Management of head injury

Question 1

Describe the pathophysiology of primary brain injury?
and secondary brain injury?
-What is the Mono-killie doctrine in terms of ICP?

Answer 1

-release of escittairy amino acids (glutamate, aspartate)
Binding to receptors (NMDA)
there is then a release of intracellular Ca and activation ofphospholipases, breakdown of the cell membrane, cell swelling, activation of apoptosis

-Loss of the BBB, leucocyte infiltration = inflammation
Loss of cerebral auto regulation of BP & blood flow = ischeamia & metabolic decoupling, even more ischaemia causing further brain oedema

-an increase in vol of one component must produce a decrease in another component otherwise the ICP will rise

Question 2

Cerebral perfusion pressure:

• calculated how?
• factors?
• perameters after head injury?
• normal ICP?

Answer 2

• CPP= MAP-ICP
• hypotension i.e. causes ischeamia
• > 60mmHg after injury
• 9-11mmHg

Question 3

What are the different types of head injury?

Answer 3

Open
i.e. missile

Closed
acceleration/deceleration/rotation

Question 4

Physical findings in head injury?

-what focal signs should be observed?

Answer 4

scalp swelling
Skull vault fracture (linear, Depressed, Compound)
Skull base fracture
(ant cranial fossa= racoon eyes, Middle cranial fossa= battle sign over mastoid)

-lateralising motor signs
Pupillary response to light

Question 5

Assessment of consciousness

• method used?
• explain ^ (3-4, 5, 6)
• highest & lowest score?
• definition of come?

Answer 5

-Glasgow Coma Scale

-Eye opening
(spontaneously
To command
To pain
none)

Verbal response
(Orientated
confused
inappropriate words
incomprehensible sounds
none)

Best motor response
(obeys commands
localises pain
flexes to pain
abnormal flexion
extension
None)

-GCS 8 or less

Question 6

Immediate management of head injury?

Answer 6

ABCDE

-vital to maintain circulation

Question 7

When should a CT be requested for head trauma?

Answer 7

any patient with: 
skull fracture 
not orientated
focal neurological signs
taking anticoagulants

Question 8

Types of traumatic intracranial bleed:

-name 6 superficial -> deep

Answer 8

extradural haematoma 
Subdural haematoma
Traumatic subarachnoid haemorrhage
Intracerebral contusion
intracerebral haematoma
Intraventricular haemorrhage

Question 9

Intensive care management of head injury

• involves what 5 areas?
• what might be given/done for cerebral protection? (6)

Answer 9

-sedation
reduces cerebral metabolic rate, blood flow and ICP

Ventilation
maintain adequate oxygenation & normocapnia

Blood Pressure
manipulate to maintain CPP of >60

Glucose
maintain normoglycemia

Temp
maintain euthermia

-CSF drainage 
Mannitol
Hypertonic saline 
Hyperventilation 
Decompressive craniotomy

Question 10

What are the late effects of head injury?

Answer 10

Epilepsy
CSF leak- nose/middle ear
(salty taste when tip head back)
Cognitive problems- post concussion syndrome e.g. poor concentration and memory