TBI, neck injury Flashcards by Elaina Collins

how many americans are living with TBI related disability?

2.5-6.5 million

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what is the leading cause of TBI in the US?

MVA

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what three types of responses make up the GCS? how many criteria in each category?

eye responses (4)
verbal responses (5)
motor responses (6)

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what are the three levels of TBI severity according to GCS score?

mild=GCS 13-15
moderate=GCS 9-12
severe=GCS less than 8

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what are the three types of tissue deformation seen in TBI?

1) compression
2) tensile (tissue stretching)
3) shearing (tissue sliding over tissue)

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what do we worry about occurring minutes to days after the initial primary insult in TBI?

secondary injury:

1) microscopic/cellular injury
2) cerebral arterial dilation
3) cerebral edema
4) ischemia/hypoxia
5) increased ICP

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battle’s sign, raccoon eyes, CSF rhinorrhea, otorrhea, or hemotympanum should make you think of what?

basilar skull fracture

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who should always get a CT scan following head injury, regardless of severity of symptoms?

those on oral anticoagulants

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what is the diagnostic imaging of choice for head injury?

CT without contrast

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a vacant stare, delayed verbal expression, inability to focus attention, gross incoordination, emotionality out of proportion to circumstances are signs of what?

concussion

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where do we want to maintain mean arterial pressure (MAP) when dealing with TBI patients?

90 mmHG

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what are the three first things you should set your patient with suspected TBI up with STAT when they present to the ED?

1) put patient on O2
2) cardiac monitoring
3) IVF w/ normal saline infusion

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does a concussion reflect more of a functional or a structural injury?

functional

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what will imaging of concussion show?

it will be grossly normal

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what percentage of patients with a past concussion did not recognize it as such?

80 percent

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having a seizure within the first week of injury puts you at risk for what?

post-traumatic epilepsy resistant to typical anticonvulsant RX

25 percent risk increase

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your patient is a 12 year old boy with a very mild concussion. he lives with his demented grandmother because his mom can’t take care of him. should you send him home?

NOOooO

admit even if healthy patient has no responsible adult available to observe the patient

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according to the cantu guidelines, if your patient had a loss of consciousness for more than 1 minute OR post traumatic amnesia for longer than 24 hours, when can they return to play?

1 month if asymptomatic at rest and on exertion for 7 days

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most common cause of intracerebral hemorrhage?

HTN

ruptured vessel WITHIN the brain

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what must you do if patient presents with intracerebral hemorrhage?

lower ICP!

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what is normal ICP? what is pathologic ICP?

normal = 0-10 mmHG

pathologic is over 20 mmHG

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at what mmHG is cerebral perfusion pressure considered critical?

50-70 mmHg

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what are the two ways that we can bring down intracranial pressure?

1) increase MAP: IVF, pressors

2) decrease ICP: osmotic diuresis, HOB elevation, drain CSF (burr hole), hyperventilation

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what is the mechanism of injury for a diffuse axonal injury?

acceleration/deceleration causes a shear force that injures the axons at the junction of the grey and white matter

if you are in a coma between 6-24 hours due to a diffuse axonal injury, what does your prognosis look like?

recover without long term sequelae

if you are in a moderate staged coma for over 24 hours following diffuse axonal injury, what does you prognosis look like?

you wake up, but will have long-term cognitive defecits

what is the prognosis for a severe diffuse axonal injury (prolonged coma)?

persistent vegetative state in 90 percent

if patient presents in collar and boarded, what should your highest suspicion be?

C-spine injury evaluate immediately!

patient presents on a board with suspected C-spine injury, what should your first priority be?

get the patient off the board as soon as possible..they are painful and can lead to necrosis

where do the majority of spinal injuries occur?

cervical region in 55 percent

what is the MOI of central cord syndrome?

forced hyperflexion of neck

how will a patient with central cord syndrome present? what is their prognosis?

weakness in the UPPER extremities; sensation probably okay probably will recover okay

which type of cord syndrome is related to vascular injury, infarct or compression fractures?

anterior cord syndrome

how will your patient with anterior cord syndrome present?

loss of sensation, temp, pain on BOTH sides proprioception and vibration sense will be intact (dorsal unaffected) probably not a great recovery

a penetrating trauma (stabbing, gunshot) is most likely to cause which spinal cord syndrome?

brown-sequard syndrome half the spinal cord is impacted

how will someone with brown-sequard syndrome present?

loss of strength, proprioception, vibration on the same side as the injury loss of pain and temperature on the other side

what is the maneuver we use to maintain spinal immobilization when moving a patient from board to wherever we take them next?

log roll

what will you lose with an injury to C4?

spontaneous breathing

what will you lose with an injury to T1/T2?

loss of intercostal muscles and abdominal use

you will be able to detect 70 percent of C-spine abnormalities of which x-ray view?

lateral neck view

what imaging modality should you use for "low risk" patients with c-spine injury suspicion?

plain films

what imaging modality for high risk patients with c-spine injury suspicion?

what are some examples of "high risk" patients in terms of C-spine injury evaluation?

true trauma, unreliable, demented, obese

at what level of the spinal cord does a jefferson fracture occur? what is the MOI?

C1 axial loading (diving)

how will a patient with a jefferson fracture present?

may have few symptoms although the fracture is very unstable

what is the most common type of C2 fracture?

odontoid fracture also may have few symptoms but is extremely unstable

what type of fracture, and at what level, occurs with forced hyperextension of the neck?

hangman's fracture -- C2

MOI of hangman's fracture (C2)?

falls, motor vehicle fractures...hanging

how may a patient with hangman's (C2) fracture present? what is a major complication?

they might just walk in! complication: central cord syndrome (more weakness in UE than LE)

patient states they were gardening this morning and heard a "pop" followed by sudden pain between the shoulder blades. whats up?

clay shoveler's fracture (STABLE fracture in spinal cord)

how will someone with a clay shoveler's (spinous process) fracture present?

pain but NOT neurologic symptoms

which type of brain bleed is often missed on early CT (within 6 hours of injury)?

subarachnoid hemorrhage

acute "thunderclap" headache should make you think of what type of brain bleed?

subarachnoid hemorrhage

what pattern will you see on CT of a patient with a subdural hematoma?

crescent shaped concave hematoma

who are we most likely to see subdural hematomas in? how do we manage them?

elderly with dementia/cerebral atrophy, alcoholics they are slow venous bleeds so may only require observation

which type of brain bleed is characterized by a brief LOC followed by a lucid period, and then often death?

epidural hematoma

what will we see on CT of a patient with an epidural hematoma?

lens (biconvex or football shaped) bleed

what physical findings will we note on PE of a patient with an epidural hematoma?

fixed dilated pupil on ipsilateral side with a contralateral hemiparesis (late finding)

why does an epidural hematoma carry such a poor prognosis? how do we manage these patients?

as opposed to subdural hematoma (venous bleed), this is a high pressure arterial bleed IMMEDIATE neurosurgical intervention for decompression to prevent brain herniation