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Y3 PPNP Midterms > Traumatic Brain Injury > Flashcards

Traumatic Brain Injury Flashcards

1
Q

What are the conditions causing brain injury?

A
  1. Trauma
  2. Tumor
  3. Stroke
  4. Metabolic derangements
  5. Degenerative disorders
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2
Q

What are the manifestations of traumatic brain injury?

A
  1. Changes in LOC (may fluctuate depending on extent & level of injury/damage - RAS dependent)
    • confusion ^ mild
      drowsy
      obtundation
      stupor
      coma v extreme
  2. Alteration in sensory & motor functions
  3. Posturing: decorticate and decerebrate
  4. Cranial nerve reflexes
    A) Pupil reflex (function of brainstem + CN II & III)
    - indicator of brain herniation
    - increased IVP may impair eye movements controlled by CN III, IV & VI
    B) Oculovestibular reflex
    - sign of brainstem dysfunction
    - 2 tests to do:
    I. Caloric ice water test (invasive)
    > ice water is injected into ear canal
    > normal = conjugate eye movement (both eyes move together towards direction of water entering)
    > abnormal = dysconjugate/asymmetric eye movement
    > absent = no eye movement
    II. Doll’s eye test (non-invasive)
    > Oculocephalic head turning test (absent response)
    > indicate brainstem damage
    > normal = eyes turn in direction oop of head rotation
    > abnormal = eyes stay midline & don’t turn when head is rotated
    C) Corneal reflex
    - absence of blink response
    - indicator of severely impaired brain function
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3
Q

Who is more likely to get traumatic brain injury?

A
  1. Males
  2. People of lower SES
  3. 21-60 years old
  4. Young and active
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4
Q

How many types of brain injuries are there?

A

Primary/Direct
- caused by impact/initial insult
- include diffuse axonal injury & focal lesions of laceration, contusion and haemorrhage
- types:
1. Focal/coup injury
> localised at site of impact of skull
2. Polar - coup/countercoup injury
> occur as a result of brain shifting within skull and meninges during course of acceleration/deceleration movement = cause local injury in two separate poles of brain
3. Diffuse
> movement of brain within cranial cavity causing wide neuronal damage
4. Intracranial haematomas
> epidural, subdural and subarachnoid

Secondary (*TBI often initiates mechanism of secondary injury - ischaemia, increased ICP and altered vascular regulation)
- progressive damage from physiologic response to an initial insult
- damage results from
1. Subsequent brain swelling
2. Infection
3. Cerebral hypoxia
- often diffuse/multifocal, including:
1. Concussion
2. Infection
3. Hypoxia brain injury

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5
Q

What are the causes of traumatic brain injury?

A
  1. Motor vehicle collisions
  2. Industrial accidents
  3. Minor HI
  4. Criminal assault
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6
Q

What are the different types of skull fractures?

A

Linear, Depressed and Basal skull fractures

*fractures of cranial vault is obvious on skull xray
*2/3 of skull fractures are associated with intracranial lesions (but intracranial lesions can also occur without skull fractures/external injuries - need to do hx/pe TRO HI)

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7
Q

What can you see on linear skull fractures?

A
  1. Lucent xray = brain separation
  2. Dense xray = brain overlap
  3. Cause rupture of meningeal vessels
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8
Q

What are depressed fractures and what do they indicate?

A

Depressed fractures are open fractures associated with infection

  1. Stellate (multiple fractures radiating from a single point): impact from blunt object ; underlying brain injury
  2. Egg shell = child abuse
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9
Q

What is a basal skull fracture and how to detect one?

A
  • most important/critical case
  • difficult to detect in X-rays due to irregular and dense bones
  • other soft tissue injuries may give clue:
    1. Haemotympanum (blood in middle ear)
    2. CSF rhinorrhoea/otorrhoea
    3. Periauricular/retoauricular ecchymoses (bruise behind ear) - Battle’s sign
    4. Periorbital ecchymoses (bruise ard eyes) - Racoon’s eyes
  • often associated with CN injuries (CN are located at base of skull)
    1. Anosmia
    2. Partial loss of vision
    3. Facial palsy
    4. Vertigo
    5. Nystagmus

*indications of HI include: scalp wound, fracture, swelling/bruising, LOC, nasal discharge and stiff neck

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10
Q

What are the types of intracranial lesions?

A
  1. Concussion
  2. Contusion
  3. Epidural/Extradural haematoma
  4. Acute subdural haematoma
  5. Chronic subdural haematoma
  6. Subarachnoid haemorrhage
  7. Intracerebral haemorrhage
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11
Q

What is a concussion?

A

It is an immediate transient LOC (dazed/star struck)

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12
Q

What are the causes of concussion?

A
  1. Rotation of cerebral hemisphere to relatively fixed brainstem
  2. Electro-physiological dysfunction of RAS
  3. No structural lesion & residual sequelae
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13
Q

What are the signs and symptoms of concussion?

