Neuro-Path-Pharm extra lectures

Question 1

Recall signs and symptoms of concussion.

Answer 1

• Confusion and amnesia (of event, retrograde and anterograde); with or WITHOUT loss of consciousness; headache, dizziness (vertigo or imbalance), lack of awareness of surroundings, nausea and vomiting.
• Over the next hours and days, patients may also complain of mood and cognitive disturbances, sensitivity to light and noise, and sleep disturbances

Question 2

Signs observed in someone with a concussion may include the following

Answer 2

• Vacant stare (befuddled facial expression)
• Delayed verbal expression (slower to answer questions or follow instructions)
• Inability to focus attention (easily distracted and unable to follow through with normal activities)
• Disorientation (walking in the wrong direction, unaware of time, date, place)
• Slurred or incoherent speech (making disjointed or incomprehensible statements)
• Gross observable incoordination (stumbling, inability to walk tandem/straight line)
• Emotionality out of proportion to circumstances (appearing distraught, crying for no apparent reason)
• Memory deficits (exhibited by patient repeatedly asking the same question that has already been answered or inability to memorize and return three of three words and three of three objects for five minutes)
• Any period of loss of consciousness (coma, unresponsiveness to stimuli)

Question 3

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
• The patient should be awakened from sleep every two hours for the first night and should avoid strenuous activity for at least 24 hours. The following warning signs should prompt the caregiver to seek immediate medical help:
- 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 4

Second impact syndrome.

Answer 4

• The term “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 a rare but generally fatal complication of mild head injury
• All guidelines agree that athletes suspected of having a concussion should be removed from sports participation immediately, that athletes should not return to play while signs or symptoms of concussion are present, and that athletes who have any loss of consciousness, any symptoms of concussion lasting more than 15 minutes, or who have post-traumatic amnesia should not be permitted to resume sports participation until asymptomatic for at least one week. An emergency department evaluation is indicated for any athlete who suffers loss of consciousness
• Premature return to play by a symptomatic athlete places that athlete at greater risk for subsequent concussion and cumulative brain injury

Question 5

management of blood pressure and oxygenation in severe head injury.

Answer 5

• These are two systemic insults known to be major causes of secondary injury after TBI. Prevention of hypoxia (PaO2 <90 mmHg) are priorities in the management of patients with severe TBI beginning with their prehospital care

Question 6

List factors that should be avoided to prevent secondary neurologic injury

Answer 6

Fever, hyperglycemia, coagulopathy, glucocorticoids

Question 7

Summarize intracranial pressure recommendations in severe head injury

Answer 7

• 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
• Indications for ICP monitoring in TBI are a GCS score ≤8 and an abnormal CT scan showing evidence of mass effect from lesions such as hematomas, contusions, or swelling
• treatment for elevated ICP should be initiated when ICP rises above 20 mmHg- ventricular drainage, osmotic therapy (mannitol), possible hyperventilation at later stages only, and sedation