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Block 8 week 2 > Traumatic Brain and Spine injuries - Morgan > Flashcards

Traumatic Brain and Spine injuries - Morgan Flashcards

1
Q

When the brain moves around in the skull and hits the skull what are these types of injuries called and how might they be caused?

A

The types of contusions seen when the head is ‘knocked’ back and forth are called coup and countercoup injuries. These can be caused by blows to the head, impacts during car accidents or other types of accidents and more rarely by whiplash type events.

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2
Q

How are traumatic brain injuries classified?

A
  1. Mechanism - how did it happen. Describes if injury is open or closed or if there is/was something penetrating the skull - ie. gun shot wounds, stabbings
  2. Severity - how bad is the injury. Described as mild, moderate or severe
  3. Morphology - includes presence of skull fractures and intracranial lesions
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3
Q

Closed head injuries are further classified how?

A
  1. high velocity - i.e. by auto accidents

2. low velocity - i.e. by falls, assaults

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4
Q

Gunshot wounds cause injury via the bullet but what other types of injuries does it cause to the bain?

A
  1. bullet causes the brain to expand and then contract
  2. can get shearing of white matter tracts
  3. can also get herniation
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5
Q

Why is it important to not remove a penetrating object from the head before doing a CT scan?

A

You want to see where the object is in relation to the major blood vessels. If you just pull the object out first then you risk making the bleeding worse and you are not in the OR so it would be hard to deal with it in a timely manner.

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6
Q

What type of CT scan do you do with a traumatic head injury and why?

A

You want to do a CT scan without contrast because if you inject dye you will not be able to see the injury and its extent because now all the blood vessels and area around the injury will show up as white.

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7
Q

What is the Glascow coma score used for?

A

To determine the severity of an injury and give uniformity between doctors. It should be combined with an eye/pupil exam to establish a neurological baseline.The scale goes from 3-15, low score is negative and the higher the score the better.

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8
Q

Describe the Glasgow coma scale.

A
  1. Mild injury - GCS of 14-15, pt is talking and is confused but clearing.
  2. Moderate injury - GCS of 9-13, pt may have neurologic deficits , may not be clearing and may not even be talking.
  3. Severe injury - GCS of 8 or less, pt will be comatose and probably intubated.
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9
Q

Describe when a patient should be evaluated with the GCS.

A
  1. after BP and O2 are normalized
  2. before sedative medications or paralyzing meds are given
  3. should be given frequently thereafter to check for deterioration
  4. GCS evaluation can be done by nurse along with vitals in ICU
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10
Q

What is done for a patient whose GCS is lower than 8?

A

Intracranial pressure should be measured. Ideally it should be kept below 20. This is achieved by giving the patient Mannitol. Mannitol is a hypertonic solution that pulls fluid out of the brain and is good for up to 72 hours.

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11
Q

What are the 3 components of the GCS?

A
  1. eye opening
  2. motor response
  3. verbal response
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12
Q

Describe the eye opening component of the GCS.

A

Grading for this component is 1-4.
4 for spontaneous opening
3 if they open their eyes in response to speech
2 if they open their eyes to painful stimuli
1 if they do not open their eyes to any stimuli

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13
Q

Describe the motor response component of the GCS.

A

Grading for this component is 1-6
6 if they can perform motor function on command
5 if they perform purposeful movement towards painful stimuli
4 if they withdraw from pain
3 if decorticate posturing is accentuated by pain
2 if decerebrate posturing is accentuated by pain

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14
Q

What is decorticate posturing?

A

If a painful stimulus is applied and the patient’s posture changes or increases in- elbows, wrists and fingers flexed and legs extended and rotated inward. Indicates that there may be damage to areas including the cerebral hemispheres, internal capsule, thalamus and the midbrain.

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15
Q

What is decerebrate posturing?

A

Involuntary extension of the upper extremities in response to painful stimuli. Includes arching the head back, arms (including elbows) extended by sides and rotated inward, legs extended and turned inward. Exhibited by patient who have lower brainstem and cerebellar lesions.

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16
Q

Describe the verbal response component of the GCS.

