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HHD 2 > Traumatic Brain Injury > Flashcards

Traumatic Brain Injury Flashcards

1
Q

What are the most common causes of traumatic brain injury (TBI)?

A

road traffic collisions (RTCs)
falls <2m

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2
Q

What is the presentation of a traumatic brain injury?

A

history of a blow to the head
headache
vomiting
decreased consciousness
fixed pupils- due to pressure on interpupillary nerves (abducens nerve CNVI- lateral rectus muscle- no lateral movement of eye)
post traumatic amnesia
seizure
neurological deficit

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3
Q

A glasgow coma scale score of 15 is the best score. Why is this?

A

this is indicative of a responsive patient
good eye, verbal and motor responses

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4
Q

A glasgow coma scale score of </=8 is indicative of a _________ patient

A

a comatosed patient

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5
Q

A glasgow coma scale score of 3 is indicative of an _________ patient

A

unresponsive

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6
Q

What does the Monroe-Kellie doctrine hypothesise/state?

A

it states that the sum of the volumes of the brain, CSF and intracerebral blood, are constant

this means that when the volume of one component increases, the volume of the other component decreases to keep the sum of the volumes constant

for instant if a mass is present, there are compensatory decreases in the volume blood and CSF

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7
Q

What are the things inside the brain that makes up its volume?

A

brain tissue
blood
CSF

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8
Q

When compensatory decreases in blood and CSF volumes stops, what happens?

A

rise in intracranial pressure

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9
Q

What is the consequence of a rise in intracranial pressure?

A

there is a decrease in cerebral perfusion pressure (CPP)
CPP= MAP - ICP
therefore an increase in ICP leads to a reduction in CPP
this leads less nutrients and oxygen for brain cells and this ischaemia and cell death (infarction)

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10
Q

What are the consequences of an elevated ICP?

A

midline shift
central descent
uncal herniation —> compression of CNIII (oculomotor)
tonsillar herniation —> cushings response

there is no where for the pressure to go in an enclosed space this, tissue is shifted or pushed downwards leading to brain herniation. Hernias in the brain can compress CNIII

CNIII is located in midbrain

Midbrain also contains breathing and respiratory centres

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11
Q

How are traumatic brain injuries classified ?

A

acute V chronic
lesion type
diffuse or local
blunt vs penetrating
Severity (glasgow coma scale)

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12
Q

What is the most common type of TBI?

A

Concussion

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13
Q

Concussions are referred to as _________ TBIs

A

“mild”

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14
Q

What are the characteristics of a concussion?

A

brief alteration in neurology (transient)
there is a functional disturbance
no structural injury on CT scan

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15
Q

What is the long term consequence of a concussion referred to as?

A

post- concussive syndrome

41% of people with concussions will develop post concussive syndrome

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16
Q

What is the management for a concussion?

A

discharge home with medical device and appropriate adult
graduated return to normal activity

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17
Q

A skull vault fracture is the result of …

A

a significant force

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18
Q

What are the type of a skull vault fracture?

A

Linear fracture
Depressed fracture
Open Wound fracture

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19
Q

What is the management of a linear skull fracture?

A

if no underlying brain injury then no treatment is required

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20
Q

What is the management of depressed skull fracture?

A

may need elevating if there is an underlying contusion as this increases seizure risk

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21
Q

What is the management of an open skull fracture?

A

wound closure

-Open fracture breaks through the skin-

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22
Q

Base of the skull fracture is caused by …

A

high impact injury

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23
Q

Base of skull fractures are usually associated with …

A

brain injury

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24
Q

What are the clinical presentations of a base of skull fracture?

A

CSF:
Otorrhoea- CSF drainage from ear
Rhinorrhoea- CSF drainage from nose

Battles sign- bruising over the mastoid process; bleeding and therefore bruising behind the ear

Racoon eyes- fracture bled into the eyes

Deafness
Diplopia

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25
Q

What is the management for a base of skull fracture if the patient is at risk of future meningitis?

A

pneumovax- pneumococcal vaccine

do not give antibiotics

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26
Q

When should a base of skull fracture be fixed?

A

if the CSF leak is >2 weeks

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27
Q

What is encephalitis ?

A

infection of the brain

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28
Q

What is meningitis?

A

infection of meninges surrounding the brain

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29
Q

List some causes of penetrating TBIs

A

knife
gun crime
battle TBI- secondary blast, ballistic

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30
Q

Penetrating TBIs have a high rate of infection. True or false

A

True

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31
Q

How are penetrating TBIs managed?

A

do not chase all fragments
manage raised ICP

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32
Q

Acute subdural haematomas are common injuries. What are they?

A

a collection of acute blood (and therefore clot) in the subdural space
subdural space is where the venous sinuses exist

they result from tears in the veins- hence acute collection of blood as blood leaks out into the subdural space

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33
Q

What is the characteristic presentation of an acute subdural haematoma?

