Traumatic brain and head injury and spontaneous intracranial haemorrhage Flashcards
distribution and 3 peaks of neurotrauma death
at time of trauma
several hours later
several days later
when is the golden hour
1st hour after trauma
what is traumatic brain injury
non-degenerative, non-congenital insult to the brain from an external mechanical force
what is the initial management of any trauma
Airway & c-spine control Breathing Circulation Disability Everything else
what does the Glasgow coma scale consist of
eye opening
verbal response
motor response
what is the minimum GCS you can get
3
what is the maximum GCS you can get
15
what must you do if GCS <8
intubate
describe eye opening scoring
1 - none
2 - open to pain
3 - open to voice
4 - open spontaneously
describe voice response scoring
1 - none 2 - incomprehensible 3 - inappropriate 4 - confused 5 - orientated
describe motor response scoring
1 - none 2 - decerebrate/extension 3 - decorticate/abnormal flexion 4 - withdraws to pain 5 - localises 6 - obeys
head injury severity scale
mild
moderate
severe
mild - 14 or 15
moderate - 9-13
severe - 3-8
patients with appropriate risk factors should get a CT scan within what time frame
within 1 hour
risk factors for getting a CT scan within 1 hour
GCS <13 on arrival GCS <15 after 2 hours suspected skull fracture basal skull fracture post traumatic seizure focal neurological deficit >1 episode of vomiting NAI suspicion in children
CT should also be requested if patients have amnesia and what other risk factors
age >65
coagulopathy
dangerous mechanism of injury
what are signs of base of skull fracture
raccoon eyes / peri orbital haematoma
battles sign / bruise behind ear
blood or CSF from ear
where is blood in an extradural haematoma
bone and dura
describe findings of extradural haematoma on imaging
bright white - blood on CT
lens/biconvex shape because dura is fixed to skull at suture lines
describe clinical characteristics of extradural haematoma
head injury and initial loss of consciousness
recover with no deficits - “lucid interval”
then sudden rapid deterioration of neurological deficit - deteriorating GCS, unilateral fixed and dilated pupil, apnoea and death
classification of subdural haematomas
acute
chronic
where is blood in a subdural haematoma
dura and arachnoid
describe findings of acute + chronic subdural haematomas on imaging
crescent shaped
acute - bright white/hyperdense
chronic - dark/isodense
what vessel is damaged in extradural haematoma
middle meningeal artery
what vessels are damaged in subdural haematoma
bridging cerebral veins
what is diffuse axonal injury and how severe is it
brain swelling from stretching, shearing and twisting of axons
excitotoxicity and apoptosis
devastating injury
where does diffuse axonal injury occur
grey white matter interface
MAP - ICP = ?
CPP cerebral perfusion pressure
medical management of raised ICP
sedation - propofol, BZDs, barbiturates maximise brain venous drainage tilt head of bed at 30 degrees CO2 control - 4.5kPa osmotic diuretics - mannitol CSF release - shunt, drain
as PCO2 increases, CPP increases/decreases
increases
what is the last resort in management of ^ICP
decompressive craniectomy
how should nutrition be delivered
NG tube ASAP
steroids are beneficial/harmful in head injury resulting in swelling eg DAI
harmful
what is it important to rule out when confirming brainstem death
every other option has been exhausted
no anaesthetics, recreational or sedative drugs
no hypothermia or severe metabolic disturbances
how do you diagnose brainstem death
assessment repeated twice: no pupil response no corneal reflex no gag reflex no vestibulo-ocular reflex no motor response no respiration
who can diagnose brainstem death
need 2 doctors both registered for at least 5 years
1 of whom is a consultant
when is time of death confirmed
after completion of first set of tests
2nd round is just for confirmation
how should patients be followed up after acute management
seizures depression alcohol and drugs personality changes aggression suicide financial and jobs
where does bleeding in subarachnoid haemorrhage occur SAH
between arachnoid and pia mater in the subarachnoid space
how does SAH present
thunderclap headache sudden onset severe headache meningismus collapse vomiting photophobia
differential diagnosis of sudden onset severe headache
SAH
migraine
cluster headache
benign coital cephalgia
which investigations should be done for SAH
CT
LP
CTA
causes of SAH
berry aneursym
trauma
AVM
idiopathic
how can you tell a SAH from imaging
blood appears white so there is white in the subarachnoid space ie where the ventricles are
role of LP in SAH
if CT scan is negative for SAH, LP is done if there is no focal neurological deficit or ^ICP
wait 12 hours before doing a LP, true or false
false, despite NICE guidelines do a LP as soon as
take 3 samples so that the last sample has less blood in case of traumatic tap
CSF findings in SAH
xanthochromatic CSF
yellow staining from RBC breakdown
which investigation is gold standard in SAH
CT angiogram
list complications of SAH
rebleeding delayed ischaemic neurological deficit hydrocephalus hyponatraemia seizures
what can be done to prevent rebleeding in SAH
endovascular techniques and surgical clipping
when is the highest risk of delayed ischaemic neurological deficit after SAH
3-12 days post SAH
what can be given to improve outcome and prevent cerebral ischaemia after SAH
PO/IV nimodipine (CCB)
what is triple H therapy and what is it used for
management of delayed ischaemic neurological deficit try to induce: hypertension hypervolaemia haemodilution
how does hydrocephalus present as a complication of SAH
increasing headache after 1 week
causes of hyponatraemia after SAH and its management
SIADH
cerebral salt wasting
fludrocortisone
any brain injury lowers the seizure threshold, true or false
true
what is intracerebral haemorrhage
bleeding into the brain parenchyma
causes of intracerebral haemorrhage ICH
HTN
aneurysm
AVM
presentation of ICH
headache
focal neurological deficit
decreased conscious level
management of ICH
surgical evacuation of haematoma
or non-surgical management - same as haemorrhagic stroke
