LOC/Coma Flashcards
- What is a concussion?
- Caused by?
- What does this result in?
- Resolution of clinical & cognitive sx follows a _______course?
- Associated w/ what?
- Trauma induced alteration in mental status may or may not involve loss of consciousness:
- Caused by direct blow to head, face, neck or body
- Result in neuropathological changes—functional not structural
- sequential
- grossly normal neuroimaging studies
Glasgow Coma Scale
See picture
- What is a TBI?
- MIld TBI is measured how?
- Moderate is measured how?
- Severe is measured how?
- Traumatic Brain Injury (TBI): Head injury due to contact and/or acceleration and/or deceleration forces
- Mild: GCS—13-15 measured 30 min after injury
- Moderate: GCS—9-12 4. Severe: GCS
Pts at high risk for a TBI?
Patients at higher risk: less than 5YO and > 60YO
Etiologies of TBI? 7
- MVAs (20-45%)
- Falls (30-38%–increasing in the older patient)
- Occupational accidents (10%)
- Recreational accidents (10%)
- Assaults (5-17%–increasing)
- Contact sports—U.S.: 1.6-3.8 million sports-related concussions
- Soldiers in combat
- Cortical contusion (direct trauma) is what?
- Severe is characterized pathologically how?
- Mild?
- -Coup-direct blow to brain -Contrecoup-injury to brain on opposite side of brain
- axonal rupture
- Mild: diffuse axonal injury:
What kind of axonal injury occurs in mild Cortical contusion? 2
- Disruption of axonal neurofilament organization
- Impairs axonal transport and leads to axonal swelling
Describe the closed head injury (coup and contracoup)
Secondary and Primary impact
Secondary Brain Injury
- Begins when?
- Continues for how long?
- Begins quickly after primary phase
- Continues for hours to days
Secondary Brain Injury: Cascade of molecular injury mechanisms? 5
- Neurotransmitter-mediated excitotoxicity causing glutamate, free-radical injury to cell membranes
- Electrolyte imbalances
- Mitochondria dysfunction
- Apoptosis
- Secondary ischemia from vasospasm, focal microvascular occlusion and vascular injury
Clinical Features of TBI 4
Associated symtpoms? 4
- (+) or (-) LOC,
- confusion,
- stupor,
- amnesia
- Headache
- Dizziness
- Disorientation
- Nausea and vomiting
Signs w/ TBI 7
- Vacant stare
- Inability to focus
- Gross incoordination
- Memory difficulties
- Delayed verbal expression
- Slurred or incoherent speech
- Emotionality out of proportion to events
What symptoms Indicates more serious brain injury or rising intracranial pressure (ICP)? 6
- Seizures
- Focal neurologic signs
- Worsening HA, confusion, lethargy
- Protracted N/V
- Other injuries to head and neck
- Decreasing GCS
Amnesia almost always involves loss of memory of traumatic event and frequently includes loss of recall for events immediately before and after trauma. What does this tell us about the severity of the injury?
The longer the frame of amnesia the more serious the injury**
Guidelines for CT Scan in the ER 9
- GCS less than 15
- Open or depressed skull fracture
- Any sign of basilar skull fracture: CSF Leak, etc
- Two or more episodes of vomiting
- 65 years of age or older
- Amnesia before impact of 3 or more minutes
- Dangerous mechanism (ejected from vehicle, fall > 3 ft)
- Bleeding diathesis or on oral anticoagulant
- Seizure or focal neurologic sign Intoxication
CT scan abnormalities indicating TBI? 4
- Subdural hematoma
- Intracranial bleeding
- Cerebral edema
- Skull fracture
Review of brain injuries
See picture
Management of TBI: Hospitalization for those at risk? (who should we admit) 4
- GCS less than 15 or deteriorating
- Abnormal CT 3. Seizures
- Abnormal bleeding parameters
If the pt has a GCS of 13-15 and a normal CT sacn what can we do?
Outpatient: (must have RESPONSIBLE companion!)