A

cresent shaped haematoma

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34
Q

What kind of injury leads to a subdural haematoma?

A

de-acceleration injury
often leads to tears in the veins

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35
Q

What is the management for an acute subdural haematoma?

A

reverse any coagulopathy- dissolve the colt
neuroobeservations
manage intracranial pressure
seizure prophylaxis
+/- surgery

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36
Q

Extradural haemotomas are less common injuries. What are they?

A

they result from tears in the arteries that exist in the space between the skull and the dura mater (outer protective lining of the brain)

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37
Q

What artery is most implicated in extradural haematomas?

A

middle meningeal artery

38
Q

Extradural haematomas have a “talk and die” presentation. Briefly explain what this means

A

loss of consciousness for the second time; this is because the middle meningeal artery continues to bleed

39
Q

What is the clinical presentation of extradural haematomas?

A

biconvex haematoma

40
Q

What is the management of extradural haematomas?

A

if they are neurologically stable then close monitoring
if neurologically unstable URGENT SURGICAL EVACUATION

41
Q

What is the main cause of chronic subdural haemtomas?

A

innocuous (offensive) bump to the head weeks previously

leads to chronic bleeding from bridging veins

the clot forms and then acts as a sponge for CSF

42
Q

Why are elderly patients at risk of subdural haematomas?

A

veins in the subdural space (venous sinus) are very prone to tearing in the elderly

43
Q

The symptoms for a chronic subdural haematoma presents over days. What are the symptoms ?

A

hemiplegia- lack of control/stiffness/weakness of one side of the body
headache
confusion

44
Q

What is the management for a chronic subdural haematoma?

A

surgical evacuation
reverse anti-coagulants/antiplatelets to stop bleeding
?dexamethasone??

45
Q

What is a cerebral contusion?

A

scattered areas of bleeding on the surface of the brain
intraparenchymal bleeding- bleeding in the brain

46
Q

What are the consequences of cerebral contusions?

A

may cause generalised swelling

47
Q

What is the management for a cerebral contusion ?

A

limited surgical options

48
Q

What is a diffuse axonal injury?

A

this is when rotational/twisting forces in the brain cause shearing of axons

when the brain twists and shifts inside the bony skull

shearing of microvessels occurs as well
there is multiple petechial haemorrhage (multiple sites of bleeding)

49
Q

There is good prognostic factor for diffuse axonal injuries. True or false

A

False
prognostic factor is poor

50
Q

What are the management options for diffuse axonal injury?

A

limited surgical options

51
Q

What are clinical investigations can be performed for traumatic brain injuries?

A

CT- includes c-spine
MRI
Coagulation studies
Intra-cranial pressure

52
Q

What is the aim of the management of TBIs?

A

to reduce the damage caused by secondary injury

53
Q

What is a primary brain injury ?

A

these are the immediate damages caused to the brain by the trauma

54
Q

What is a secondary brain injury?

A

ischaemic insult from hypotension, hypoxia, disrupted autoregulation, raised intracranial pressure

55
Q

What are the management techniques employed for TBIs ?

A

prevention- education surrounding alcohol, driving
Prehospital- advanced trauma life support protocol ABCDE
Acute- Advanced trauma life support protocol ABCDE
Neuro ITU
Surgical
Rehab

Diuretics- reduce fluid and therefore reduce ICP

56
Q

List neuro-protective measures that are employed in TBIs

A

remove hard collar
sit to 45 degree angle
protect airway
avoid hypoxia
avoid hypotension
mannitol to reduce ICP
induced coma
normothermic
AED (automated external defib) - prophylaxis

57
Q

What are the surgical management techniques for TBIs

A

CSF diversion
craniotomy- hole in skull
craniectomy
burr-hole- extradural haematoma, acute subdural haematoma
elevation of depressed skull fracture

58
Q

What are poor prognostic factors of TBIs ?

A

loss of grey white differentiation
bilateral F&D pupils (full and dilated???)
diffuse injury (not localised)
poly trauma- extracranial injury
brainstem involvement

59
Q

What are some complications of TBIs?

A

infection- intra/extracranial
spectrum of disability
affective disorders
psycho-social impairment
pituitary dysfunction
vitamin D deficiency
post traumatic seizures
post- concussive syndrome (long term)

60
Q

What are the dental considerations for TBIs?

A

Loose teeth
polypharmacy
poor dental hygiene
concurrent maxillofacial trauma
may be primary presentation of brain injury

61
Q

What are the stages of a seizure

A

Prodromal
Aura (early ictal)
Ictal /ictus
Post ictal period

62
Q

What occurs in the prodromal stage of a seizure?

A

mood or behavioural change preceeding attack
(hours)

63
Q

What does the the early ictal/aura stage of a seizure refer to?

