MDT closed head injury to include aneurysm Flashcards
most common demographic for TBI
Young (15-34), male, and drunk are most accident prone
What is
Coup-contrecoup
Injury will be present at site of impact as well as opposite side from rebound
motion
Concussion is _____ subset of traumatic brain injury (TBI)
Mildest
Concussion Hallmarks are ____ and _____
confusion and amnesia
Concussion Hallmarks are ____ and _____
confusion and amnesia
Amnesia almost always includes the _______ itself, but may also extend to events _______ trauma
traumatic event
before and after
Concussion periodicity of symptoms
Headache, dizziness, vertigo, imbalance, nausea, vomiting
Early symptoms (minutes to hours)
Concussion periodicity of symptoms
Mood/cognitive disturbance, light/noise sensitivity, sleep disturbance
Delayed symptoms (hours to days)
Common signs of what?
1) Vacant stare (befuddled facial expression)
2) Delayed verbal expression (slower to answer questions)
3) Inability to focus attention (easily distracted)
4) Disorientation (walking in the wrong direction, not A&O)
5) Slurred or incoherent speech (making disjointed statements)
6) Gross observable incoordination (stumbling)
7) Emotionality out of proportion to circumstances (appearing distraught, crying
for no apparent reason)
8) Memory deficits
Concussion
If seizures occur within _____ of head injury, much more likely to be related to ___ than epilepsy. Occurs in 5% of TBI patients.
one week
TBI
What type of concussion?
(a) Any concussion with concomitant hemorrhage
(b) May present as acute, subacute or chronic
(c) Usually arterial in origin
(d) Treat based on complication
Complicated concussion
MACE exams are completed on patients within that timeframe
48 hours
Acute Evaluation of concussion
Focus on ______ exam to detail extent of damage
neurologic exam
Management of concussion
(a) Direct observation for____
(b) Awaken the patient every _____ to ensure normal alertness
(c) ________ for 24 hours after injury
(d) No alcohol, sedatives, or pain relievers other than NSAIDs should be given for ________
a. 24 hours
b. two hours
c. Low level of activity
d. 48 hours
Concussion criteria for what?
(a) Inability to awaken the patient
(b) Severe or worsening headaches
(c) Somnolence or confusion
(d) Restlessness, unsteadiness, or seizures
(e) Difficulties with vision
(f) Vomiting, fever, or stiff neck
(g) Urinary or bowel incontinence
(h) Weakness or numbness involving body part
Immediate Referral/MEDEVAC
What complication of concussion?
1) Diffuse cerebral swelling that can develop in setting of a second concussion
2) Occurs when patient symptomatic from the 1st concussion and sustains 2nd concussion
3) Rare but potentially fatal complication
Second impact syndrome
What complication of concussion?
Headache, dizziness, cognitive impairment, psych symptoms that develop in the first few days after mild TBI and resolve in weeks to months
Postconcussion syndrome
25-78% of patients experience _______ headaches within 7 days of the event
Posttraumatic headaches
What complication of concussion?
Excessive daytime somnolence, increased sleep need, insomnia, sleep fragmentation
Sleep disturbances…….
What complication of concussion?
Repeated concussions can lead to cumulative neuropsychologic deficits
a) Behavior changes, personality changes, depression, increased suicidality
b) Parkinsonism
c) Speech and gait abnormalities
Chronic traumatic encephalopathy (CTE)
In an open skull fracture what should you look for?
Look for CSF leakage
The skull is difficult to break, but is thin in several areas what two?
1) Temporal region
2) Nasal sinuses
Theses are signs for_____
1) Battle sign
2) “Raccoon” eyes
3) Hemotympanum(blood behind TM)
4) CSF rhinorrhea/otorrhea
5) Cranial nerve deficits
basilar skull fracture (base of skull)
If an open basilar skull fracture is suspected what type of airway might be more appropriate
Orogastric tube
Acute Management of skull fracture
treatment
Oxygen, C-spine precautions and MEDEVAC ASAP
ultimately needs Head CT and Neurosurgeon
Cushing’s Triad (reflex):
Bradycardia + Hypertension + Respiratory irregularity
If signs show rapid increase in ICP or herniation
1) Secure & maintain an open airway
2) Elevate head of bed (25-30 deg): “Reverse Trendelenburg”
3) Ventilate to maintain oxygenation & avoid hypercarbia (increased CO2 in
blood) .
