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EM RAP-Becoming a badass ER PA > Major head trauma > Flashcards

Major head trauma Flashcards

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1
Q

The goal of treatment in patients with major head trauma is to prevent secondary injury to the brain, primarily through avoidance of _______ and ______

A

hypotension, hypoxia

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2
Q

After the initial airway management and resuscitation, the focus is to identify injuries amenable to surgical therapy such as ________, subdural hematoma (SDH) and traumatic hydrocephalus

A

epidural hematoma (EDH)

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3
Q

After the initial airway management and resuscitation, the focus is to identify injuries amenable to surgical therapy such as epidural hematoma (EDH), _________ and traumatic hydrocephalus

A

subdural hematoma (SDH)

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4
Q

After the initial airway management and resuscitation, the focus is to identify injuries amenable to surgical therapy such as epidural hematoma (EDH), subdural hematoma (SDH) and ________

A

traumatic hydrocephalus

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5
Q

Elevation of the head of the bed by ______ (reverse Trendelenburg position) helps to decrease intracranial pressure (ICP) and improves oxygenation.

A

20 degrees

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6
Q

________ is utilized as a means to reduce ICP only in the scenario of impending herniation and death; it causes cerebral vasoconstriction and exacerbates brain ischemia

A

Hyperventilation

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7
Q

_______ injury is closely associated with major head trauma; cervical spine imaging with the initial head CT is indicated

A

Cervical spine

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8
Q

_______ is an injury that occurs at the time of the insult (e.g. the actual traumatic incident itself).
Primary injury is generally considered irreversible

A

Primary injury

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9
Q

Our aim is to prevent ________, which is the ongoing and progressive damage that occurs to brain tissue after the injury itself.

A

secondary injury

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10
Q

_______ occurs as a result of many factors, including impaired blood flow, edema, release of excitatory neurotransmitters and neurotoxins.

A

Secondary injury

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11
Q

______ is the pressure within the skull.

A

Intracranial pressure

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12
Q

The effects of increased ______ include headache, and possible neurologic dysfunction.

A

ICP

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13
Q

increasing ICP will force the brain to ________ (slide out of) the skull through the foramen at the bottom of the skull.

A

herniate

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14
Q

________ is the difference between mean arterial pressure (MAP) and intracranial pressure (ICP).

A

Cerebral perfusion pressure (CPP)

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15
Q

Cerebral perfusion pressure (CPP)

can be calculated using the following equation:

A

CPP = MAP - ICP

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16
Q

In the injured brain, cerebral autoregulation is impaired, so changes in ______are felt more directly by the brain

A

MAP

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17
Q

If the CPP falls too _____, ischemia and infarction of uninjured brain can occur.

A

LOW

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18
Q

The management of ________ in patients with major brain injury reflects the delicate balance between MAP, CPP and ICP.

A

blood pressure

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19
Q

CPP cannot be measured directly in the ED but when ICP is increasing, we know that ______ must rise to provide sufficient CPP

A

MAP

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20
Q

Major Head Trauma

The reasons for intubation include:

A
  • Not maintaining airway, oxygenation or ventilation
  • Rapidly progressive deterioration
  • Unable to obtain needed neuroimaging due to agitation (these patients require sedation and then usually intubation for airway protection)
  • Need for surgery
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21
Q

Prior to intubation, think of rapidly reversible reasons for a decreased mental status.

A
  • Administer glucose in hypoglycemia

* Administer naloxone in cases of opiate intoxication/overdose

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22
Q

___________ position of 20 degrees during and after RSI helps with preoxygenation and prevents rises in ICP by utilizing gravity and by promoting venous drainage.

A

A Reverse Trendelenburg

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23
Q

RSI medications

A

Ketamine and etomidate are both good choices for sedation.

Succinylcholine and rocuronium are both acceptable choices for paralytic.

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24
Q

________ has more contraindications but a shorter duration of action.

A

Succinylcholine

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25
Q

_______is the most powerful determinant of cerebral blood flow.

A

PaCO2

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26
Q

______ PaCO2 causes vasoconstriction which can cause cerebral ischemia.

A

Low

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27
Q

_____ PaCO2 can cause hyperemia and increase ICP.

A

High

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28
Q

Ventilator settings, particularly the ________, have a huge effect on PaCO2

A

respiratory rate

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29
Q

The current recommendation is for normal ventilation to maintain a normal PaCO2 (______ mm Hg).

