Neuro Injury/Trauma

Question 1

Traumatic Brain Injury

Answer 1

Open or closed: penetrating wound (cranium opened up), or closed with no loss of skin integrity

Focal or diffuse: Affecting only one area, or affecting a larger portion of the brain

Severity: Mild/moderate/severe based on GCS, how long unconscious, how much amnesia

Question 2

Brain Trauma: closed, focal, coup/contrecoup

Answer 2

Primary: Head hitting wall or ground, shock wave hitting head.

Closed: Dura intact, no external exposure

Focal: Observable precise location - hit forehead or back of head - we can see where it was hit

Coup-contrecoup:
Coup = damage at site of impact
Contrecoup = bounce back injury. front of head hit, bounce back in the back is the contrecoup injury

Coup/Contrecoup = both sides injuries

Question 3

Brain trauma: Contusions

Answer 3

Contusions - Coup injury- compression at point of impact. Oozing from blood vessel damaged at site of impact.

Smaller point of damage = larger damage (consider a book at one speed vs hammer at same speed)

Brain edema forms around injury - increases intracranial pressure

Can have multiple hemorrhages, edema, infarction, necrosis within the contusion.

Damage peaks at 18-36 hr after impact.

Most contusions in frontal lobe (emotion, judgement, speaking)

S&S: loss of consciousness, reflexes may fall due to trauma, recall increased ICP stages. These pts usually in first stages. May see decreased HR, RR, BP

Question 4

Contusions vs hematoma

Answer 4

A hematoma is a collection of blood outside a blood vessel that occurs when the wall of a blood vessel has been injured and leaks into surrounding tissues

A contusion is a type of hematoma which occurs when blood vessels are damaged or broken as the result of an injury. Blood leaks from the damaged blood vessels into the surrounding tissues causing them to turn a purplish color.

Question 5

Epidural Hematoma

Answer 5

Artery is source of bleed. can be vein but less common

•80% accompanied by skull fracture which causes bleeding.
•Temporal fossa most common location - medial meningeal artery or vein
•Does not cross suture like
•Lemon shaped
•More severe
•LOC decrease fast if severe hematoma
•Ipsilateral pupil dilation on side of trauma

Question 6

Subdural Hematoma

Answer 6

•Veins are more often source of bleed
•Within dura matter and brain
•10-20% with TBI will have subdural hematoma
•Crosses suture line
•Develops quickly. Most common on top of skull.
•Bilateral hematomas not as common, about only 25%
•Chronic hematomas: develop slowly, alcoholics due to brain atrophy which causes increase in extra dura space.
•Can develop bleed over weeks or month. Extra space fills slowly with blood

S&S: Headache, tenderness over hematoma, progressing dementia, generalized rigity

Question 7

Intracerebral Hematoma

Answer 7

Bleeding within the tissues of the brain

Trauma, ruptured blood vessels (aneurysm) is main cause, can be caused by birth defects, hypertension, tumour

Question 8

Blast injuries

Answer 8

Shock waves: overpressure followed by under-pressure phase occurring mili-seconds apart

Blast injury could increase vessel and cause a rupture or the recurring overpressure and under-pressure could cause a vessel to spasm

•Rare to only have a blast injury. Usually occurs with other types of brain injury - focal wound hitting skull, open wound from shrapnel, secondary trauma following being blown against other objects

Question 9

Signs if basal skull fracture

Answer 9

Racoon eyes (blackened eyes)
Battle sign (darkening behind ears)

Question 10

Mild Concussion

Answer 10

A mild traumatic brain injury

Immediate transitory (memory suddenly disappears) - GCS 15 or a bit confused - lasts only a few minutes. Potential amnesia.

Headache, not feeling themselves for a few days

Question 11

Cerebral Concussion

Answer 11

Loss of consciousness lasts longer than a few minutes, but less than 6 hours.
(More than 6 hr = diffuse axonal injury)

•Retrograde amnesia: loss of memories before event

•Antegrade amnesia: inability to create memories

•Confused state that can lasts hr-days. Periods of decreased RR, BP, HR, but will resolve quickly

Question 12

Diffuse Axonal Injury (Mild to severe)

