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Neurology > Trauma > Flashcards

Trauma Flashcards

1
Q

What is a penetrating (missile) injury

A

When an object travels through the head to cause injury

Can be at high or low velocity

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2
Q

What are the effects of a penetrating (missile) injury

A

Focal damage - affects region the object strikes
Lacerations in the brain
Haemorrhage

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3
Q

What is cavitation

A

Where a high velocity object causes low pressure

Leads to short term cavity forming which then collapses causing damage

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4
Q

Describe high vs low velocity penetrating head injury’s

A

The speed an missile is travelling when it hits the head often determines the extent of the damage
Fast moving projectiles often cause more damage
Important in gun shot wounds

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5
Q

What is a non-missile (blunt) injury

A

When there is a sudden acceleration/deceleration of the head
Brain moves within the cranial cavity and makes contact with the inside of the skull

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6
Q

What are the common causes of blunt/ non-missile injury

A

RTAs
Falls
Assault
Alcohol

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7
Q

What is the primary head injury

A

The injury that occurs on impact/trauma
Includes the injury to the neurons
Irreversible - brain tissue has limited repair capacity

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8
Q

What is the secondary brain injury

A

Haemorrhage, oedema, infection, hypoxia etc
Occurs as a result of the primary one
Usually leads to a lack of oxygenation of the brain
Potentially treatable

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9
Q

What are the main effects of scalp lesions

A

Bruising
Can cause extensive bleeding
Route of infection

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10
Q

What are the types of skull fracture

A

Linear - straight fracture line that may cross sutures
Compound - open fracture with scalp laceration
Depressed - bones displace inwards (often also compound)

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11
Q

Why should base of skull fractures be considered open fractures

A

Because they usually create an opening into the paranasal sinuses which gives a route for infection

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12
Q

What is the difference between coup and contra-coup injury

A

Coup injury occurs at the point of impact – brain will impact the skull at the point the head has been struck
Contra-coup occurs at the opposite point oof the skull

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13
Q

What tends to be the worse injury - coup or contra-coup

A

Contra-coup
Could either be due to movement of CSF which gives it higher impact
OR
Cavitation - bubbles of low pressure damage the tissue

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14
Q

What is diffuse axonal injury

A

Widespread disruption of axons due to tearing force
Mainly affects central structures
Occurs at the moment of injury
Can lead to a vegetative state, coma and reduced consciousness

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15
Q

What causes diffuse axonal injury

A

Blunt force trauma to the head

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16
Q

What causes cytotoxic oedema

A

Intoxication

Severe hypothermia

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17
Q

What causes ionic oedema

A

Hyponatremia

Excessive water intake - SIADH

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18
Q

What causes vasogenic oedema

A

Trauma, tumours, inflammation, infection

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19
Q

What is more common, intradural or extradural haemorrhage

A

Intradural

Includes subdural and subarachnoids

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20
Q

What causes a traumatic extradural haematoma

A

Occurs when middle meningeal artery is damaged usually after fracture of squamous part of temporal bone
Minimal immediate damage but if untreated can cause midline shift, compression and herniation

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21
Q

What causes a subdural haemorrhage

A

Disruption of the bridging veins that extend into the subdural space
Occurs after trauma
Common in the elderly

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22
Q

What happens in an acute subdural haematoma

A

Clear trauma history
Brain swells and the haematoma has a mass effect
Can cause shifts and herniations

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23
Q

What happens in a chronic subdural haematoma

A

Very subtle presentation
Often present to GP or very late to hospital
older haemorrhage so will have a yellow appearance
Associated with brain atrophy

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24
Q

What is the definition of a traumatic brain injury

A

A non-degenerative, non-congenital insult to the brain from an external mechanical force, possibly leading to temporary or permanent impairment of cognitive, physical and psychosocial functions

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25
Q

Head injury is the commonest cause of death and disability in people age 1-40 in UK - true or false

A

TRUE

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26
Q

Who is at high risk of traumatic brain injuries

A

Young men and the elderly
Those with previous head injuries
Alcohol and drug abuse
Low income

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27
Q

What situations have high risk of traumatic brain injury

A 
Alcohol - cause of almost half 
Assault 
Falls 
RTCs 
Sports
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28
Q

When do the majority of deaths from traumatic brain injury occur

A

Within the first hour

After that there is a second peak as the secondary complications start

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29
Q

How do you immediately manage a TBI

A

ABC - intubate to secure airway and use C-spine control
GCS and pupil check
Secondary survey for other injuries

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30
Q

What might be relevant in the drug history for a TBI

A

Anticoagulants

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31
Q

What are the 3 sections of the GCS

A

Eye opening - out of 4
Verbal - out of 5
Motor - most significant and out of 6

Minimum score is 3, max is 15

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32
Q

The lower the GCS the better the outcome - true or false

A

FALSE!