A

35-45

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30
Q

_________, once recommended routinely in severe head trauma, is now reserved for cases of impending herniation when no other options to lower ICP are available.The consequence of hyperventilation is brain ischemia

A

Hyperventilation

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31
Q

The current recommendation is to maintain PaO2 >____mm Hg, but also to avoid hyperoxia.

A

PaO2 >60 mm Hg

32
Q

________ (PaO2 higher than the normal range) is thought to be toxic to many organs, especially the brain by mechanisms that are poorly understood.

A

Hyperoxia

33
Q

In general, because ICP is significantly elevated in most cases, MAP must be kept above a ______ of 100-110 mm Hg in order to provide sufficient CPP.

A

systolic

34
Q

Normal saline is a good choice initially. ______fluids and albumin should be avoided.

A

Hypotonic

35
Q

Head CT _______ contrast is the mainstay of imaging in the ED.

A

without contrast in head trauma

36
Q

who are you calling to consult?

Consultation is appropriate for patients with major head injury, even in the absence of surgical lesions such as epidural and subdural hematomas

A

Neurosurgical Consultation

37
Q

Immediate __________ in patients with intracranial hemorrhage is appropriate.

A

reversal of anticoagulation

38
Q

Reverse heparin with ________

A

protamine

39
Q

Reverse ______ with prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP) and IV vitamin K

A

warfarin

40
Q

Reverse __________ with either idarucizumab (the specific reversal agent for dabigatran, dose is 5 mg IV) or PCC

A

direct oral anticoagulants (DOACs)

41
Q

Seizure prophylaxis in head trauma

A
  • Phenytoin and levetiracetam are commonly used, but it is unclear if these are effective.
  • Levetiracetam may be a better choice of seizure
42
Q

______ is used to reduce edema in a patient at risk for brain herniation.

A

Hyperosmolar therapy

Osmotic diuresis

43
Q

______ is indicated for patients with clinical signs of progressive deterioration or herniation (decreasing GCS, pupillary changes and paralysis/posturing).

A

Hyperosmolar therapy

Mannitol

44
Q

Mannitol

dose

A

Dose is 0.25 g/kg to 1.0 g/kg

45
Q

Mannitol

Requires close monitoring for ______and ______

A

hypotension and urine output

46
Q

__________ may be used in patients with concomitant hypotension (e.g. in a bleeding, multiply injured patient with signs of herniation).

A

Hypertonic saline

47
Q

Most commonly from a direct blow to the head, with a skull fracture and injury to the middle meningeal artery, resulting in brisk bleeding into the epidural space (between the skull and the dura mater)

A

Epidural hematoma (EDH)

48
Q

The CT appearance is of a white lens-shaped lesion on the convexity of the skull, confined by the suture lines, but sometimes crossing the midline.

A

Epidural hematoma (EDH)

49
Q

The classic presentation is an initial loss of consciousness (e.g., the initial impact and primary brain injury) followed by a lucid period and then a secondary neurological deterioration. However, only 20% of patients have this classic story.

A

Epidural hematoma (EDH)

50
Q

Epidural hematoma (EDH)

management:

A
  • Emergent neurosurgical consultation

* surgical evacuation.

51
Q

Most commonly from a sudden deceleration injury, resulting in tearing of the bridging veins on the convexity of the brain.this is much more likely in older patients and those with cerebral atrophy

A

Subdural hematoma (SDH)

52
Q

Subdural hematoma (SDH)

Because the bleeding is more commonly ______, it may ooze slowly. Patients may not become symptomatic until days or even weeks after the initial injury.

A

venous

53
Q

The CT appearance is of a white crescent-shaped lesion on the convexity of the skull which does not cross the midline but rather invaginates into the brain alongside the falx and on top of the tentorium.

A

Subdural hematoma (SDH)

54
Q

Over time, the white lesion representing acute blood turns isodense with the brain tissue (typically around 2 weeks post injury) as the clot breaks down; thereafter, the lesions turn darker and closer to the appearance of CSF.

