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FRCS Part 2 > Trauma > Flashcards

Trauma Flashcards

1
Q

What are the guidelines to CT scan a child following a head injury?

A

CT scan for neurological or cognitive dysfunction or suspicion of a depressed / basilar skull fracture

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2
Q

What imaging would you perform for a child <1 year old who is not having a CT head?

A

Skull xrays

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3
Q

Define minor head injury.

A

GCS > 13 without neurological deficit

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4
Q

What proportion of children with >5min LOC have a brain injury?

A

22% compared to 8% if LOC <5 mins

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5
Q

What imaging modality should be considered instead of CT head?

A

MRI

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6
Q

What is a ping-pong fracture?

A

A green stick fracture of the skull with caving of the skull in a region. Mainly in newborns due to skull plasticity.

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7
Q

How would you manage a temporo-parietal ping-pong fracture?

A

Conservative if no underlying brain injury - usually corrects itself as the skull grows

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8
Q

When would you operate on a ping-pong fracture?

A

Raised ICP CSF leak through to the subgaleal space Neurological deficit Cosmesis if on the forehead

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9
Q

What proportion of <10 year olds with a head injury are NAI?

A

10%

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10
Q

What age group is NAI highest?

A

<3 years old

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11
Q

Which assocated injuries are suggestive of NAI?

A

Retinal haemorrhage Bilateral CSDH <2 years Multiple skull fractures Where neurological injury does not fit external trauma

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12
Q

What is the pathological mechanism in shaken-baby syndrome?

A

Angular acceleration / deceleration of the head (due to larger proportion to body and weaker neck muscles). Death is due to uncontrollable ICP **look for CCJ injury**

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13
Q

What is Purtscher’s retinopathy?

A

Loss of vision following major trauma / pancreatitis / child birth etc due to posterior pole ischaemia. No known treatment

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14
Q

Where do NAI skull fractures occur?

A

90% are parietal

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15
Q

How can NAI fractures be differentiated from non-NAI trauma fractures?

A

Multiple / bilateral fractures or those that cross sutures

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16
Q

What is a traumatic leptomeningeal cyst?

A

Growing skull fracture in which a CSF leak causing the fracture edges to widen with time

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17
Q

What age do growing skull fractures occur?

A

<3 years

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18
Q

What are the radiological features of a growing skull fracture?

A

Widening sutures with scalloping of the edges

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19
Q

What is the management of a growing skull fracture?

A

Closure of the dural defect. The dural defect is usually larger than the bony defect so perform a craniotomy around the fracture, repair the dura and then replace the bone

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20
Q

How do you manage depressed skull fractures in children?

A

Conservatively unless: 1) Dural penetration 2) Persistent cosmetic defect 3) Focal neurological deficit attributable to the fracture

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21
Q

What are the suitability criteria for brainstem testing?

A

A catestrophic irreversible brain injury

Absence of depressant drugs

Absence of hypothermia

Absence of reversible causes (metabolic derangements)

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22
Q

How is brainstem death confirmed?

A

No response to pain (supraorbital pressure)

Pupils fixed and dilated

Absent corneal reflexes

Absent occulo-vestibular reflexes

Absent of gag reflex

Apnoea with pCO2>6 KPa

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23
Q

Which open fractures do you operate on?

A

Depression > thickness of the skull Dural penetration ICH needing evacuation Depression >1 cm Frontal sinus involvement Infection or gross contamination Gross cosmetic deformity

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24
Q

What surgery is recommended for depressed skull fractures?

A

Elevation of bone fragmentes and debridement of skin edges. Repair of dural lacerations.

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25
Q

Is there any evidence that elevating a skull fracture affects post-traumatic seizures?

A

No

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26
Q

What structures may be disrupted with longitudinal temporal bone fractures?

A

Along the EAC and potentially leads to disruption of the ossicular chain

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28
Q

What structures may be disrupted with transverse temporal bone fractures?

