Pt w/ Headache / Head Injury Flashcards
What signs and symptoms might there be if someone has a head injury?
In the absence of OBVIOUS TRAUMA and/or a HISTORY people might present in the following way:
- Nausea and Vomiting
- Impaired consciousness
- Headache
- Rhinorrhoea
- Otorrhoea
- Diplopia
- Pupil changes
- Cushing’s response
- ABG changes
Why is it important to get an ABG in someone who has had a head injury?
Close monitoring of their PaCO2 is really important. Even small increase will lead to vasodilation and marked vasodilation increasing the ICP
What is the cerebral perfusion pressure equation?
CPP = MAP - ICP
Was does the Monroe-Kellie doctrine state and what does this mean in the context of head injuries?
Cerebral/skull volume is fixed meaning that if ICP increases for any reason (due to a bleed or a SOL) this will have the affect of decreasing the CPP.
Even small increases in ICP will lead to clinical signs and larger increases may even lead to brain herniation
What are the early symptoms of raised ICP?
Altered consciousness
Confusion
Drowsiness
When ICP increase considerably where does the herniation occur and what affect does this have?
Into the tentorial hiatus which leads to compression of the parasympathetic portion of the oculomotor nerve (which runs in this tract)
Clinically this leads to FIXED DILATED PUPILS
What if the ICP continues to rise despite tentorial hiatus herniation?
Brain continues to herniate out of the skull
Initially this will cause CONTRALATERAL HEMIPARESIS and then as the brainstem becomes compressed it can lead to CARDIOPULMONARY ARREST
What affect can increasing ICP have on haemodynamics?
CUSHING’S RESPONSE
Hypertension
Bradycardia
Irregular breathing (triad)
What are some more specific symptoms of a basal skull fracture?
Haemotympanum Otorrhoea (CSF leak) Rhinorrhoea (CSF leak) Battle's sign (bruising over mastoids) Panda eyes (bilateral orbital bruising) Subconjunctival haemorrhage
What are the two types of head injury?
PRIMARY (occurs at the time of accident) - axonal shearing or haemorrhage
SECONDARY (due to other problems such as hypoxia, hypovolaemia, seizures, infection, haematoma)
What is the CPP at which we would start to become concerned?
70mmHg or below
What investigation should be done in a patient with a head injury?
Head and neck CT Pupil responses Limb power Monitor obs closely AVPU, GCS and AMTS
What factors are really important to ask about in the history of someone who’s had a head injury?
When it happened
Mechanism of injury (MoI)
Did they lose consciousness? Before or after hitting their head? Did they have a seizure?
Do they remember the event or do they have AMNESIA?
Ask about symptoms above (rhinorrhoea, pyorrhoea etc.)
PMH (cardiac arrhythmias, diabetes, epilepsy, prev HI)
DH: alcohol, other drugs, regular meds
SH: is their home situation suitable for discharge?
What should the examinations and assessment of someone with a head injury involve?
Full CNS and PNS C-SPINE assessment - immobilise until happy no fracture (Canadian C-Spine rules) GCS Regular obs ECG FBC, U&E, Glucose, Clotting Pupil examination
What are some signs of cerebellar damage?
DANISH Dysdiadochokinesia Ataxia Nystagmus Intention tremor Slurred/Staccato speech Hypotonia
How should a head injury patient be managed initially?
A-E assessment (if GCS<8 call anaesthetist)
Check blood pressure and treat hypoglycaemia if necessary
Correct hypovolaemia
Make ICU, anaesthetics and neurosurgery aware
Arrange CT and make sure radiologist is there to interpret
IV abx for compound skull fracture (IV cefuroxime)
What are the criteria for CT scan in the ED in patients with head injury?
GCS <13 at presentation
GCS <15 at 2 hours post injury after assessment in department
Suspected open or depressed skull fracture
Any signs of basal skull fracture
Post-traumatic seizure
Any focal neurological deficit
More than one episode on vomiting post injury
PERFORM WITHIN 1 HOUR
Other RFx that should warrant scan within 8 hours include (on warfarin, >65, dangerous MoI, hx of bleeding or clotting disorder or more than 30m retrograde amnesia)
