Trauma and head injury

Question 1

Differentials for headaches

Answer 1

tension headaches
migraines
cluster headaches
secondary headaches
sinusitis
GCA
glaucoma
ICH
SaH
analgesic headache
hormonal headache
cervical spondylosis
trigeminal neuralgia
RICP
meningitis, encephalitis

Question 2

headache red flags

Answer 2

Fever, photophobia or neck stiffness (meningitis or encephalitis)
New neurological symptoms (haemorrhage, malignancy or stroke)
Dizziness (stroke)
Visual disturbance (temporal arteritis or glaucoma)
Sudden onset occipital headache (subarachnoid haemorrhage)
Worse on coughing or straining (raised intracranial pressure)
Postural, worse on standing, lying or bending over (raised intracranial pressure)
Severe enough to wake the patient from sleep
Vomiting (raised intracranial pressure or carbon monoxide poisoning)
History of trauma (intracranial haemorrhage)
Pregnancy (pre-eclampsia)

Question 3

RICP red flags

Answer 3

worse on coughing or straining
postural
worse on standing or bending over
vomiting

Question 4

CSF bacteria

Answer 4

cloudy
low glucose <50%
high protein
10-5000 polymorphic WBC/mm3

Question 5

viral CSF

Answer 5

clear/cloudy
60-80% of plasma glucose
protein normal
15-1000 lymphocytes/mm3

Question 6

CT head in adults <1hr criteria

Answer 6

GCS<13 on initial assessment
GCS <15 2 hours after injury
suspected open or depressed skull fracture
basal skull fracture
post-traumatic seizure
focal neurological deficit
>1 episode of vomiting

Question 7

CT head in adult within 8 hours of injury
Who have experienced LoC or amnesia

Answer 7

> 65
history of bleeding or clotting disorder
dangerous mechanism of injury
30 minutes retrograde amnesia

Question 8

GCS:
opens eyes in response to voice
inappropriate words
abnormal flexion

Answer 8

9

Question 9

GCS:
doesnt open eyes
orientated conversation
localizes to stimulus

Answer 9

11

Question 10

GCS:
abnormal extension
opens eyes to voice
incomprehensible sounds

Answer 10

7

Question 11

Cushing’s reflex

Answer 11

irregular breathing
widening pulse pressure
bradycardia

Question 12

flail chest

Answer 12

> 2 rib fractures along >3 consecutive ribs
moves during respiration and impairs ventilation
contusional injury

Question 13

tension pneumothorax

Answer 13

May occur following thoracic trauma when a lung parenchymal flap is created.

This acts as a one way valve and allows pressure to rise.

The trachea shifts and hyper-resonance is apparent on the affected side.

Treatment is with needle decompression and chest tube insertion.

Question 14

triangle of safety pneumothorax

Answer 14

The 5th intercostal space (or the inferior nipple line)
The mid axillary line (or the lateral edge of the latissimus dorsi)
The anterior axillary line (or the lateral edge of the pectoris major)

Question 15

Primary pneumothorax <2cm and breathless

Answer 15

aspiration

Question 16

Primary pneumothorax <2cm and not breathless

Answer 16

discharge

Question 17

Primary pneumothorax >2cm

Answer 17

chest drain

Question 18

Secondary pneumothorax >2cm and >50YO

Answer 18

chest drain

Question 19

Secondary pneumothorax SoB and >50YO

Answer 19

chest drain

Question 20

secondary pneumothorax 1-2cm

Answer 20

aspiration
if aspiration fails try chest drain

Question 21

secondary pneumothorax <1cm

Answer 21

oxygen and admit 24hrs

Question 22

discharge advice pneumothorax

Answer 22

smoking
no flying 2 weeks after successful drainage
permanent ban on scuba diving

Question 23

cardiac tamponade triad

Answer 23

hypotension
raised JVP
muffled heart sounds

Question 24

other features of cardiac tamponade

Answer 24

dyspnoea
tachycardia
absent Y descent on JVP
pulses paradoxus
electrical alternans on ECG

Question 25

AMPLE assessment

Answer 25

Allergies and ADT status

Medications

Past Medical History

Last ate and drank; LMP (check for pregnancy in females of child bearing age)

Events / environment related to injury (i.e. a detailed account of the mechanism of injury)