A

Perpendicular to EAC through the cochlea and may stretch the geniculate ganglion causing CN7 and 8 deficits

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29
Q

What should be given to all patients with CSF leak following skull base fracture?

A

Pneumovax

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30
Q

What is the difference between proptosis vs exopthalmos?

A

Proptosis means the eye ball is pushed forward Exopthalmos means the eye ball is in the right place but the surrounding structures are not

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31
Q

Why check sensation of the forehead with frontal sinus fractures?

A

Supratrochlear / supraorbital nerve injury

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32
Q

When is the frontal sinus radiographically visible?

A

8 years

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33
Q

How is the frontal sinus approached surgically following trauma?

A

Bicoronal incision Forehead skin crease / eyebrow incision

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34
Q

What are Le Fort fractures?

A

Maxillary fractures: >1 - Above the upper teeth >2 - Across the maxilla to the top of nasion >3 - Across the top of the orbits separating the face from the skull

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35
Q

What does cranialisation of the frontal sinus mean?

A

Removal of the posterior wall and stripping of mucosa down to the frontonasal duct. Any residual mucosa may form a mucocele. The sinus can be packed with fat / muscle / gel foam etc and covered with periosteum.

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37
Q

What are the HU of air?

A

-1000 (remember Fat is -40, CSF is 0; Blood is 60-80 and bone is >500)

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38
Q

Which skull fractures should you give antibiotics for?

A

Open skull fractures

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39
Q

What radiological sign suggests pneumocephalus?

A

Mt Fuji sign

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40
Q

How do you classify skull fractures?

A

Closed (simple fracture) vs open (compound fracture)

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41
Q

What proportion of skull fractures are simple, linear calvarial fractures in children?

A

90%

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42
Q

How do you calculate cerebral perfusion pressure?

A

CPP = MAP - ICP

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43
Q

What metric does autoregulation maintain?

A

CBF to meet CMRO2 (cerebral metabolic rate for oxygen)

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44
Q

What is normal CPP?

A

>50mmHg (Note: autoregulation occurs between a CPP of 50-150 mmHg)

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45
Q

What is the approximate intracranial blood volume? CSF volume?

A

150ml for both

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46
Q

What is the normal ICP in a young child?

A

3-7mmHg

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47
Q

What is the normal ICP in a term infant?

A

1.5-6mmHg

48
Q

What are the different types of ICP monitors?

A
  1. EVD - (most accurate) 2. Intraparenchymal (different models, some prone to drift) 3. Subdural/subarchnoid/epidural 4. Fontanometry in infants with open AF
49
Q

How do you convert mmHg into cmH2O?

A

1mmHg = 1.36cmH2O 1cmH2O = 0.735cmH2O

50
Q

What is your target CPP for a head injury patient?

A

60-70mmHg

51
Q

What is your target blood glucose in trauma?

A

7-10mmol/l

52
Q

What is targeted temperature management (TTM)?

A

Aiming for normothermia or mild hypothermia (35.5-37)

53
Q

What did CRASH 3 show?

A

Safe to give TXA within 8 hours of TBI with intracranial haemorrhage or GCS<12 Improved mortality rates in mild and moderate head injuries. No improvement in severe head injuries

54
Q

What is your target for ICP in head injury patients?

A

Brain trauma foundation guidelines suggest intervention to keep ICP <22mmHg

55
Q

What are the indications for ICP monitoring in head injury?

A

BTF guidelines (2016)- All salvageable patients with severe head injury and abnormal CT head Or - all salvageable patients with severe head injury, normal scan and 2 or more of the following - age>40 motor posturing SBP <90 Consensus statement in 2014 suggests that in light of a normal CTH patient should not have ICPM

56
Q

What is the volume of the brain?

A

1400 ml

57
Q

What is Cushing’s triad?

A

Hypertension Bradycardia Respiratory irregularity

58
Q

What are Lundberg A waves?

