MDT closed head injury to include aneurysm

Question 1

most common demographic for TBI

Answer 1

Young (15-34), male, and drunk are most accident prone

Question 2

What is
Coup-contrecoup

Answer 2

Injury will be present at site of impact as well as opposite side from rebound
motion

Question 3

Concussion is _____ subset of traumatic brain injury (TBI)

Answer 3

Mildest

Question 4

Concussion Hallmarks are ____ and _____

Answer 4

confusion and amnesia

Question 5

Amnesia almost always includes the _______ itself, but may also extend to events _______ trauma

Answer 5

traumatic event
before and after

Question 6

Concussion periodicity of symptoms
Headache, dizziness, vertigo, imbalance, nausea, vomiting

Answer 6

Early symptoms (minutes to hours)

Question 7

Concussion periodicity of symptoms
Mood/cognitive disturbance, light/noise sensitivity, sleep disturbance

Answer 7

Delayed symptoms (hours to days)

Question 8

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

Answer 8

Concussion

Question 9

If seizures occur within _____ of head injury, much more likely to be related to ___ than epilepsy. Occurs in 5% of TBI patients.

Answer 9

one week
TBI

Question 10

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

Answer 10

Complicated concussion

Question 11

MACE exams are completed on patients within that timeframe

Answer 11

48 hours

Question 12

Acute Evaluation of concussion
Focus on ______ exam to detail extent of damage

Answer 12

neurologic exam

Question 13

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 ________

Answer 13

a. 24 hours
b. two hours
c. Low level of activity
d. 48 hours

Question 14

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

Answer 14

Immediate Referral/MEDEVAC

Question 15

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

Answer 15

Second impact syndrome

Question 16

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

Answer 16

Postconcussion syndrome

Question 17

25-78% of patients experience _______ headaches within 7 days of the event

Answer 17

Posttraumatic headaches

Question 18

What complication of concussion?
Excessive daytime somnolence, increased sleep need, insomnia, sleep fragmentation

Answer 18

Sleep disturbances…….

Question 19

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

Answer 19

Chronic traumatic encephalopathy (CTE)

Question 20

In an open skull fracture what should you look for?

Answer 20

Look for CSF leakage

Question 21

The skull is difficult to break, but is thin in several areas what two?

Answer 21

1) Temporal region
2) Nasal sinuses

Question 22

Theses are signs for_____
1) Battle sign
2) “Raccoon” eyes
3) Hemotympanum(blood behind TM)
4) CSF rhinorrhea/otorrhea
5) Cranial nerve deficits

Answer 22

basilar skull fracture (base of skull)

Question 23

If an open basilar skull fracture is suspected what type of airway might be more appropriate

Answer 23

Orogastric tube

Question 24

Acute Management of skull fracture
treatment

Answer 24

Oxygen, C-spine precautions and MEDEVAC ASAP
(ultimately needs Head CT and Neurosurgeon)

Question 25

Cushing’s Triad (reflex):

Answer 25

Bradycardia + Hypertension + Respiratory irregularity

Question 26

If signs show rapid increase in ICP or herniation

Answer 26

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).

Question 27

Acute Management of skull fracture
IV fluids – Resuscitate with normal saline or lactated ringers, DO NOT USE
_______ or ________

Avoid ________

Answer 27

solutions containing glucose or hypotonic solutions

Overhydration

Question 28

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

Answer 28

Osmotic therapy

Question 29

What drugs would you use for osmotic therapy in management for ICP

Answer 29

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

Question 30

Management of ICP
True/false
Consider hyperventilation as last resort

Answer 30

True

Question 31

Your pt with ICP is having seizures what med would you give to treat the seizures

Answer 31

Diazepam (Valium) 10 mg IV q10min (max dose 30mg)

Question 32

Intracranial hemorrhage (ICH)
what type?
bleed between dura mater and skull

Answer 32

Epidural hematoma

Question 33

Intracranial hemorrhage (ICH)
what type?
bleed between dura mater and arachnoid mater

Answer 33

Subdural hematoma

Question 34

Intracranial hemorrhage (ICH)
what type?
-bleed between arachnoid mater and pia mater
-High association with aneurysms or AV malformations

Answer 34

Subarachnoid hematoma

Question 35

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

Answer 35

Epidermal hemorrhage

Question 36

_________ 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

Answer 36

Epidural hemorrhage

Question 37

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 _______

Answer 37

a. < 8
b. neurosurgical consultation
c. ICP/herniation

Question 38

disposition for a Epidural hematoma

Answer 38

MEDEVAC for immediate neurosurgical consultation and Head CT.

Question 39

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

Answer 39

Subdural Hemorrhage

Question 40

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

Answer 40

Subdural hematoma

Question 41

Subdural hematoma acute management

Answer 41

(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

Question 42

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

Answer 42

Subarachnoid Hemorrhage (SAH)

Question 43

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

Answer 43

Subarachnoid hemorrhage

Question 44

Activities that increase risk of SAH

Answer 44

Drug use (cocaine, amphetamines), smoking, hypertension, alcohol use

Question 45

SAH treatment
(a) Bedrest
(b) Analgesia with ____
(c) Avoid drugs that can lead to _____
(d) MEDEVAC

Answer 45

b. Tylenol
c. anticoagulation

Question 46

Concussion Hallmarks are ____ and _____

Answer 46

confusion and amnesia