Neuro DS - Traumatic Brain Injury

Question 1

What are some signs and symptoms of a concussion?

Answer 1

• Confusion and amnesia (retrograde and anterograde)
• with or w/o loss of consciousness; headache, dizziness (vertigo or imbalance), lack of awareness of surroundings, nausea and vomiting.
• Over the next hours/days, may complain of mood and cognitive disturbances, sensitivity to light and noise, and sleep disturbances

Question 2

What are some other signs in someone with a concussion?

Answer 2

• vacant stare
• Delayed verbal expression (slow to answer questions)
• Inability to focus attention (easily distracted)
• Disorientation (ex. walking in wrong direction)
• Slurred or incoherent speech (making disjointed or incomprehensible statements)
• Gloss observable incoordination (stumbling, inability to walk straight line)
• Emotionality out of proportion to circumstance (appearing distraught, crying for no apparent reason)
• Memory deficits (exhibited by patient repeatedly asking the same question that has already been answered)
• Any period of loss of consciousness (coma, unresponsiveness to stimuli)

Question 3

Discuss the criteria for outpatient observation for mild traumatic brain injury?

Answer 3

• GCS=15, normal examination and head CT, and no predisposition to bleeding; responsible person must be available at home to monitor the patient for progression of symptoms

Question 4

What is the process of monitoring an outpatient for observation for mild traumatic brain injury?

Answer 4

• Patient should be awakened from sleep every 2 hrs for the first night and should avoid strenuous activity for at least 24 hrs. The following warning signs should indicate a potential problem:
  
  • inability to awaken the patient
  • Severe or worsening headaches
  • Somnolence or confusion
  • Restlessness, unsteadiness, or seizures
  • Difficulties with vision
  • Vomiting, fever, or stiff neck
  • Urinary or bowel incontinence
  • Weakness or numbness involving any part of the body.

Question 5

What is second impact syndrome?

Answer 5

Second impact syndrome is used when diffuse cerebral swelling occurs after a second concussion while an athlete is still symptomatic from an earlier concussion.

• diffuse cerebral swelling is rare but can be fatal
• Guidelines: all athletes suspected should be removed from sports participation and should not return to play while symptoms are present. If return within 15 min should be out for 1 week. ER eval for any LOC

Question 6

What is the relevance of blood pressure and oxygenation in severe head injury?

Answer 6

• two systemic insults known to be a major causes of secondary injury after TBI. Prevention of hypoxia (<90) are priorities of patients with severe TBI

Question 7

What factors should be avoided to prevent secondary neurologic injury?

Answer 7

• Fever
• Hyperglycemia
• Coagulopathy
• Glucocorticoids

Question 8

What are the ICP recommendations in sever head injury?

Answer 8

• Head of bed elevation to 30 degrees ( optimization of venous drainage), keeping the neck in neutral position, loosening neck braces if too tight, monitoring central venous pressure and avoiding excessive hypervolemia.

Question 9

What are the indications for ICP monitoring in TBI patients?

Answer 9

• A GCS score < or equal to 8 and an abnormal CT scan showing evidence of mass effect from lesions such as a hematoma, contusions, or swelling

Question 10

What is the treatment for elevated ICP when ICP rises above 20 mmHg ventricular drainage

Answer 10

• Hyperventilation, osmotic therapy (mannitol), and sedation.