Traumatic Brain Injury - Management Flashcards
Describe a Primary Brain Injury
- Occurs at the moment of impact
- Pattern & extent of damage depends in nature of impact
- Not treatable
- Target prevention (public health issue)
What is the main focus of a secondary brain injury?
Focus of medical intervention to minimise secondary brain injury
What should be optimised and observed in secondary brain injury?
- optimise oxygenation
- optimise cerebral perfusion
- Blood glucose
- hypo/hyperthermia
- Body temp –> aim for normathermia
What are the secondary processes that occur at the cell and molecular level to exacerbate neurological damage?
- NT release (glutamate)
- Free radical damage
- calcium mediated damage
- inflammatory response
- mitchondrial dysfunction
- eary gene activation
What are the main results of secondary brain injury?
- ischaemia, excitotoxicity and cellular energy failure
- neuronal death cascades
- cerebral oedema
- inflammation
Draw a diagram to illustrate Normal ICP
Draw a diagram to illustrate a compensation for an expanding mass with a normal ICP
Draw a diagram to illustrate a compensation for an expanding mass with an elevated ICP
Draw a diagram illustrating the pathophysilogy of primary and secondary brain injury
Draw a diagram highlighting the critical volume with regards to ICP and ICV
What are the steps of early management in a secondary brain injury?
- Assessment and identifcation of the patient AT RISK
- Pre-emptive investigation (CT Scan)
Who should be sent to hospital in the cases of suspected brain injury?
- Extremes of age (65years)
- Amnesia for events before or after injury
- Any loss of consciousness
- High energy injury
- Vomiting
- Seizure (previous neurosurgery)
- Bleeding /clotting disorder
What is the function of the Glasgow Coma Scale?
- Is central to the classification,
- initial management
- and ongoing assessment of a patient with head injury
Outline the Eye Opening classification of the GCS
E4
4 = Spontaneous
3 = Open to speech
2 = Open in response to pain
1 = Do not open
NT = unable to open due to swelling
Outline the Verbal Response classification of the GCS
V5
5 = Orientated
4 = Confused
3 = Inappropraite words
2 = incomprehensible sounds
1 = No response despite verbal and physical stimuli
NT = dysphasic
T = intubated
Outline the Motor response classification of the GCS
M6
6 = Obeys commands
5 = localised to central pain
4 = Normal flexion towards the source of pain
3 = Abnormal flexion
2 = Extension to pain
1 = No response to painful stimuli
What are the different degrees of head injury?
- Minimal = 15 (no history of unconsciousness)
- Mild = 13-15
- Moderate = 9-12
- Severe = 8 or less
When should a CT scan be requested in adult patients?
- GCS <13 on initial assessment in A & E
- GCS <15 2 hours after injury
- Suspected open or depressed skull #
- Any sign of basal skull #
- Post traumatic seizure
- 1 or more episode of vomiting (3 in kids)
- Amnesia for events more than 30 mins before impact
What are major red flags and would influence a decision not to discharge a patient?
- Loss of consciousness, drowsiness, confusion, fits
- Painful headaches which don’t settle, vomiting or visual disturbance
- clear fluid from ear or nose, bleeding from ears, new deafness (CSF rhinorrhoea test for glucose or beta-2-transferrin)
- Problems understanding or speaking, loss of balance, difficulty walking or weakness in arms or legs
Why is it important to optimise oxygenation?
When assessed pre admission SpO2 <90% in 50% of cases
What is the imaging of choice for a cervical spine?
Plain (lateral) X-Ray
What are the main aspects to monitor in a patients breathing?
- Administer oxygen
- Monitor SpO2
- Monitor ABGs
- GCS <8 = INTUBATE
What is the targeted PaCO2
4.5-5 kPa
How should circualtion be balanced?
- Maintain CPP above 60-70 mmHg
- Maintain systolic BP >90 mmHg
- ICP < 20mmHg