Acute Management of skull fracture
IV fluids – Resuscitate with normal saline or lactated ringers, DO NOT USE
_______ or ________
Avoid ________
solutions containing glucose or hypotonic solutions
Overhydration
Management of ICP
What type of therapy?
-Reduce brain volume by drawing free water out of the tissue and into circulation where it is excreted by the kidneys
Osmotic therapy
What drugs would you use for osmotic therapy in management for ICP
Mannitol: 1g/kg IV as 15-20% solution, may repeat 0.25-0.5g/kg as needed,
generally every 6-8 hours.
7.5% Hypertonic NaCl 250cc bolus
Management of ICP
True/false
Consider hyperventilation as last resort
True
Your pt with ICP is having seizures what med would you give to treat the seizures
Diazepam (Valium) 10 mg IV q10min (max dose 30mg)
Intracranial hemorrhage (ICH) what type? bleed between dura mater and skull
Epidural hematoma
Intracranial hemorrhage (ICH) what type? bleed between dura mater and arachnoid mater
Subdural hematoma
Intracranial hemorrhage (ICH)
what type?
-bleed between arachnoid mater and pia mater
-High association with aneurysms or AV malformations
Subarachnoid hematoma
Epidemiology of what ICH
(a) 1-4% of head trauma cases
(b) Uncommon, but serious complication
(c) Highest among adolescents
(d) Rare in patients >50 years
(e) Usually caused by traffic accidents, falls, and assaults
(f) 75-95% have associated skull fracture
Epidermal hemorrhage
_________ hemorrhage presentation
(a) Classic picture involves:
1) Immediate loss of consciousness after significant head trauma
2) “Lucid interval” with recovery of consciousness
(b) After a period of hours, increasing headache with deteriorating neurologic
function
(c) May also see seizure, coma, anisocoria, respiratory collapse
(d) Evaluation incudes H&P, complete and serial neuro exams, and examination of
eyes for papilledema
Epidural hemorrhage
Epidural hematoma acute management
(a) Oxygenation, prepare/initiate intubation if GCS____
(b) Immediate _______ (operation likely required- trephination, burr hole)
(c) Closely monitor neurologic signs for increased _______
a. < 8
b. neurosurgical consultation
c. ICP/herniation
disposition for a Epidural hematoma
MEDEVAC for immediate neurosurgical consultation and Head CT.
epidemiology of what ICH
(a) More common than epidural, 20% of severe head injuries
(b) Elderly, EtOH abusers, anticoagulated at risk
(c) Underlying brain injury is often severe
(d) May occur without impact
(e) Dismal prognosis - 60% mortality
Subdural Hemorrhage
clinical manifestations of what ICH
(a) May or may not have history of head trauma
(b) Acute subdural hematoma presents 1-2 days after onset
1) May have lucid interval after injury
(c) Chronic subdural hematoma presents 15 days or more after onset
(d) Insidious onset of headaches, light headedness, cognitive impairment, apathy, somnolence are typical symptoms
Subdural hematoma
Subdural hematoma acute management
(a) Oxygenation, prepare/initiate intubation if GCS < 8
(b) Immediate neurosurgical consultation (operation likely required- trephination, burr hole)
(c) Closely monitor neurologic signs for increased ICP/herniation
epidemiology of what ICH
(a) Usually rupture of blood vessel aneurysm (~80%)
(b) Sometimes trauma or congenital anomaly
(c) Bleeding is high pressure and into subarachnoid space which normally carries CSF
Subarachnoid Hemorrhage (SAH)
clinical presentation of what ICH?
(a) Hallmark “Thunder clap headache” or “worse headache of my life”
(b) Headache onset is sudden and may have meningeal irritation
1) Blood from cerebral blood vessels irritates the brain and meninges
(c) Prior to onset patient may have been doing activity that increased intrathoracic pressure
Subarachnoid hemorrhage
Activities that increase risk of SAH
Drug use (cocaine, amphetamines), smoking, hypertension, alcohol use
SAH treatment
(a) Bedrest
(b) Analgesia with ____
(c) Avoid drugs that can lead to _____
(d) MEDEVAC
b. Tylenol
c. anticoagulation