A

Plateau waves with ICP elevations >50 mmHg for 5-20 minutes

59
Q

What are Lundberg B waves?

A

Pressure pulses with amplitudes 10-20 mmHg lasting 30 sec - 2 minutes

60
Q

What are Lundberg C waves?

A

Low amplitude elevations in ICP every 10 seconds.

61
Q

What level of pBt02 should be maintained following head injury?

A

>25 mmHg improves outcome

62
Q

What are the calorific requirements following head injury?

A

100% if paralysed

140% if not paralysed

Mortality is reduced if this is achieved by day 7 and started within 72 hours.

>15% should of calories should be protein.

Enteral route is prefered

63
Q

How is the calorific requirement calculated?

A

As the basal energy expenditure (BEE) using the Harris-Benedict equation.

64
Q

Why does urea increase following trauma?

A

Catabolic state breaks down proteins and Nitrogen is excreted as urea. To replace this >15% of the BEE should be protein.

65
Q

How do you differentiate post-traumatic hydrocephalus from ex vacuo hydrocephalus?

A

High pressure on >1 LP Papilloedema Headaches Transependymal oedema Neurological decline or altered rehabilitation

66
Q

Which basal cisterns are viewed following trauma?

A

The quadrigeminal and 2x ambient cisterns. Correlated with mortality.

67
Q

What is the biparietal diameter?

A

A measure of midline shift. Measure the inner skull vault distance at the level of the foramen of Monroe, dividing by 2 and subtracting the distance of the septum pellucidum from the inner table of the vault.

70
Q

What is a genetic risk factor for severe head injury?

A

Apolipoprotein E4 (also risk factor for Alzheimer’s!)

71
Q

What are the delayed complications of head injury?

A

Seizures (10% severe, 5% moderate and 0% mild)

Encephalopathy

Pituitary deficiencies

72
Q

What are the histological findings in chronic traumatic encephalopathy?

A

Beta-Amyloid plaques and cererbral amyloid angiopathy - similar to Alzheimer’s disease. Present with clinical features of Parkinsonism.

73
Q

What underlies the risk of second impact syndrome?

A

Dysfunction of cerebral autoregulation causing diffuse cerebellar swelling

74
Q

What are Duret haemorrhages?

A

Small haemorrhages within the brainstem as a result of damage to perforators following herniation.

75
Q

What is implied by dorsal pontine haemorrhages?

A

Severe diffuse axonal injury

76
Q

Why do you get a PCA infarct with raised ICP?

A

Due to the PCA being compressed against the tentorium

77
Q

What are the histological features of DAI?

A

Gliding/shearing forces cause disruption of axoplasmic transport resulting in retraction balls (axonal swellings), haemorrhages and accumulation of APP (amyloid precursor protein)

78
Q

What is the grading of DAI?

A

Petechial haemorrhages in the:

  1. Cortex
  2. Corpus callosum
  3. Brainstem
79
Q

What is chronic traumatic enchephalopathy?

A

Repeat head injuries resulting in a neurodegenerative tau pathology (tauopathy) affecting the deep sulci

80
Q

What is the incidence of TBI?

A

250 per 100,000 population, based on TBI hospital admissions

81
Q

Define TBI

A

Alteration in brain function or evidence of brain pathology caused by an external force

82
Q

What is the weight of the brain?

A

1.4Kg

83
Q

What is elastance?

A

Elastance = dPressure / dVolume

84
Q

What is compliance?

A

Compliance = dVolume / dPressure

85
Q

What are the indications for ICP monitoring?

A

Abnormal CT head in a patient that cannot be assessed neurologically i.e. intubated and ventilated

86
Q

What is the conversion between cmH20 and mmHg?

A

10cmH20 = 7mmHg

87
Q

What are Lundberg waves?

A

A waves = ICP>50 for >5 mins

B waves = ICP up to 25 for 2-3 mins

C waves = physiological fluctuations in ICP every 10 seconds

88
Q

What is Pouseille’s equation?