A
  1. Retrograde amnesia (before events; indicate severity of lesion)
  2. Antegrade amnesia (after events, very brief)
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14
Q

What is a contusion?

A

A head injury resulting in haemorrhage into brain tissue

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15
Q

What are the causes of contusion?

A
  1. Deceleration of brain against skul = rupture surface of brain
  2. Frontal and occipital pole affected
  3. Coup injury - directly under point of impact
  4. Countercoup - at point opposite point of impact
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16
Q

What are the signs and symptoms of contusion?

A
  1. Hemiparesis/gaze paralysis (frontal injuries)
  2. Visual defect - occipital lobe
  3. CN dysfunction - commonly olfactory
  4. Cerebral oedema, decorticate, decerebrate = more severe injury
  5. Coma - if bilateral cerebral lesions
17
Q

What is an extradural/epidural haematoma

A

*shows convex on xray

It is a haemorrhage between skull and dura mater
- due to direct trauma causing fracture to temporal bone and damage to middle meninges
- as there’s an arterial bleed = condition will worsen rapidly (fast blood leak)

18
Q

What is the symptom of extradural/epidural haematoma?

A

Brief LOC -> short lucid interval -> coma/other signs of deteriorating LOC (*depend on whether patient is herniating/progress of neurological deterioration due to herniation)

*carries a bad prognosis for severe extradural haematoma

19
Q

What treatment does extradural/epidural haematoma require?

A

Immediate surgical evacuation to drain bleed

20
Q

What if extradural/epidural haematoma do not get treated?

A

It will cause decerebrate rigidity, coma then death

21
Q

What is an acute subdural haematoma?

A

*shows concave (look like a cave) on xray

It is a haemorrhage between dura mater and arachnoid membrane (bleed through veins)
- may not be associated with any surface injuries on scalp
- follows severe HI due to change in velocity
- due to rupture of surface cerebral veins that join dural venous sinuses
- twice as common as epidural haematomas

22
Q

What are the symptoms of acute subdural haematoma?

A

Brief LOC due to concussion -> relatively longer lucid interval (few mths to years) -> coma (progressive neurological deterioration due to herniation)

*bad prognosis if accompanied with cerebral injury due to high velocity

23
Q

What is the treatment for acute subdural haematoma?

A

Surgical evacuation

24
Q

What happens if acute subdural haematoma is not treated?

A

It will cause decerebrate rigidity, coma then death

25
Q

At what age is chronic subdural haematoma commonly found in?

A

Elderly above 60

26
Q

What are the causes of chronic subdural haematoma?

A
  1. Minor head injury which may not be remembered
  2. Shrinking of brain tgt with fragility of blood vessels
27
Q

What are the signs and symptoms of chronic subdural haematoma?

A

*SS occur mths to year after trivial injury (due to slow accumulation of venous blood ard atrophied brain)

*SS may be absent, non-specific and non-localising

Common SS - minor headache (from slow bleed)

Other SS
1. Personality changes
2. Fluctuating drowsiness
3. Confusion
4. Weakness
5. Seizures

*can be confused with stroke/dementia

28
Q

What is the plus point of chronic subdural haematoma?

A

It is potentially treatable and not as fatal as epidural haematoma

29
Q

What are the assessments to be done for traumatic brain injury?

A
  1. VS - ABC
  2. Secure airway and IV
  3. Protect C-spine with collar
  4. Don’t use morphine/depressants (an accurate assessment is needed)
  5. Hourly VS & GCS
  6. Arrange for urgent CT scan
  7. Neuro assessment for severity of HI
30
Q

What is the management for minor HI/injury?

A

If patient is conscious and has no deficits , can admit and observe for deficits if needed

31
Q

What is the management for patient with intermediate HI/injury?

A

If patient has brief LOC, confusion and neurological deficits, to do CT scan/MRI

32
Q

What is the management for severe HI/injury ?

A

If patient fell into a coma, to perform
1. Investigations
2. Resus and ICP mgt
A) BP
- maintain Bp at usual level (MAP @ 90mmHg)
- increase too much = increased ICP; too low = inadequate CPP
- maintain CPP within 50-70mmHg
B) Hypocarbia
- low pCO2 = vasoconstrict = lesser vasodilation
- hyperventilate patient on respirator if needed
C) Infusion of osmotic diuretics
- IV mannitol/glycerol
- decrease brain oedema
- caution for water depletion and hyperNa (*monitor for f&e freq)

33
Q

What are the prognostic factors for traumatic brain injury?

A
  1. Neuropsychotic disturbances are more common cause of disability than specific neurological deficits (e.g. impaired conc, attention and memory)
  2. Post-traumatic amnosia rarely resolves
  3. GCS < 8 = formal rehab

Y3 PPNP Midterms (7 decks)

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