A

Subdural hematoma (SDH)

55
Q

Presentations vary widely and may include:

  • headache
  • focal findings
  • progressive decline in level of consciousness
  • coma
  • seizures.
A

Subdural hematoma (SDH)

56
Q

Subdural hematoma (SDH)

Management involves

A
  • emergent neurosurgical consultation

* surgical evacuation

57
Q

results in shearing of blood vessels in the subarachnoid space.

A

Traumatic SAH

58
Q

In contrast to SAH resulting from the rupture of an aneurysm (spontaneous SAH), which causes a central collection of blood in the basal cisterns,_________tends to occur on the periphery of the brain in the cerebral sulci.

A

traumatic SAH

59
Q

Large traumatic SAH may dissect into the ventricles, causing __________

A

hydrocephalus.

60
Q

_________ are collections of blood within the brain parenchyma, typically along the base of the brain as it slides along the irregular contour of the skull base during deceleration injury.

A

Cerebral contusions

61
Q

These appear as white lesions with surrounding edema (darker appearance).

A

Cerebral contusions

62
Q

Unlike EDH and SDH, these lesions are often not amenable to surgical evacuation.

A

Cerebral contusions

63
Q

Cerebral contusions/hematomas

management:

A

Serial CT imaging is critical to monitor the progression of these lesions.

64
Q

is a primary brain injury caused by the shearing of axons in the deep white matter at the instant of the traumatic deceleration.

A

Diffuse axonal injury (DAI)

65
Q

The typical clinical picture is of a comatose patient with no or minimal signs of injury on the initial CT. MR will detect the extent of injur

A

Diffuse axonal injury (DAI)

66
Q

These injuries are devastating and can progress to massive swelling and herniation within hours or days after injury.

A

Diffuse axonal injury (DAI)

67
Q

Diffuse axonal injury (DAI)

treatment:

A

Treatment is supportive.

68
Q

All of the patterns of injury described above result in an increase in intracranial volume; thus all have the potential to result in a herniation syndrome (literally the brain sliding out of its compartments and out of the skull).

A

Herniation syndromes

69
Q

The uncus (shoulder) of the temporal lobe gets pushed into the midbrain (brainstem) under the edge of the tentorium.

A

Uncal (transtentorial) herniation

70
Q

Clinically manifests as deepening coma, pupillary dilation (usually ipsilateral to the lesion) and hemiparesis or posturing (usually contralateral to the lesion).

A

Uncal (transtentorial) herniation

71
Q
  • The tonsils of the cerebellum slide through the foramen magnum pressing against the medulla.
  • May result in sudden death.
A

Cerebellar tonsillar herniation

72
Q

_______ is fatal. When it is suspected either on the basis of a changing clinical exam or on imaging it requires immediate emergent neurosurgical consultation and steps to reduce ICP including hyperventilation

A

Herniation

73
Q

Herniation is fatal. When it is suspected either on the basis of a changing clinical exam or on imaging it requires immediate emergent neurosurgical consultation and steps to reduce ICP including ________

A

hyperventilation

74
Q

______ and ________tools are used to clear the c-spine without films; these are not applicable in patients with major head injury who have alteration of their mental status (see Minor head injury chapter next month for further discussion).

A

The NEXUS and Canadian c-spine

75
Q

_____ is appropriate in patients with any signs or symptoms of spinal cord injury (paralysis, weakness, sensory changes, incontinence or decreased rectal tone); spinal injury may be present in these patients even in the absence of CT findings.

A

MR

76
Q

If any of the above are met the c-spine cannot be cleared clinically

  • Focal neurologic deficit
  • Midline spinal tenderness
  • Altered level of consciousness
  • Intoxication
  • Distracting Injury
A

NEXUS C-Spine

77
Q

Age ≥65

Extremity paresthesias

Dangerous mechanism:

    Fall from ≥3 ft or 5 stairs
    Axial load injury
    High speed MVC/rollover/ejection
    Bicycle collision
    Motorized recreational vehicle
A

Canadian C-Spine

EM RAP-Becoming a badass ER PA (4 decks)

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