Head Trauma Part 2 Flashcards
What is the New Orleans Head CT Rules (who to image?)
- HA
- Vomiting
- Age >60
- Alcohol/drug intoxication
- Short term memory deficits
- Visible trauma above the clavicles
- Seizures
- (head trauma w/ GCS 15)
Presentation of Epidural bleeds
- Immediate LOC w/ lucid period prior to deterioration/ second LOC
- Young>old
- High pressure ARTERIAL bleeding can cause brain herniation in a few hours
Presentation of Subdural bleeds
- rapid LOC (*No LOC in elderly common)
- lucid period possible
- Increased risk in the elderly and alcoholic pts
Presentation of Subarachnoid bleeds
- Mild, moderate or severe TBI with
- meningeal signs and sx
- Any age group after blunt trauma
- HA
- Nausea
- photophobia
Presentation of Head Contusions
- Sx range from normal to LOC
- any age group after blunt trauma
- neurologic deficits, confusion or coma
Presentation of Diffuse Axonal Injury (DAI) bleeds
- Obtunded
- associated w/ post-traumatic coma
- Any age group after blunt trauma
Common Cause of Epidural bleeds
- Skull fracture with tear of the middle meningeal artery
* fast bleed
*Caused by blunt trauma temporal region
Common Cause of Subdural bleeds
Acceleration-deceleration with tearing of the bridging veins
*slow bleed
*Brains w/ extensive atrophy are at increased risk (elderly and alcoholics)
Common Cause of Subarachnoid bleeds
Acceleration-deceleration with tearing of the subarachnoid vessels
*Common with contusions, other injuries
Common Cause of contusions
- Severe or penetrating trauma; shaken baby syndrome
- Coup or Contracoup injury (ie. car accident- hit and counter hit)
Common Cause of diffuse axonal injury (DAI)
- Severe blunt trauma;
- shaken baby syndrome;
- Rotational acceleration and then deceleration
CT findings of Epidural bleed
Biconvex, football-shaped hematoma
- can cross midline
- arterial blood
CT findings of Subdural bleed
Crescent- or sickle-shaped hematoma
*does not cross the midline
*venous
CT findings of Subarachnoid bleed
Blood in the basilar cisterns and hemispheric sulci and fissures
CT findings of a brain contusion
May be normal initially with delayed bleed
- Contused area is usually hemorrhagic with surrounding edema
- Depending on location may cause herniation
CT findings of diffuse axonal injury
May be normal or punctae hemorrhagic injury**
*More commonly found on MRI
Collection of blood in the potential space between the dura and skull
epidural hematoma
Acceleration-deceleration of the brain with tearing of the bridging VEINS beneath the dura
subdural hematomas
In infants ___is associated w/ non accidental trauma
subdural hematomas
Tx of subdural hematomas
surgical evacuation of epidurals and acute SDH
-burr holes if concern for herniation
Basilar skull fractures usually occurs through the ___ of the skull base and is associated with __ and __
anterior fossa
TM rupture and torn dura
Clinical findings of basilar skull fractures
- CSF otorrhea, rhinorrhea
- Raccoon eyes (bilateral)
- Periorbital ecchymosis - Battle’s sign
- bruising over the mastoid, - hemotympanum
- deafness
- Vertigo
What is Battle’s sign
bruising over the mastoid
What should you do with a basilar skull fx
Consult with neurosurgery regarding antibiotic coverage and admission
Focal trauma to parenchymal blood vessels leading to petechial hemorrhages and surrounding edema
brain contusion
___ lobe is most commonly affected in brain contusions
frontal
Herniation sx of early brainstem
- small sluggish pupils
- decorticate posturing
- cheyne-stokes respiration
Herniation sx of late brainstem
- pupils fixed and dilated
- flaccidity
- slow or apneic breathing
What is decorticate posturing associated with?
corticospinal dysfunction/disruption
What is decerebrate posturing associated with?
brainstem dysfunction, worse prognosis than decorticate
Arms abducted and flexed against chest, legs are plantar flexed with knees extended
Decorticate posturing
Arms adducted, pronated and wrist flexion, legs are plantar flexed with knees extended
Decerebrate posturing
Describe the GCS
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
Most common CT abnormality in patients with mod/severe TBI
Subarachnoid hemorrhage
Injuries occur at interface of white and grey matter with axonal shear injury occurring and subsequent edema
Diffuse Axonal Injury
Describe the initial management of traumatic brain bleed and/or skull fracture
- Consult Trauma and Neurosurgery
- Seizure prophylaxis (Keppra)
- IV ABX if open skull fracture
- Repeat stat CT head if neuro changes
- Correct any condition which aggravates an existing brain injury
- Hypotension –> maintain normal BP
- Hypoxia –> maintain airway and ventilation