A

these are the symptoms immediately before the attack
localises to point of origin

64
Q

What is the ictal stage of a seizure?

A

refers to where the seizure is occuring
the seizure itself

65
Q

What does the post-ictal stage of a seizure refer to ?

A

the time immediately after ictus
pt is often confused and irritated

66
Q

What is the pathogenesis of epilepsy ?

A

balance between excitatory and inhibitory neurotransmitters is disturbed

decreased GABA action
increased glutamate action

67
Q

What are the main classifications of epilepsy?

A

Partial seizures (restricted to one part of the cortex)
Generalised seizures (all over the brain)
Unclassified

68
Q

Partial seizures can be classified according to their severity. What are the classes of partial seizures according to their severity

A

simple partial
complex partial
secondar generalised

69
Q

Partial seizures can be classified according to their site of onset. List the sites of onset for a partial seizure

A

frontal lobe
parietal lobe
temporal lobe
occipital lobe

70
Q

What are the types of generalised seizures/epilepsy?

A

tonic clonic
absence
myoclonic
tonic

71
Q

What are the characteristics of a simple partial seizure?

A
  • consciousness preserved
  • they are of cortical origin
72
Q

What are the characteristics of complex partial seizures?

A
  • degree of impaired consciousness level- wider effects
  • cortical origin
73
Q

What is a partial seizure?

A

in a partial seizure only one part of the brain is affected; one area of the cortex, one lobe or one hemisphere

74
Q

What are the characteristics of a frontal lobe partial seizure?

A
  • jacksonian march- involuntary muscl movement from one group of muscle to the next, usually begins in the hands and face
  • todds paralysis- post ictal weakness in the limb affected
  • adversive seizures- movement of the head and eyes away from the site of origin
  • supplementary motor area- stereotyped movements in sleep e.g.cycling

remember frontal lobe: face, arms, limbs and trunk; watch videos in lect

75
Q

What are the characteristics of a parietal lobe partial seizure?

A

sensory cortex origin
parasthesiai in extremity or face

76
Q

What are the characteristics of a temporal lobe partial seizure?

A
  • complex aura- taste, smell, lip smacking, memory disturbance, semi-purposeful movements, affective disturbance
  • automatism involuntary, complicated movement
  • associated with hippocampal sclerosis (learning and memory)
77
Q

What is a generalised seizure?

A

there is widespread electrical discharge/ disturbance
might be left/right hemispheres or both

78
Q

What can the initial symptoms of a generalised seizure identify?
Why is this ?

A

the origin of the seizure

only the origin can be identified by the initial symptoms because the seizure (electrical disturbance) will spread to sub-cortical regions and release discharge before spreading bact to the cortex of both hemispheres (at this time a more diverse range of symptoms can be produced)

79
Q

What are the characteristics of the tonic phase of a tonic clonic attack?

A

sudden stiffness of joints and muscles in muscles of arms, legs and trunk
* lasts for 10 seconds
* LOC
* eyes open
* elbows flexed
* legs extended
* teeth clenched
* breath held

80
Q

What are the characteristics of the clonic phase of a tonic clonic attack?

A

repeated jerking movements of the arms and legs on both sides of the body
* lasts minutes
* tremor gives way to violent shaing
* eyes roll back
* tachycardia
* tongue biting

81
Q

What are the post ictal symptoms of a tonic clonic attack?

A

confusion
headache

82
Q

Absence seizures are also known as …

A

Petit mal seizures

83
Q

List the characteristics of absence seizures

A
  • more common in children
  • vacant staring
  • may occur multiple times a day
  • 5-15 seconds
84
Q

What are the characteristics of myoclonic seizures?

A
  • sudden brief generalised muscle contractions; of a muscle or group of muscles
  • commoner in the morning
  • onset after puberty
  • degenerative and metabolic disease
  • do not last more than a second or two
85
Q

What does status epilepticus refer to?

A

a seizure that does not stop after 5 minutes
consciousness does not return between attacks

86
Q

What are some consequences of status epilepticus?

A

pyrexia
coma
circulatory collapse

87
Q

What are some clinical investigations used for diagnosis of epilepsy?

A

CT
MRI
Electrocencephalogram (EEG)
video telemtry
ECG
serum glucose

88
Q

What is the management of acute phase epilepsy?

A

ABCDE
Once seizure is over put in recovery position
do not put anything in their mouth

89
Q

What are the long term management strategies for epilepsy?

A

Medical
Surgical

90
Q

List the dental considerations for patients with epilepsy

A
  • carry out treatment when seizures are infrequent when possible
  • keep as much apparatus away from area as possible
  • some medicines precipitate condition- be aware of those
  • conscious sedation is generally safe (midazolam)
  • acrylic best for prostheses
  • seizures can result in cranio-facial trauma
  • tongue lacerations

HHD 2 (37 decks)

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