Management of head trauma

Question 1

What is the Glasgow Outcome Score?

Answer 1

Grading used to determine objective degree of recovery

1. Dead
2. Vegetative state
3. Severely disabled
4. Moderately disabled
5. Good recovery (although this does not mean pt will have no lasting damage!)

Question 2

What is the general time length for people reaching their final outcome score (GOS)?

Answer 2

2/3 within 3 months

90% within 1 year

Question 3

What are the common findings in hospital fatalities following head trauma?

Answer 3

Raised ICP
Intracranial haematoma
Ischaemic damage

Question 4

What is ABCDE of head trauma management?

Answer 4

Airways (may require cervical immobilisation) 
Breathing 
Circulation 
Disability (assessed using GCS) 
Exposure

Question 5

What considerations need to be taken into account for management of uncomplicated injuries?

Answer 5

ABC
Diffuse or focal injury?
Skull fracture?
Improvement/ deterioration?

Question 6

What is the immediate aim when managing an unconscious patient with a head injury?

Answer 6

To prevent secondary brain damage due to impaired cerebral oxygenation (e.g. due to hypoxia or hypotension)

Question 7

What is the significance of a skull fracture in patients with head trauma?

Answer 7

Risk of acute haematoma

Impaired GCS

Question 8

What can unequal ventricles be indicative of?

Answer 8

Raised ICP caused by subdural haematoma (compression of ventricle on side of haematoma)

Question 9

What is a diffuse axonal injury?

Answer 9

Brain injury not localised to one area (small contusions scattered throughout the brain damaging connections - contusions at centre of brain indicate great force)
‘Twisting force’ applied to axons causing permanent neuron death

Question 10

What is a normal pressure ICP?

Answer 10

Approx. 10mmHg

Question 11

What needs to be monitored in comatose patients?

Answer 11

ICP
If above 20mmHg then it should be treated
Maintenance of of cranial perfusion pressure (CPP)

Question 12

What is the gold standard for ICP monitoring?

Answer 12

External ventricular drain (ventriculostomy)

Question 13

What is cranial perfusion pressure?

Answer 13

Mean arterial pressure (MAP) - Intracranial pressure (ICP)

Question 14

What is the effect of CO2 on cerebral blood flow?

Answer 14

Acidosis

Dilation of vessels causing CO2 to raise ICP further (due to increased blood volume in cerebral vessels)

Question 15

What must be controlled to prevent CO2 effects on cerebral blood flow?

Answer 15

Airways and breathing

Question 16

What is normovolaemic and its importance in patients with brain injury?

Answer 16

Normal blood volume 
Must be maintained through fluid management in patients with brain injuries to prevent hypotension, SIRS or organ failure 
Free water (dextrose solution) should NOT be administered as it will decrease plasma osmolarity and increase water content of brain tissue

Question 17

Why must blood glucose levels be managed in patients with severe head injuries?

Answer 17

Elevated blood sugar levels associated with worsening neurological injury after episodes of global cerebral ischaemia as ischaemic brain metabolises glucose to lactic acid (lowering tissue pH and exacerbating injury)

Question 18

What long-lasting psychological and cognitive issues can occur in brain trauma survivors?

Answer 18

Personality disorders
Memory disorders 
Reduced reasoning power
Apathy / lack of drive 
Tantrums 
Family disruption 

[Can cause problems in rehabilitation due to lack of drive and reduced capacity to cope with therapeutic programmes]

Question 19

What long-lasting focal damage can occur in brain trauma survivors?

Answer 19

Hemispheric sequelae (e.g. hemianopia) 
Cranial nerve palsies (commonly CN I causing anosmia or CN VIII causing vertigo and nystagmus)

Question 20

What disabilities are most impactful following brain trauma?

Answer 20

Mental disability tends to be more significant in contributing to handicap than physical disability following head injury

Question 21

What is a subfalcine herniation?

Answer 21

Cerebral herniation in which the brain (typically the cingulate gyrus) is displaced beneath the free edge of the falx cerebri (between falx cerebri and corpus callosum) due to raised ICP (e.g. due to tumour or haemorrhage)

Question 22

What is Cushing’s Triad?

Answer 22

Triad seen as compensation for raised ICP:
Irregular, decreased respiration
Bradycardia
Systolic hypertension

Question 23

What is uncal herniation?

Answer 23

Uncus of the brain (parahippocampal gyrus) is herniated over the tentorial notch of the tentorium cerebelli

Question 24

When (and why) is a CT more useful in head injury/ stroke?

Answer 24

Low cost
Quick
More useful in obese patients
Able to differentiate between ischaemic and haemorrhagic strokes immediately (ischaemic stroke will not show up but will be able to identify bleed)
Trauma/ skull fractures easily identified on CT
If patient has metal implant then CT

Question 25

When is an MRI most useful in strokes?

Answer 25

More detailed

Able to identify brainstem lesion and old haemorrhages

Question 26

When is diffusion weight imaging (DWI) MRI and when is it best to use?

Answer 26

MRI technique mapping the diffusion of water molecules in tissue.
Useful for revealing ischaemic damage more quickly than MRI following a stroke