Answer 12

•Coma that lasts longer than 6 hr
•Caused by axonal destruction
•Mild: 6-24 hr, decerebrate or decorticate posturing, prolonged stupor or restlessness
•Moderate: GCS lower when first diagnosed (4-6), increases slightly in 24 hr but still not responding (6-8)
•35% have decerebrate or decorticate posturing which may last days or weeks
•When out of coma: confused, retrograde amnesia, antegrade amnesia, may have permanent defects in speech, memory, attention, reasoning, vision, problem solving, mood
•Severe: Involves both hemispheres and brainstem. Comatose state lasts days to months. Autonomic dysfunction will subside in weeks, caused by increased ICP for over 6 days. Pulmonary complications due to profound sensory/motor/cognitive deficits

Question 13

Diffuse Axonal Injury: Shaken Baby Syndrome

Answer 13

•Brain injury caused by forceful shaking
•Occurs quickly, within 5 seconds
•Repeated coup injury as brain comes in contact with skull
•More common under 2 yrs but can occur up to 5 yr. Most common 6-8 wks

S&S: difficulty staying awake, tremors, abnormal RR, poor eating, vomiting, discolored skin, seizures, coma, paralysis. Permanent vision and hearing loss, seizure disorder, developmental delays, cerebral palsy, subdural hematoma, vertebrae damage

Question 14

Post-concussion syndrome

Answer 14

Concussion symptoms days -months after concussion occured

Headache, dizzy, nervousness, fatigue, irritable, depression, forgetfulness

Question 15

Post-traumatic seizures

Answer 15

•Highest risk in open brain injuries
•Start within days, can last 2-5 yrs

Question 16

Chronic Traumatic encephalopathy

Answer 16

•Due to recurrent TBIs
•Strongly related to sports, blast injuries, work-related trauma (construction work)
•Long term complications (decrease in cognitive abilities, pneumonia, suicidality)

Question 17

Spinal cord injury types

Answer 17

Compression: pressure causing ischemia

Laceration: Tearing of neural tissue. can be reversable depending on which part of spinal column affected

Transection: Severing of spinal cord. Total loss of function below injury.

Partial transection: may preserve some motor or sensory function below injury

Question 18

Secondary spinal cord injury

Answer 18

Cascade of vascular cellular biochemical events that start within minutes of initial event, but carries on for potential weeks causing further damage

Microscopic haemorrhage in gray matter that continues until all gray matter is haemorrhagic in that area.

Can become necrotic which leads to oedema in white matter.

Impairs microcirculation, resulting in inflammation, increases disfunction. Can mask permanent damage.

overtime the tissues replaced with collagenous tissue, so csn have return of some function in 3-4 weeks.

** these are the patients we here who had a spinal injury, and then walked again**

Question 19

Vertebral Injury

Answer 19

Simple fractures: no dislocation - no other damage - stable

Compressed vertebral fracture: Spine pushed down on itself - no displacement - no other damage. Loss of function or sensation

Burst fracture: One vertebrae - disintegration of vertebrae, damage to spinal column

In burst or dislocation there is a loss of protection for spinal column. Results from direct or indirect trauma. Supporting ligaments are torn from spine - spine moves out of alignment - flexion or extension or flexion rotation injury that results in dislocation
•Fracture that no longer supports the spinal column - may see damage to sensory motor function

Question 20

Spinal shock

Answer 20

Immediately after injury
•Normal activity at or below level of injury completely gone
•Complete loss of reflex
•Poikilothermic: loss of ability to control body temperature
•1-3 weeks. Can be as short as a fee days or as long as 3 months
•Return of reflexes = end of spinal shock
•Everything lost with spinal shock, but when reflexes return, we can see the damage caused by the initial injury
•Sympathetic NS gone, parasympathetic unopposed - vasodilation, hypotension, bradycardia, poiklethermia

Question 21

Autonomic Dysreflexia (AD)

Answer 21

•Emergency situation
•In spinal cord injury T6 or higher
•Sympathetic NS pushed into fight or flight - parasympathetic NS not responding appropriately
•Noxious stimulus causes exaggerated SNS response. Causes vasoconstriction below injury and increased blood flow above injury.

S&S: bradycardia, vasodilation above injury, anxiety, bowel/bladder issues, blurry vision, dizzy, lightheaded, fever, diaphoretic above point of injury, profound hypertension is hallmark of autonomic dysreflexia.

If left untreated, seizures, pulmonary edema, renal insufficiency, MI, can cause cerebral edema. Can lead to brain injury or death.