Lower the GCS the worse the outcome

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33
Q

Who needs a CT scan

A 
GCS<13 on initial assessment in the ED
GCS <15 at 2 hours after injury
Suspected open or depressed skull fracture
Any sign of basal skull fracture
Post traumatic seizure
Focal Neurological Deficit
More than one episode of vomiting
Suspicion of NAI
Over 65 
Coagulopathy
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34
Q

What are the signs of a base of skull fracture

A 
Racoon eyes - bruising around orbit 
Battle's sign - bruise behind ears 
Blood or CSF leaking from ears or nose 
Haemotympanum
Bump
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35
Q

How does an extradural haematoma present on CT

A

Occurs outside the dura and pushes inward - pressure

Gives a bi-convex/lens shape

36
Q

How does a extradural haematoma present clinically

A

Usually due to an injury and they have loss of consciousness
Recovery with a lucid interval
They will then have a rapid deterioration - lowering GCS, possible hemiparesis, unilateral fixed and dilated pupil
Will then go into apnoea and death

37
Q

What is an intracerebral haematoma

A

Blood clot within the brain itself

38
Q

What is the goal of treatment after a head injury

A

Cant undo the primary insult so focus is on preventing the secondary issues
Avoid hypoxia – give oxygen
Mass lesions – can these be removed so that ICP is reduced
To get a good cerebral perfusion pressure you need to keep MAP up and ICP down

39
Q

What is the monro-kellie principle

A

Skull is a closed box, and increased pressure means one component of the contents gets pushed out
CSF will get pushed out into spine first
Once this is exhausted, the brain and blood vessels get pressed on

40
Q

Which type of herniation can be life threatening

A

Central

Brain gets pushed out of the foramen magnum which compresses the brain stem

41
Q

Why do you sedate someone with a brain injury

A

It reduces the metabolic demand on the brain

42
Q

Why should you intubate someone with a brain injury

A

You need to avoid hypoxia as this will cause further brain injury

43
Q

How can you monitor ICP

A

Can place a wire inside the head to give a pressure reading

It sits in the ventricles to give accurate reading

44
Q

How can you manage raised ICP medically

A

Sedation - benzos etc
Maximise venous drainage - head of bed tilt, cervical collars etc
Osmotic diuretics - mannitol
CSF release - can put in drains

45
Q

What position should you put the head in to reduce ICP

A

30’ position

Adjust the head of the bed to achieve this

46
Q

What is a decompressive craniotomy

A

Surgical procedure to remove part of the skull to reduce pressure
Risky operation – high infection risk
Need to put an artificial plate in – cosmetic procedure

47
Q

Should you give prophylactic anti-epileptics to those with head injury

A

Can cause secondary insult but little evidence that prophylaxis helps

48
Q

Describe the process of excitotoxicity

A

Occurs after injury
Excitatory amino acids (Glutamate) released
Activates NMDA receptors
Calcium mediated activation of proteases and lipases
Further cell death

49
Q

What is needed to confirm a brainstem death

A 
No pupil response
No Corneal reflex
No Gag reflex
No Vestibulo-ocular reflex
No motor response
No respiration
No severe metabolic or endocrine disturbance 
No hypothermia 
No drugs

2 doctors must carry out all test
Basically a lack of all brain stem function/reflexes

50
Q

How do you test vestibulo-ocular reflex

A

Inject ice cold water into ear and look for eye response

Would normally induce nystagmus

51
Q

How do you confirm lack of respiration

A

Pre-oxygenate and then turn off the respirator – look for the CO2 to rise to at least 6Kpa
If there is no attempt at spontaneous respiration then they are brain stem dead

52
Q

What is a subarachnoid haemorrhage

A

When there is bleeding into the subarachnoid space - into the CSF
Can be fatal

53
Q

What usually causes a subarachnoid haemorrhage

A

Usually a berry aneurysm rupturing
Sometimes AVM
Sometimes its spontaneous
Rarely trauma

54
Q

How does a SAH present

A 
Sudden onset severe headache - explosive/thunder-clap, worst they've ever had
Collapse 
Vomiting 
Neck pain 
Photophobia 
May have a reduce consciousness
55
Q