A

The flow through a tube is proportional to the radius^4

89
Q

Where does autoregulation occur? CO2 reactivity?

A

Pial arteries Pial small vessels

90
Q

What is the Marshall classification?

A

1 = normal CT

2 = Diffuse injury; MLS<5 mm visible basal cisterns

3 = Diffuse injury; MLS <5mm compression of the basal cisterns

4 = Diffuse injury; MLS>5 mm with no mass lesion >25 cm^3

5 = Evacuated mass lesion

6 = Non evacuated mass lesion (>25 cm^3)

91
Q

Decision tree of Marshall classification?

A

Abn yes / no Mass yes / no (mass requiring evacution yes / no) cisterns yes / no midline shift yes / no

92
Q

How do you classify the mechanisms of TBI?

A

Closed, penetrating, crush and blast. There is overlap

93
Q

What are the tiers of treatment for raised ICP?

A

Tier 1 - HOB, sedation / analgesia, intermittent ventricular drainage, repeat CT Tier 2 - Hyperosmolar therapy, PCo2, paralysis Tier 3 - DHC, barbiturates (hypotherapy in rescueICP has worse outcome)

94
Q

When should orthopaedic patients be performed in TBI?

A

Delay for 48 hours until ICP is stable

95
Q

When should clexane be given in TBI?

A

Within 72 hours (prophylactic IVC filter can be placed if big contusions etc) Note - 20% of TBI will have a VTE

96
Q

How should you treat an elderly patient on anticoagulation with ASDH?

A

Consider it to be similar to EDH as the elderly patient will have minimal brain injury if surgery is performed earlier

97
Q

Which penetrating injuries carry a very low prognosis?

A

Transventricular and multilobar path / injury

98
Q

How extensive do you debride a penetrating head injury?

A

Minimal debridement

99
Q

What are the principles of management for penetrating head injury?

A

Antibiotics Full exposure Control of vascular components Minimal debridement Water tight dural closure (depending on ICP)

100
Q

What are the complications of penetrating head injury?

A

Infection Sinus - mucocoele Pseudo-aneurysm ..

101
Q

How do you manage a pseudo-aneurysm?

A

Vessel sacrifice

102
Q

What is the relationship between ICP and volume?

A

Exponential

103
Q

How is CBF affected by CO2?

A

Rising CO2 affects ICP with a sigmoidal relationship

106
Q

What are the reversible factors of raised ICP?

A

Pyrexia

Seizure

Raised MAP

Low Na

Low protein

Pain

Sedation / paralysed

107
Q

Which study showed no difference with using ICP monitoring?

A

BEST:TRIP (Chestnut et al 2012)

108
Q

What are the outcomes of DECRA?

A

Decompressive craniectomy worsens outcome even though ICP was lower

Early decompression at ICP 20mmHg

More people had blown pupils in the surgery group

109
Q

What are the outcomes of RescueICP?

A

Overall survival is increased with decompressive hemicraniectomy but they are made vegetative

High proporion of bifrontal craniectomies

Cranioplasty side-effects were not counted

110
Q

What BP do you aim for in TBI?

A

Look up

111
Q

What does cerebral microdialysis measure?

A

Mitochondrial dysfunction: Lactate to pyruvate ration

112
Q

What is brain tissue oxygenation monitoring?

How does it work?

A

look up

113
Q

Explain the rational of jugular venous saturation

A

Look up

114
Q

What does Xe-CT show?

A

CBF measurement

115
Q

How does near infrared spectroscopy work?

A

Look up

Different wavelengths correspond to HbO2 etc so able to monitor the response to treatment

116
Q

Does gender affect TBI outcome?

A

No

117
Q

When would you place a brain tissue monitor?

A

…Variable, most would place with any depressed GCS

118
Q

What threshold would you treat at brain tissue oxygenation?

A

Brain trauma foundation recommend >15 but more recent evidence suggests 20.

FRCS Part 2 (17 decks)

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