A

Grading is 1-5.
5 if the patient is oriented
4 if they are confused
3 if they use inappropriately used words and cannot converse
2 if there are incomprehensible sounds - i.e. moaning but no words
1 if there is no verbal response

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17
Q

It is important to check the eyes in traumatic head injury patients because it indicates what?

A

Herniation. Damage can result in loss of pupillary light reflex and loss of corneal reflex.

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18
Q

What are other tests that check eye responses?

A
  1. Doll eye test

2. Oculovestibular reflex

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19
Q

Describe the Dolls eye test.

A

If a patient is not wearing a collar and does not have a neck injury then the head is turned sharply to one side and if the eyes do not follow then this is indicative of a brainstem injury.

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20
Q

Describe the oculovestibular reflex.

A

If you put cold water in the ear of a normal person their eyes would look towards the ear you put water in and would have nystagmus to contralateral side. If a patient has damage then they will look to the side the water was put in but will not have nystagmus. If only one responds then there is probably some type of brainstem injury. Do not use calorics unless the tympanic membrane is intact.

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21
Q

The Doll’s eye test and the cold caloric response is used on what type of patient?

A

A comatose patient in which you are suspicious of a brainstem injury.

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22
Q

What type of test is used to look at the morphology of a traumatic brain injury?

A

A CT scan.

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23
Q

Describe some types of skull fractures that can be seen on CT.

A
  1. Vault - over the brain - can be linear or stellate, depressed or nondepressed
  2. Basilar - under the brain - can be with or without CSF leak or with or without VII or other cranial nerve palsy.
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24
Q

Describe some types of intracranial lesions that can be seen on CT.

A
  1. Focal - subdural or epidural

2. Diffuse - concussions and diffuse axonal injury

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25
Q

What is a risk of depressed bone fractures?

A

If a depressed bone fracture results in bone fragments they may possibly penetrate the dura and lacerate the brain. These injuries deed debridement and repair.

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26
Q

What type of skull fracture can occur in infancy?

A

A ping-pong ball fracture. This is a type of depressed fracture. It can be repaired by inserting an instrument through a burr hole and popping the fracture out.

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27
Q

What can feel like a depressed skull fracture but is not?

A

A hematoma. It may have a soft center and hard edges that make if feel like a fracture. A CT is needed to confirm.

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28
Q

Describe some characteristics of Basilar head injuries.

A
  1. comprise up to 25% of head injuries
  2. are hard to see on X-ray
  3. best visualized with CT scans (bone windows)
  4. 5% may have cranial nerve injuries
  5. 10% may have CSF leak
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29
Q

What nerves are often involved with basilar skull fractures?

A

Cranial nerves 7 and 8. Fractures often go right across the base of these nerves and palsy can result. They often heal on their own.

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30
Q

Basilar skull fractures often involve what bone?

A

The petrous portion of the temporal bone. Can also affect the anterior cranial fossa and cribriform plate.

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31
Q

What type of basilar skull fracture is associated with Facial nerve injury with a prevalence of up to 20%?

A

Longitudinal fractures of the petrous portion.

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32
Q

What type of basilar skull fracture is associated with Facial nerve injury with a prevalence of up to 50%?

A

Transverse fractures of the petrous portion.

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33
Q

What are some clinical indications of basilar skull fractures?

A
  1. Pneumocephalis - presence of air or gas in the cranial cavity
  2. CSF leak in the nose (Rhinorrhea) or ear (otorrhea)
  3. Cranial nerve damage - often CNVII and/or CNVIII
  4. Hemotympanum - blood behind the ear drum
  5. Battle’s sign - bruising behind the ear
  6. Raccoon eyes - bruising of both eyes
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34
Q

80-90% of patients with a basilar skull fracture do not have surgery to repair the fracture and they heal on their own (swelling causes closure of Dura mater) . Do they still need to be monitored?

A

Yes. These patients can become unstable and can have hemorrhages, increased ICP and herniation of brain tissue.

35
Q

CSF leak can occur in 10% of those with basilar skull fractures. How is it treated?

