of secondary injury processes can occur?

A
  1. Intracranial HPN

2. Cerebral ischaemic (global or regional)

30
Q

What type of secondary ischaemic insults can occur?

A
  1. Decreased O2 delivery via decreased CBF (e.g. increased ICP)/CaO2 (e.g. anaemia) and increased consumption (e.g seizures).
31
Q

Why should free water (as dextrose solution) not be administered to head injury patients?

A

Decrease plasma osmolality increasing water content of brain tissue as BBB is acting as a semipermeable membrane

32
Q

Why is elevated blood sugar dangerous to head injury patients?

A

Associated with worsening of neurological injury after episodes of global cerebral ischaemia as ischaemic brain metabolises glucose to lactic acid, lowering tissue pH and exacerbating ischaemic injury

33
Q

What mental sequelae can arise from head injury?

A 
Personality disorders
Memory disorders
Reduced reasoning power
Apathy/lack of drive
Temper tantrums 
Family disruption
34
Q

Why is mental sequelae a problem in patients recovering from head injury?

A

Features of post-traumatic mental dysfunction create problems in rehabilitation as patients lack the motivation, insight and capacity to cope with therapeutic programmes w/o constant prompting

35
Q

What other more focal damage can occur as a result of head injury?

A

Hemispheric sequelae (e.g. hemiplegia, sensory deficits, hemianopia)

CN palsies:

  • Anosmia (occurs in 10%)
  • CNVIII n. injury (most commonly damaged and may persist for months)
36
Q

What symptoms will cranial nerve (CN) VIII nucleus injury cause?

A

Vertigo

Nystagmus

37
Q

What is the significant factor determining ultimate handicap in brain damaged patients?

A

Mental disability rather than physical disability - severely disabled patients have little life expectancy reduction which is important in assessing damages

Block 3 (40 decks)

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