Outpatient Observation: Why would we have to have them come back to the ER? 7
- Somnolence or confusion
- Difficulties w/ vision, severe or worsening HA
- Urinary or bowel incontinence
- Weakness or numbness involving any body part
- Unsteadiness or seizures
- Nausea/vomiting more than 2 episodes
- Allow the patient to rest as needed but check on the patient and if any of the above occur return to ED
Sequelae from TBI What are the some of these? 7
- Post-concussion syndrome
- Post-traumatic headaches
- Post-traumatic seizures/epilepsy
- Post-traumatic vertigo
- Other cranial nerve injuries
- Second impact syndrome
- Cumulative neuropsychological impairment:
- What are raccoon eyes a sign of?
- What is the battle sign a sign of?
- What does blood behind the TM tell us?
- basilar skull fracture
- Subdural hematoma
- Hemitympani- CSF flud coming out of nose or ears
- What is post concussion syndrome?
- Symptoms? 4
- direct brain injury/psychogenic
2.
- Headache
- Dizziness
- Neuropsychiatric
- Cognitive impairment including noise sensitivity
PCS diagnosis? 2
Treatment? 4
- Clinically and w/ history
- If severe sx and patient hasn’t had MRI-get one!
- Education, education, education!!!
- Minimize meds, but use appropriately—low dose
- Typically resolves by 3 months 90% of the time\
- May need more extensive neurocognitive rehab
What is the definition of a Coma?
“unarousable and unresponsive” Lasts > 1 hour
Common etiologies of coma? 6
- TBI
- Hypoxic-ischemic encephalopathy (HIE)- heart is going brain is not
- Drug overdose
- Intracranial hemorrhage
- CNS infections
- Brain tumors
Primary cerebral disorders:
Bilateral? 8
Unilateral? 4
- TBI
- Malignancy
- Ischemia
- Infections
- Hemorrhage
- Status epilepticus
- HIE
- Hydrocephalus
- Trauma (subdural hematoma, etc)
- Large hemispheric stroke
- Cerebral abscess
- Tumor
Coma Pathophysiology is caused by lesions that affect what?
Focal lesions to the upper brainstem can alter alertness by damaging the ARAS -Ascending reticular activating system (ARAS)
Coma: Obtained from family, witnesses, medical personnel, questions to ask? 5
- Time course of LOC
- Focal signs or symptoms precede?
- Did patient have previous neurologic episode?
- Recent illness, fever, HA, falls, confusion?
- Prescription drugs, illicit drugs or alcohol?
Coma: PE? 4
- LOC
- Brainstem reflexes
- Pupillary light, extra-ocular and corneal reflexes
- Motor exam
What should we do on the motor exam?3
- Assess muscle tone
- Spontaneous and elicited movement- note if asymmetric
- Reflexes
- Describe decorticate posturing.
- Wheres the dysfunction?
- Prognosis?
- UE adduction, (flexion at the elbows and fingers) with LE extension (plantar flexion and inversion
- Dysfunction of cerebral cortex or thalamic damage
- (better prognosis)
- Describe Decerebrate posturing?
- Where is the dysfunction?
- Prognosis?
- UE extension, adduction and pronation with LE extension
- Injury to caudal diencephalon, midbrain or pons
- Poorer prognosis
What is Cheyne-stokes and what is it seen in 2?
- cyclic pattern, hypernea and apnea—
- seen patients w/ -bilateral hemispheric or -diencephalic insults
Hyperventilation happens in an injury to what? 2
- injury to pontine or
- midbrain tegmentum
What is Apneustic breathing and where is the injury? 2
- prolonged pause end of inspiration
- indicates lesions to mid- and caudal pons
What is Ataxic breathing and what is it an injury to?
- irregular in rate an tidal volume
- damage to medulla
Goal: identify treatable causes? 5
Treatment? 5
- Infection,
- metabolic abnormalities,
- seizures,
- intoxications/overdoses,
- surgical lesions
- Give O2,
- thiamin,
- fluids,
- Narcan,
- glucose
What do Papilledema/focal neurologic findings suggest?
structural etiology—urgent brain CT
Diagnosis of coma: What labs should we order? 6
- Complete blood count
- Electrolytes,
- glucose,
- thyroid,
- kidney and liver function
- Carbon monoxide poisoning
- Drug or alcohol overdose
Management of Cma? 3
INDENTIFY TREATABLE CAUSE
- Protect airway
- Hydrate
- Monitor blood glucose and electrolytes
