Surgery Tips 4

Question 1

CT head immediately

Answer 1

GCS < 13 on initial assessment
GCS < 15 at 2 hours post-injury
Suspected open or depressed skull fracture.
Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
Post-traumatic seizure
Focal neurological deficit
> 1 episode of vomiting

Question 2

CT head scan within 8 hours of the head injury

Answer 2

Adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury
> 65 years old
Any history of bleeding or clotting disorders
Dangerous mechanism of injury (a pedestrian/cyclist struck by a motor vehicle, being ejected from a motor vehicle or a fall from a height > 1 metre or 5 stairs)
More than 30 minutes’ retrograde amnesia of events immediately before the head injury
Pt taking warfarin with no risk factors

Question 3

Extradural haematoma

Answer 3

Following trauma
Lump coming from skull into brain on CT
Temporal area is most common site
Middle meningeal artery is most commonly affected
Fast onset of symptoms
Features of raised ICP

Question 4

Subdural haematoma

Answer 4

Frontal and parietal areas are most common
RFs - old age, alcoholism, anticoagulation
Extra layer next to brain on CT
Slow onset of symptoms

Question 5

Subarachnoid haemorrhage

Answer 5

Occurs spontaneously due to ruptured cerebral aneurysm or traumatic brain injury
Thunderclap headache
Can get signs of meningism
Ix - CT head (if CT head is clear, LP 12 hours after symptoms started (xanthochromia))

Question 6

Signs of raised intracranial pressure

Answer 6

Cushing’s reflex - hypertension + bradycardia

Question 7

Diffuse axonal injury

Answer 7

Due to mechanical shearing following deceleration, causing disruption and tearing of axons
MRI is preferable
MRI/CT - small bleeds are visible in the corpus callosum or the cerebral cortex

Question 8

Rupture of the globe

Answer 8

Gross loss of vision

Question 9

Hyphaema

Answer 9

Monocular visual blurring, and would be diagnosed by inspection

Question 10

Ramus fracture

Answer 10

Difficulty opening eye and no visual changes

Question 11

Maxillary antrum rupture

Answer 11

Secondary to a comminuted maxillary fracture or blowout fracture of the orbit

Question 12

Depressed fracture of the zygoma

Answer 12

Binocular vision (double vision with both eyes open) and facial trauma
Painful to open mouth
Inspection and palpation of the orbital margins typically demonstrates a step deformity in the orbital margin or a depressed contour of the cheek

Question 13

Fractured zygoma

Answer 13

Due to assault with a punch impact on the cheek bone, or around the eye

Question 14

Pupil unilaterally dilated

Answer 14

Light response - sluggish or fixed

Due to 3rd nerve compression secondary to tentorial herniation

Question 15

Pupils bilaterally dilated

Answer 15

Light response - sluggish or fixed

Due to poor CNS perfusion or bilateral 3rd nerve palsy

Question 16

Pupil unilaterally dilated or equal

Answer 16

Light response - cross reactive (Marcus - Gunn)

Due to optic nerve injury

Question 17

Pupils bilaterally constricted

Answer 17

Light response - difficult to assess

Due to opiates, pontine lesions or metabolic encephalopathy

Question 18

Pupil unilaterally constricted

Answer 18

Light response - preserved

Due to sympathetic pathway disruption

Question 19

Pt with intracranial bleed + becomes unresponsive

Answer 19

Do CT head to check for hydrocephalus

Question 20

CT neck (c-spine)

Answer 20

> 65 years old
Dangerous mechanism of injury (fall from a height of > 1 metre or 5 stairs; axial load to the head, eg, diving; high-speed motor vehicle collision; rollover motor accident; ejection from a motor vehicle; accident involving motorised recreational vehicles; bicycle collision)
Focal peripheral neurological deficit
Paraesthesia in the upper or lower limbs.

A provisional written radiology report should be made available within 1 hour of the scan being performed