Neuro emergencies Flashcards
1
Q
Neuro exam in emergency setting?
A
- key is medical hx
- time of onset
- sx progression
- assoc sxs
- exacerbating factors
- once at ER assess neuro status
- use glasgow coma scale - if pt deteriorated during transport needs immed non-contrast CT scan and possible neurosurgery consult
- if pt stable and not comatose with stable VS and no focal neuro findings: you can proceed more slowly
- goal is to prevent brainstem or uncal herniation and brain edema with elevated ICP that causes further brain injury
2
Q
What is impt hx information for head trauma injury?
A
- when, where and how injury happened
- mechanism of injury
- if there was LOC at the scene
- if ETOH or drugs were involved
- length of time from injury
- underlying medical problems (diabetes, previous stroke, CVD)
- allergies and meds
3
Q
What should be eval on a head trauma physical exam?
A
- vital signs
- glasgow coma scale
- examine head for signs of outward trauma (penetrating trauma, lacerations, swelling, bruises, abrasions)
- pt should be in cervical spine collar
- neuro exam:
pupils
level of alertness
look for focal deficits: facial droop, leg or arm not fxning
4
Q
What is a TBI? GCS ratings?
A
- head injury due to contract or accel/deceleration forces
- mild: GCS 13-15 measured 30 min after injury
- moderate: 9-12
- severe: 8 and lower
5
Q
WHat is a concussion?
A
- trauma indcued alteration in mental status may or may not involve LOC
- caused by direct blow to head, face, neck or body
- fxnl not structural neuropathologcial changes
- normal imaging studies
6
Q
What are associated sxs with TBI?
A
- LOC or not, confusion, amnesia, length of these sxs
- assoc sxs:
HA, dizziness, vertigo or imbalance, lack of awareness of surroundings (disorientation), N/V
7
Q
Signs assoc with TBI?
A
vacant stare inability to focus gross incoordination memory deficits delayed verbal expression slurred or incoherent speech emotionality out of proportion to events
8
Q
Presentation of complicated TBI?
A
- post traumatic seizures
- focal neuro signs
- neuro deterioration
- worsening HA, confusion, focal neuro signs or lethargy - think Intracranial hemorrhage
- other injuries to head and neck (esp in older pts)
9
Q
PP of primary injury phase of TBI? Cortical contusion and indirect trauma?
A
- cortical contusion: direct trauma
coup and contrecoup - diffuse axonal injury: disruption of axonal neurofilament organization - impairs axonal transport leads to axonal swelling
- indirect trauma: SBS or severe whiplash that shakes or rotates the brain
- greatly stretches and damages nerve cells causing sig damage and even death in adults and may cause perm brain damage
10
Q
Indications for CT scan in ER?
A
- GCS of less than 15
- susp open or depressed skull fracture
- any sign of basilar skull fracture: CSF leak, battle’s sign, raccoon eyes, hemotypanum
- 2 or more episodes of vomiting
- 65 or older
- amnesia before impact of 3 or more minutes
- dangerous MOI (eject from vehicle)
- bleeding diathesis or oral anticaog use
- seizure
- focal neuro sign
- intoxication
11
Q
What to look for on CT scan in ED?
A
- cranial contours
- cisterns (any opening in subarachnoid space created by sep of arachnoid and pia mater) - open vs closed
- midline shift?
- lesions? type, location
- acute blood - white
- old blood - dark
- ventricles and cisterns are black
12
Q
CT scan abnorm that require a consult?
Likelihood of neuro normal pt with normal CT scan having a problem?
A
- subdural hematoma
- intracranial bleeding
- cerebal edema
- sig skull trauma
- low risk for neuro deterioration with normal CT scan
13
Q
What pts should be hospitalized or transfered?
A
- GCS of less than 15 or deteriorating
- abnorm CT
- seizures
abnorm bleeding parameters
14
Q
What pts can leave?
A
- if GCS = 15
- normal CT scan
- responsible caretaker to awaken pt from sleep q 2 hrs to check for warning signs:
- inability to waken pt
- severe or worsening HAs
- somnolence or confusion
- diff with vision
- urinary or bowel incont.
- weakness or numbness involving any part of the body
- unsteadiness or seizures
- vomiting, fever or stiff neck
15
Q
Scalp lacerations and tx of bleeding?
A
- common with head injuries
- source of sig bleeding
- hemostasis: is best achieved with closure of laceration
- may be delayed in unstable pt
- direct compression or compression bandage may be applied
16
Q
Scalp laceration repair?
A
- anesthetize wound edges with:
lidocaine1-2% with epi - thoroughly debride and irrigate
- if deep may use horizontal mattress sutures
- otherwise interrupted sutures or staples
- no need to shave head most of time
- when repairing scalp wound palpate skull for depression or step off fracture
17
Q
Clinical sig skull fractures?
A
- pass through an air filled space (sinus)
- assoc with overlapping scalp laceration
- depressed below level of skull’s inner table
- overlie a major dural venous sinus or middle meningeal artery
18
Q
When are linear skull fractures clinically impt?
What do they look like on xray? heal time?
A
- impt if they cross middle meningeal artery or major venous sinus
- most other linear fractures aren’t sig
- fractures are brighter on xray than sutures and usually are wider (3 mm compared to 2 mm for sutures)
- kids - fx heals 3-6 months
- adults: up to 3 years
19
Q
Depressed fractures presentation
A
- may be diff to view on X-ray
- can often be felt on palpation beneath scalp laceration
- impt b/c they predispose to sig underlying brain injury and to complications of head trauma (infection and seizures)
- with a depressed skull fracture traumatic impact drives bone piece below plane of skull
- 25% of pts with depressed fracture report LOC