What are the differentials for a sudden onset headache

A

SAH
Migraine - usually people know what this is but could be their first presentation
Benign coital cephalgia - severe sudden headache after exertion (often during sex)

56
Q

What is the gold standard test for a SAH

A

CT scan of the brain

May be negative in some though- follow up LP in case

57
Q

When is it safe to do an LP

A

Safe in alert patient with no focal neurological deficit and no papilloedema, or after normal CT scan

58
Q

What should you do if someone with a suspected subarachnoid haemorrhage has a normal CT

A

Lumbar puncture

Look for bloodstained or xanthochromatic (yellow) CSF

59
Q

What is the gold standard for looking for brain vessel abnormalities

A

Cerebral angiography

Travel up via femoral artery

60
Q

What are the potential complications of a SAH

A

Can be immediately fatal or lead to brain damage
Can re-bleed - often the cause of death as missed
Delayed ischaemic deficit
Hydrocephalus
Hyponatraemia
Seizures

61
Q

How can you prevent re bleeding after a SAH

A

Endovascular techniques - can place coils into the aneurysm so that blood cannot feel
Surgical clipping - place metal clip across aneurysm to occlude it

62
Q

How can you treat the delayed ischaemia associated with SAH

A

Nimodipine - CCB

High fluid intake

63
Q

How can you treat the hydrocephalus associated with SAH

A

CSF drainage

Can be done LP or EVD (shunt into brain)

64
Q

How does SAH cause hydrocephalus

A

Blood can clog the CSF pathways – either block its reabsorption in the sinuses or block its movement through the ventricles
This increased the pressure in the brain
Causes headache or altered consciousness

65
Q

How do you treat hyponatremia caused by SAH

A

Supplement the sodium intake
Fludrocortisone
DO NOT fluid restrict as this can lead to cerebral ischaemia which is worse

66
Q

SAH lowers your seizure threshold - true or false

A

TRUE

10% 5 year risk

67
Q

What commonly causes a intracerebral haemorrhage

A

Hypertension - 50% of cases

Aneurysm or AVM

68
Q

How does an intracranial haemorrhage present

A

Headache
Focal neurological deficit - feature dependant on location of bleed
Decreased consciousness level

69
Q

How do you investigate an intracerebral haemorrhage

A

CT - urgent if decreased consciousness

Angiography if there is a suspected vascular anomaly

70
Q

How do you treat and intracerebral haemorrhage

A

Surgical evacuation of the haematoma

Treatment of underlying anomaly if needed

71
Q

What areas have a poor prognosis for intracerebral haemorrhage

A

Large basal ganglia or thalamic clots

Can lead to major focal deficits or deep coma

72
Q

What causes an intraventricular haemorrhage

A

Occurs after rupture of a subarachnoid haemorrhage or if there is an intracerebral bleed into a ventricle

73
Q

How can you treat AVM

A

Surgery
Endovascular embolization
Stereotactic radiotherapy
Conservative - have to weigh up risk/benefit

74
Q

How do you open someones airway if they have a head/neck injury/trauma

A

You should only do a jaw thrust to open the airway in order to keep C-spine still
Head tilt chin lift cause too much movement

75
Q

What is the main contraindication to using a Guedel airway (oropharygeal)

A

Conscious patient as it will make them gag

Otherwise pretty safe to use

76
Q

What is the main contraindication to using a nasopharygeal airway

A

Base of skull fracture

The tube can pass through the fracture into the brain

77
Q

When can you use a full anaesthetic airway

A

Only if patient is unconscious under GA or in cardiac arrest

78
Q

What is the definition of unconscious

A

Not awake and aware of/responding to environment

79
Q

What is the definition of coma

A

A state of unarousable unconsciousness

GCS of 8 or less is a definition of coma

80
Q

At which GCS should you consider intubation

A

8 or less

This suggests a loss of protective airway reflexes

81
Q

What is the usual cause of a subdural haematoma

A

Tearing of the bridging veins under the dura

Usually due to trauma

82
Q

What is the normal cerebral perfusion pressure

A

around 70-100

83
Q

Why is raised ICP an issue

A

No where for it to go

The heart has to overcome this pressure in order to perfuse the brain (nutrients, oxygen etc.) - maintain CPP

84
Q

What is the Cushing’s reflex

A

High BP and low HR in context of brain injury
BP rises to try and overcome the raised ICP and perfuse the brain
Heart rate is lowered - reflex bradycardia triggered by baroreceptors in the neck

85
Q

How do you calculate CPP

A

CPP = MAP-ICP

Neurology (18 decks)

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