A
  1. stops leaking in 85% of patients
  2. bed rest and head elevation
  3. persistent leaks treated with lumbar drain
  4. small number requires surgical repair
  5. antibiotics NOT advised unless meningitis develops
36
Q

Battle’s sign is associated with Basilar fractures in what bone?

A

The temporal bone.

37
Q

Raccoon eyes are associated with basilar fractures in what bone?

A

The frontal bone.

38
Q

What is a subarachnoid hemorrhage?

A

Bleeding between the arachnoid mater and pia mater.

39
Q

What is the most common cause of subarachnoid hemorrhages?

A

Trauma.

40
Q

Describe some characteristics of traumatic subarachnoid hemorrhages.

A
  1. low risk for deterioration or surgical intervention
  2. onset occurs earlier and duration is shorter than in aneurysmal SAH
  3. may cause vasospasm - 19-68%
  4. in 3.9-16.6% of cases there will be clinical deficits
  5. clinical course tends to be milder then vasospasm from aneurysmal SAH
41
Q

Name 5 types of intracranial lesions.

A
  1. Epidural hematoma - between skull and dura mater
  2. Subdural hematoma - under dura mater and on top of brain (on top of arachnoid mater)
  3. intracerebral hematoma - within brain parenchyma
  4. contusions and concussions
  5. diffuse axonal injury
42
Q

What area and artery are often associated with epidural hematomas?

A

The temporal bone (squamous part) and the underlying middle meningial artery.

43
Q

Describe some characteristics of epidural hematomas.

A
  1. commonly due to arterial bleeding
  2. can be from vein or venous sinuses too
  3. associated with lenticular shape (like a biconcave lens) on CT
44
Q

What is the classical presentation of a patient with an epidural hematoma?

A

Classical presentation includes a patient with a head injury but who is awake and alert but who deteriorates as the clot enlarges.

45
Q

What is a subdural hematoma?

A

Bleeding between the dura mater and arachnoid mater.

46
Q

Describe some characteristics of subdural hematomas?

A
  1. often due to tearing of veins or brain lacerations
  2. prognosis is usually worse due to associated brain injury
  3. shape is not lenticular on CT but is more spread out across the brain
47
Q

How are acute subdural hematomas treated if they are causing pressure on the brain?

A

By surgical intervention.

48
Q

What is another type of hematoma that can show up weeks or months after a head injury?

A

A chronic subdural hematoma.

49
Q

How might a patient with a chronic subdural hematoma present?

A
  1. have had a previous head injury - injury may have been very minor
  2. headache
  3. focal neurological deficits
  4. decreased levels of concentration
50
Q

What are contusions and who might they be caused?

A

Contusions are bruising of brain tissue. Rotational forces on the head can cause shearing and twisting injuries in the brain. Coup-Contrecoup injuries can cause contusion, swelling and blood clots.

51
Q

Describe some characteristics of cerebral contusions.

A
  1. deficits will depend on the area of brain injured
  2. can involve a coup-contrecoup pattern involving the frontal and occipital lobes - most commonly involve frontal and temporal lobes
  3. patients should be observed in the ICU and have their ICP monitored if they are not conscious
  4. Patients should have repeat CT scans within 24 hours (can develop hematomas) or sooner if they are deteriorating
  5. will see ‘salt and pepper’ lesions on CT
  6. comprise 8% of all traumatic brain injuries and 13-35% of all severe injuries
52
Q

What is the treatment for intracerebral hematomas?

A

If they are 30cc’s or 3 cm across on CT they are surgically removed.

53
Q

Concussions can occur with what?

A

They can occur with or without short loss of consciousness or temporary neurological dysfunction.

54
Q

Describe some characteristics of diffuse axonal injury.

A
  1. loss of consciousness from time of injury beyond 6 hours
  2. may be mild, moderate or severe
  3. if severe - deeply comatose for prolonged periods of time and often remain severely disabled if they survive
  4. are typical shearing injuries and the tearing is often at the grey-white matter junction
  5. exam findings are worse than explained by CT - might look normal or have small hemorrhages
  6. patient may be in a deep coma
55
Q

What are some characteristics associated with head injury evaluation?

