Neurological Trauma Flashcards
How does injury occur in an acceleration/deceleration injury?
compression, tension and shearing injuries
name for brain tissue injury directly at the site of impact and at teh pole opposite of the site of impact?
coup-countrecoup injury
Blast injuries primarily affect which part(s) of the brain?
hippocampus and brain stem
How does hyperventilation lower ICP?
causes cerebral vasoconstriction
When is hyperventilation used in the treatment of a brain injury?
- when symptoms of brain herniation are present or if ICP is severely high
- causes vasoconstriction by reducing PaCO2
What is the goal PaCO2 when hyperventilating a patient with suspected herniation?
25-30 mmHg
What is the goal SBP for 50-60 y/o with brain injury?
> 100 mmHg
What is the goal SBP for > 15 y/o with brain injury?
> 110 mmHg
What does AVPU stand for when assessing neuro status?
- Awake
- responds to Verbal stimuli
- responds to Painful stimuli
- Unresponsive
What does the glasgow coma scale assess?
- eye opening
- verbal response
- motor response
What is the score range for the GCS?
- 3-15
- 3 = worst score
- 15 = best scores
A patient is considered comatose with a GCS score of?
8 or less
Term for flexion of upper extremities with inward rotation and extension of lower extremities
decorticate
term for rigidity and abnormal extension of upper extremities and lower extremities
decerebrate
What condition should be considered when pupils are sluggish, unequal or enlarged with no response?
increased intracranial pressure or herniation
What labs should be drawn on a TBI patient?
- tox screen
- CBC
- BMP or CMP
- Coagulation panel
What is the initial imaging study for a TBI patient?
non-contrast CT
What are the categories of injury related to TBI?
- primary head injury
- skull fracture
- brain injury
What is the most common head injury?
scalp laceration
What are signs of hypolemia?
- increased HR
- decreased BP
How to treat a scalp laceration?
- monitor for hypovolemia
- assess for skull fracture then apply direct pressure
- suture/staple
Lidocaine 1% with epinephrine should not be use where on the head?
nose or ears
Types of skull fractures?
- simple
- depressed
- basilar
Description of a simple skull fracture?
no displacement of bone or interface of the outside environment with the intracranial contents
Description of a depressed
bone tables and fragments depressing the thickness of the skull with exposure of the intracranial contents with the outside environment
Type of skull fracture with no displacement of bone or interface of the outside environment with the intracranial contents
simple skull fracture
Type of skull fracture where the bone tables and fragments depressing the thickness of the skull with exposure of the intracranial contents with the outside environment
depressed bone fracture
Treatment of a depressed bone fracture?
- surgery often required
- prophylactic broad-spectrum antibiotics
- tetanus is indicated
Description of a basilar fracture?
fracture in the anterior or posterior skull base
Raccoon eyes are associated with which type of fracture?
basilar fracture with anterior skull based compartment involvement
Term for periorbital ecchymosis related to an anterior skull base fracture?
raccoon eyes
Term for mastoid ecchymosis related to a posterior skull basilar fracture?
battle sign
Battle sign is associated with which type of fracture?
basilar fracture with posterior skull base involvement
Signs of a basilar fracture?
- raccoon eyes
- battle signs
- otorrhea
- rhinorrhea
Treatment of a basilar fracture?
- lumbar drain to divert CSF and minimize ICP
- surgical repair
- prophylactic antibiotics
- intubation and OG
What are considerations for placement of a gastric tube in a patient with a skull fracture?
- use oral gastric tube and intubation
- avoid nasal route
Term for transient, reversible alteration in brain function?
concussion
What is the most common location of a concussion?
the temporal lobe
Consider imaging of a concussed patient if?
- GCS < 15 at 2hr
- GCS < 14 anytime
- EtOH/drugs suspected/noted
- concern for skull fracture
- age > 60 or < 16
- coagulopathy suspected
- focal deficit
- Loss of consciousness > 5 min
- seizure activity noted
- vomiting > 2 times
- persistent, severe HA
Term for regions of hemorrhagic necrosis and bruising of the brain
contusion
Most common sites of contusion lesions in the brain?
orbitofrontal or anterior temporal regions
Consider starting which types of prophylaxis treatment for brain contusions?
antiepileptic and seizure precautions
Bleeding into the epidural space between the skull and dura mater is called?
epidural hematoma
Lenticular shape that does not cross suture lines noted on a brain CT is indicative of?
an epidural hemorrhage
Evaluation and treatment of an epidural hematoma?
