Head Trauma Part 2

Question 1

What is the New Orleans Head CT Rules (who to image?)

Answer 1

1. HA
2. Vomiting
3. Age >60
4. Alcohol/drug intoxication
5. Short term memory deficits
6. Visible trauma above the clavicles
7. Seizures
8. (head trauma w/ GCS 15)

Question 2

Presentation of Epidural bleeds

Answer 2

1. Immediate LOC w/ lucid period prior to deterioration/ second LOC
2. Young>old
3. High pressure ARTERIAL bleeding can cause brain herniation in a few hours

Question 3

Presentation of Subdural bleeds

Answer 3

1. rapid LOC (*No LOC in elderly common)
2. lucid period possible
3. Increased risk in the elderly and alcoholic pts

Question 4

Presentation of Subarachnoid bleeds

Answer 4

1. Mild, moderate or severe TBI with
2. meningeal signs and sx
3. Any age group after blunt trauma
4. HA
5. Nausea
6. photophobia

Question 5

Presentation of Head Contusions

Answer 5

1. Sx range from normal to LOC
2. any age group after blunt trauma
3. neurologic deficits, confusion or coma

Question 6

Presentation of Diffuse Axonal Injury (DAI) bleeds

Answer 6

1. Obtunded
2. associated w/ post-traumatic coma
3. Any age group after blunt trauma

Question 7

Common Cause of Epidural bleeds

Answer 7

1. Skull fracture with tear of the middle meningeal artery
   * fast bleed

*Caused by blunt trauma temporal region

Question 8

Common Cause of Subdural bleeds

Answer 8

Acceleration-deceleration with tearing of the bridging veins
*slow bleed

*Brains w/ extensive atrophy are at increased risk (elderly and alcoholics)

Question 9

Common Cause of Subarachnoid bleeds

Answer 9

Acceleration-deceleration with tearing of the subarachnoid vessels

*Common with contusions, other injuries

Question 10

Common Cause of contusions

Answer 10

• Severe or penetrating trauma; shaken baby syndrome

- Coup or Contracoup injury (ie. car accident- hit and counter hit)

Question 11

Common Cause of diffuse axonal injury (DAI)

Answer 11

1. Severe blunt trauma;
2. shaken baby syndrome;
3. Rotational acceleration and then deceleration

Question 12

CT findings of Epidural bleed

Answer 12

Biconvex, football-shaped hematoma

• can cross midline
• arterial blood

Question 13

CT findings of Subdural bleed

Answer 13

Crescent- or sickle-shaped hematoma
*does not cross the midline

*venous

Question 14

CT findings of Subarachnoid bleed

Answer 14

Blood in the basilar cisterns and hemispheric sulci and fissures

Question 15

CT findings of a brain contusion

Answer 15

May be normal initially with delayed bleed

• Contused area is usually hemorrhagic with surrounding edema
• Depending on location may cause herniation

Question 16

CT findings of diffuse axonal injury

Answer 16

May be normal or punctae hemorrhagic injury**

*More commonly found on MRI

Question 17

Collection of blood in the potential space between the dura and skull

Answer 17

epidural hematoma

Question 18

Acceleration-deceleration of the brain with tearing of the bridging VEINS beneath the dura

Answer 18

subdural hematomas

Question 19

In infants ___is associated w/ non accidental trauma

Answer 19

subdural hematomas

Question 20

Tx of subdural hematomas

Answer 20

surgical evacuation of epidurals and acute SDH

-burr holes if concern for herniation

Question 21

Basilar skull fractures usually occurs through the ___ of the skull base and is associated with __ and __

Answer 21

anterior fossa

TM rupture and torn dura

Question 22

Clinical findings of basilar skull fractures

Answer 22

1. CSF otorrhea, rhinorrhea
2. Raccoon eyes (bilateral)
   - Periorbital ecchymosis
3. Battle’s sign
   - bruising over the mastoid,
4. hemotympanum
5. deafness
6. Vertigo

Question 23

What is Battle’s sign

Answer 23

bruising over the mastoid

Question 24

What should you do with a basilar skull fx

Answer 24

Consult with neurosurgery regarding antibiotic coverage and admission

Question 25

Focal trauma to parenchymal blood vessels leading to petechial hemorrhages and surrounding edema

Answer 25

brain contusion

Question 26

___ lobe is most commonly affected in brain contusions

Answer 26

frontal

Question 27

Herniation sx of early brainstem

Answer 27

1. small sluggish pupils
2. decorticate posturing
3. cheyne-stokes respiration

Question 28

Herniation sx of late brainstem

Answer 28

1. pupils fixed and dilated
2. flaccidity
3. slow or apneic breathing

Question 29

What is decorticate posturing associated with?

Answer 29

corticospinal dysfunction/disruption

Question 30

What is decerebrate posturing associated with?

Answer 30

brainstem dysfunction, worse prognosis than decorticate

Question 31

Arms abducted and flexed against chest, legs are plantar flexed with knees extended

Answer 31

Decorticate posturing

Question 32

Arms adducted, pronated and wrist flexion, legs are plantar flexed with knees extended

Answer 32

Decerebrate posturing

Question 33

Describe the GCS

Answer 33

Eye opening:
4-spontaneous, 3- to speech, 2- to pain, 1- no response

Verbal Response:
5- alert and oriented, 4- disoriented conversation, 3- speaking but nonsensical, 2- moans or unintelligible sounds, 1- no response

Motor Response:
6-follows commands, 5- localizes pain, 4- movement or w/d to pain, 3- decorticate flexion, 2- decerebrate extension, 1- no response

Question 34

Most common CT abnormality in patients with mod/severe TBI

Answer 34

Subarachnoid hemorrhage

Question 35

Injuries occur at interface of white and grey matter with axonal shear injury occurring and subsequent edema

Answer 35

Diffuse Axonal Injury

Question 36

Describe the initial management of traumatic brain bleed and/or skull fracture

Answer 36

1. Consult Trauma and Neurosurgery
2. Seizure prophylaxis (Keppra)
3. IV ABX if open skull fracture
4. Repeat stat CT head if neuro changes
5. Correct any condition which aggravates an existing brain injury
6. Hypotension –> maintain normal BP
7. Hypoxia –> maintain airway and ventilation