A
  1. mild traumatic brain injuries are most common - 80% are concussions
  2. GCS = 14 or 15
  3. patient may be awake but amnesic about injury
  4. exam is sometimes confounded by alcohol
  5. usually make uneventful recovery
  6. some will have lingering mild neurologic symptoms and about 3% will deteriorate unexpectedly
56
Q

Describe some characteristics associated with concussion.

A
  1. symptoms and duration determine the severity of the head injury
  2. associated with loss of consciousness in about 10% of cases
  3. present with confusion, amnesia, dizziness, visual disturbances and headache
  4. must have a symptom-free waiting period of physical and cognitive rest before returning to subsequent play (if sports related)
57
Q

If a person has a sports related concussion that seems to clear quickly can they return to play the same day?

A

No.

58
Q

Once a patient with a sports related concussion is asymptomatic what happens?

A

There is a stepwise return to physical and academic activities.

59
Q

What is second impact syndrome?

A

A concussion followed by another head impact days, weeks or minutes apart. This rare but can occur - usually in young healthy athletes younger than 18 years old.

60
Q

Describe the clinical course associated with second impact syndrome?

A

May get loss of auto- regulation followed by dilated blood vessels, diffuse cerebral swelling, increased ICP, brain herniation and possible death.

61
Q

What is repetitive head injury syndrome?

A

Series of minor head injuries over time. Associated with experiences of slow decline in functions such as cognitive abilities and also with chronic traumatic encephalopathy.

62
Q

When a person presents with a traumatic brain injury what is the general course after they are evaluated?

A
  1. They may be sent home
  2. they may be admitted for 24 hours for observation
  3. they may be transferred to a neuro trauma center
63
Q

Describe categories one and two that a TBI patient may fall into after evaluation.

A

Category 0

  1. no loss of consciousness (LOC)
  2. pt is alert with GCS of 15
  3. no risk factors
  4. these patients are sent home

Category 1

  1. pt may have had LOC of less than 30 minutes and amnesia for less than 60 minutes
  2. no risk factors and have GCS of 15
  3. should get a CT scan
  4. if normal they can go home or if coagulation of other traumas are present they may be admitted
  5. if abnormal CT with no indications for surgery they are admitted for 24 hour observation and repeat CT scans and neuro consults are done
  6. if abnormal CT with indications for surgery then they are transferred to a neurotrauma center
64
Q

Describe categories two and three that a TBI patient may fall into after evaluation.

A

Category 2

  1. alert with GCS of 15
  2. has risk factors
  3. treat as category 3

Category 3

  1. GCS of 13-14
  2. with or without risk factors
  3. CT scan is mandatory
  4. patient is admitted
  5. if CT is normal then observe for 24 hours or until normal, consult neurotrauma center, repeat CT scan before discharge
  6. if CT is abnormal with no indications for surgery then observe for 24 hours or until normal, consult neurotrauma center, repeat CT scan before discharge
  7. if CT is abnormal with indications for surgery then admit to neurotrauma center
65
Q

What are some risk factors considered with evaluation of TBI patients?

A
  1. ambiguous accident history
  2. headache
  3. vomiting
  4. focal neuro deficits
  5. seizures
  6. age younger than 2 years or older than 60 years
  7. coagulation disorder o on anticoagulants
  8. high -energy/speed accident
66
Q

What are some characteristics associated with moderate traumatic brain injuries?

A
  1. comprise about 10% of head injury patients seen in the ER
  2. GCS scores of 9-13
  3. may be confused or somnolent, can follow simple commands, may have focal neuro deficits
  4. 10% of cases may deteriorate to coma and 9% may die
  5. must assure cardiopulmonary stability
  6. about 40% will have abnormal CT scan and 8% will require surgery
67
Q

What are some characteristics associated with severe traumatic brain injuries?