- noncontrast CT
- neurosurgical consult
- medical therapy
- surgical intervention
bleeding between the dura mater and arachnoid or pia layers?
subdural hematoma
What is the most frequent type of intracranial bleeding?
subdural hematoma
How long does it take for an Acute subdural hematoma to develop?
minutes to hours
How long does it take for a chronic subdural hematoma to develop?
days or weeks, generally in the elderly
Caused by the accumulation of blood between the arachnoid and pia surface?
subarachnoid hemorrhage
Symptoms of a epidural hematoma?
- initially unconscious, wakes up without deficit and then deteriorates
- deterioration may be rapid
S/S of an acute subdural hematoma?
- drowsiness
- agitation
- confusion
- HA
- unilateral or bilateral pupil dilation
- hemiparesis
S/S of a chronic subdural hematoma?
- usually in the elderly
- HA
- memory loss
- personality changes
- incontinence
- ataxia
S/S of traumatic subarachnoid hemorrhage?
- HA
- reduced LOC
- nuchal rigidity
- hemiplegia
- ipsilateral pupil abnormalities
Diffuse axonal injury is commonly observed with which type of movement?
rapid acceleration/deceleration of the head d/t shearing forces
Mild coma r/t a diffuse axonal injury lasts?
6-24 hrs
Moderate coma r/t a diffuse axonal injury lasts?
> 24 hrs
Severe coma r/t a diffuse axonal injury lasts?
prolonged and with decorticate/decerebrate posturing
Blown pupils are indicative of what type of brain injury?
cerebral herniation
What are the signs of Cushing triad r/t TBI?
1 ) HTN with widening pulse pressure
2) decreased RR
3) bradycardia
- elevated ICP is a late sign
Treatment of cerebral edema/elevated ICP/herniation?
- elevate HOB > 30 degrees
- opioids to lower ICP
- drain CSF
- hypothermia
- paralysis
Preferred choice of sedation in treatment of cerebral edema/elevated ICP/herniation?
- short acting opioids
- fentanyl
- remifentanil
What is the max dose of propofol for the treatment of cerebral edema/elevated ICP/herniation?
5mg/kg/hr
What is the dosage for a fentanyl gtt to treat cerebral edema/elevated ICP/herniation?
2-5 mcg/kg/hr
What is the dosage of propofol in the treatment of cerebral edema/elevated ICP/herniation?
20-75 mcg/kg/hr
Dexmedetomidine (precedex) gtt dosage in the treamtne of cerebral edema/elevated ICP/herniation?
0.2-0.7 mcg/kg/hr
Midazolam (versed) gtt dosage in the treatment of cerebral edema/elevated ICP/herniation?
0.2-1 mg/hr
diazepam (valium) dosage in the treatment of cerebral edema/elevated ICP/herniation?
2.5-10 mg single dose
lorazepam (ativan) dose in the treatment of cerebral edema/elevated ICP/herniation?
0.5-2 mg single dose
Cisatracurium (Nimbex) dosage in the treatment of cerebral edema/elevated ICP/herniation?
- 0.1-0.2 mg/kg bolus
- 1- 10 mcg/kg/min continuous
Nimbex is titrated to?
train of four
Why is Mannitol the drug of choice in an emergency situation when brain herniation is pending?
- creates an osmotic gradient across the blood-brain barrier that pulls water from the CNS into the intravascular space
- decreases blood viscosity
Hyperosmolar therapy with Mannitol to treat brain herniation should be avoided in what patients?
- in shock
- HF
- significant renal disease
What does CPP stand for?
cerebral profusion pressure
Prophylactic anti-seizure treatment should last no longer than how many days?
7 days
How many cervical vertebrae are there?
7
How many thoracic vertebrae are there?
12
What are the parts of the spinal cord?
- ascending tracks
- descending tracks
- gray matter
- white matter
- meningeal layer
What are the parts of the meningeal layer?
- pia mater
- arachnoid
- dura mater
Types of spinal injury?
- complete
- incomplete
Types of incomplete spinal cord injuries?
- Anterior cord syndrome
- Posterior cord syndrome
- Central cord syndrome
- Brown-Sequard syndrome
- Cauda equina syndrome
Anterior cord syndrome is cause by what type of injury?
hyperflexion injury
What is tested for in a BMP?
a. Bicarb
b. BUN
c. Creatinine
d. Calcium
e. Chloride
f. Glucose
g. Potassium
h. Sodium
What is tested for in a CMP?
a. Albumin
b. Alkaline phosphatase (ALP)
c. ALT
d. AST
e. Bicarb
f. Bilirubin
g. BUN
h. Creatinine
i. Calcium
j. Chloride
k. Glucose
l. Potassium
m. Sodium
n. Total protein
