Neuro - Tramatic Brain Injury

Question 1

According to Quality Standards Subcommittee of the American Academy of Neurology what is a concussion?

Answer 1

trauma-induced alteration in mental status that may or may not involve loss of consciousness.

Question 2

What key clinical signs will a patient with a concussion present with?

Answer 2

Confusion
Amnesia
Loss of Consciousness (may or may not occur)

Symptoms can occur several minutes after these findings

Question 3

What are some later signs and symptoms of a concussion?

Answer 3

(minutes or hours later)
Dizziness 
Headache
Nausea and vomiting
Lack of awareness of surroundings

Over the next hours or days:
Mood and cognitive disturbance
Sensitivity to light and noise

Question 4

What cognitive dysfunctions might a patient with a concussion display?

Answer 4

Delayed verbal expression
Inability to focus attention
Disorientation
slurred or incoherent speech
Memory Deficits
Loss of consciousness

Question 5

What personality signs of someone with concussion?

Answer 5

Vacant befuddled stare

Emotionality out of proportion with circumstances

Question 6

What motor symptoms?

Answer 6

Gross uncoordinated movements, falling stumbling, inability to walk tandem straight

Question 7

What language deficiencies might be shown?

Answer 7

Delayed verbal expression
Slower to answer questions or follow instructions
Slurred or incoherent speech

Question 8

What are components of the Glasgow coma scale?

Answer 8

Eye response, verbal response and Motor response

Question 9

What are the eye response in GC scale?

Answer 9

1 - does not open eyes
2 - eye opening in response to pain
3 - eye opening to speech
4 - eyes open spontaneously

Question 10

What are the verbal response in GC scale?

Answer 10

1 - no verbal response
2 - incomprehensible
3 - slurred speech, random 
4 - confused disoriented, patient responds to questions but there is some disorientation
5 - oriented conversing normally

Question 11

What are the motor responses in GC scale?

Answer 11

1 - no motor response
2 - decerebate to painful stimuli
3 - decorticate to painful stimuli
4 - flexion withdrawal to painful stimuli
5 - localizes painful stimuli
6 - obeys commands

Question 12

What is recommended in outpatient observation for patients admitted after a concussion?

Answer 12

It is recommended that the patients with a mTBI should be observed for 24 hours to rule out intracranial complications. Patient’s with normal GC (15), normal CT findings and someone to monitor the progress of the symptoms can go home.

Question 13

How should you monitor a patient with the first 24 hours of outpatient observation?

Answer 13

Patient must be awakened from sleep every 2 hours the first night and no strenuous activity for first 24 hours.

Question 14

What signs are red flags for outpatient monitoring?

Answer 14

Inability to awaken patient
Severe or worsening headaches
Somnolence or confusion
Restlessness, unsteadiness, or seizures
Difficulties with vision
Vomiting, fever and stiff neck
Urinary or bowel incontinence
Weakness or numbness involving any part of the body

Question 15

What do warning signs observed with mTBI patients indicate? What should be done?

Answer 15

Warning signs indicate intracranial complications like hemorrhage or evolving cerebral edema.

A thorough neurological examination and a CT. If CT shows new intracranial pathologic finding get consultation.

Question 16

What is second impact syndrome?

Answer 16

Diffuse cerebral swelling occuring after a second concussion, while an athlete is still symptomatic from an earlier concussion.

Question 17

What the physiological cause of second impact syndrome?

Answer 17

The process is thought to be caused bu a disordered cerebral auto-regulation causing cardiovascular congestion and malignant cerebral edema with increase intracranial pressure.

Question 18

What are the two major causes of severe head injury secondary TBI?

Answer 18

Hypoxia and hypotension

Question 19

What are the goals for managing severe head injury?

Answer 19

Normalize oxygen and blood pressure have shown better outcomes

Question 20

What are the standards of hypotension prevention?

Answer 20

Keep systolic blood pressure above 90 mmHg

Adequate fluid resuscitation using isotonic cystalloids (saline not albumin)

Ongoing monitoring of the patient vital signs

Continually asses neurological status

Question 21

What treatments are used for prevention of hypoxia?

Answer 21

Maintain of PaO2 greater than 60 mmHg (normal 75 - 100 mmHg

GCS below 8 indicates an endotracheal intubation is recommend if well trained provider is present (if not than bag-mask ventilation is used)

Still important the vital signs and neurological status

Question 22

What is a secondary neurological injury?

Answer 22

An indirect result of the insult secondary to the processes of the trauma. It occurs hours and days following the primary injury and plays a large role in the brain damage and death that results from TBI.

Question 23

What factors should be avoided with Secondary Neurological injury?

Answer 23

Hypoxia
Hypotension
Hyperventilation
Increased ICP
Low cerebral perfusion pressure

Question 24

What are some simple techniques to prevent a rise in ICP following a severe head injury.

Answer 24

• Elevate head and torso to 30 degrees
• Optimizing of venous drainage: Keep neck in neutral position and losing neck brace if too tight.
• Monitor central venous pressure and asses hypervolemia

Question 25

What are the indications for monitoring the ICP

Answer 25

GCS of 8 or less
Abnormal CT scan (mass affect from hemotoma/contusion/swelling
Older than 40
Motor posture (motor GCS of 3 or less)
Systolic of 90 mmHg or less

Question 26

When should treatment of ICP be intiated?

Answer 26

greater than 20 mHg

Question 27

What is the treatment for increase ICP secondary to TBI?

Answer 27

Ventricular drainage: Spinal tap; remove 1-2 mmHg for 2-3 minutes with intervals of 2-3 mins until statiscatory ICP has been achieve (<20mmHg).

Ventriculostomy can also allow for slow removal accomplished by passive gravitation.

Question 28

How can you lower ICP if ventricular drainage doesn’t work?

Answer 28

Use osmotic therapy, hyperventilation and sedation