A
  1. unable to follow simple commands and has GCS of 8 or less
  2. 50% may have a major systemic injury
  3. about 35-40% of cases die
  4. must prevent/correct hypotension and hypoxia by establishing airway
  5. about 35% will arrive hypotensive
  6. ICP monitoring suggested
  7. a systolic BP of less than 90 increased mortality rate to 50%
68
Q

What are the ABC’s?

A
  1. Airway - clear airway after cervical spine evaluation
  2. Breathing - evaluate rate, rhythm and breath signs - may have to intubate
  3. Circulatory status - start IV and follow with blood if necessary
69
Q

Do head injuries usually cause shock?

A

Not often, should look for other causes such as severe blood loss, spinal cord injury, cardiac contusion or tamponade and tension pneumothorax.

70
Q

In the setting of hypotension is a neurological exam in a TBI patient accurate?

A

No. Once BP is restored they may be responsive.

71
Q

In patients with severe TBI and a normal CT what 3 factors are associated with poor outcome?

A
  1. hypotension on admission
  2. age over 40
  3. decerebrate posturing
72
Q

List some things done in workup of severe TBI.

A
  1. intubation
  2. IV access established
  3. Foley catheter established to look for hematuria
  4. NG tube inserted - (be careful of frontal floor fractures)
  5. CT scan done
  6. Cervical spine films or CT
  7. chest, abdominal and pelvic films done - better if can do CT
73
Q

What is a normal ICP in a relaxed patient?

A

Normally ICP is about 10 mmHg but 10-20 mm Hg is okay.

74
Q

What is a more useful marker to follow in TBI cases than ICP?

A

Cerebral perfusion pressure - mean arterial BP minus the ICP. Normally, CPP is around 60 mmHg.

75
Q

Describe normal ICP monitoring.

A
  1. often a transducer is placed at the level of the foramen of Monro
  2. however there are various methods of monitoring such as epidural, subdural, subarachnoid, ventricular and intra-parenchymal placement of transducer
76
Q

What are the first steps in treatment of increased ICP?

A
  1. First - make sure the reading is real
  2. make sure neck is in neutral position
  3. check calibration of system
  4. place transducer at level of foramen of monro
  5. ideally want to keep ICP of less than 20 mmHg and CPP of less than than 70 mm Hg
77
Q

Describe some other parameters of the treatment of increased ICP.

A
  1. if pt is restless - then sedate
  2. elevate head to 30 degrees
  3. make sure pCO2 is not elevated
  4. can try euthermia or mild hyperventilation to 30-35 mmHg PaCO2 (causes vasoconstriction)
  5. if ICP is still elevated then repeat CT to rule out mass lesion that should be removed
  6. can give meds or perform ventricular drainage of CSF
  7. can try decompressive hemicraniectomy
  8. can try Barbiturate coma
78
Q

What are some pharmacologic ways of reducing ICP?

A
  1. Mannitol - is hypertonic and ‘pulls’ fluid out of brain, good for 48-72 hours
  2. hypertonic saline
  3. loop diuretics like Furosemide - an adjunct to mannitol
  4. Anti-seizure meds such as Dilantin and Keppra (levetiracetam)
79
Q

What is a decompressive hemicraniectomy?

A

A possible treatment for increased ICP that is described as a ‘robust craniotomy’ from the frontal to the occipital lobe including the temporal lobe and opening of the dura.

80
Q

What is a barbiturate coma?

A

A controversial last resort treatment for increased ICP. Works by lowering cerebral metabolism and reducing CBF?. It requires intensive monitoring and may cause hypotension requiring vasopressors..

81
Q

Are steroids recommended to treat TBI?

A

No, they do not reduce ICP or improve outcome.

82
Q

Why is Mannitol not effective after 72 hours of use?

A

It will slowly leak into the interstitial fluid/brain parenchyma.

83
Q

Does Hypertonic saline work after 72 hours of use?

A

Yes, it will not accumulate in the interstitial space/brain parenchyma if the BBB is intact.

84
Q

How does Furosemide work for treating TBI?

A

Furosemide is given with Mannitol and they have a synergistic effect. Furosemide acts primarily on the kidney and is not dependent on an intact BBB. It is thought to reduce CSF production.

Block 8 week 2 (4 decks)

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