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PC1-2 > Vol.4-Ch.6 "Head, Neck, and Spinal Trauma" > Flashcards

Vol.4-Ch.6 "Head, Neck, and Spinal Trauma" Flashcards

1
Q

What 3 structure help to protect the brain?

A
  • scalp
  • cranium
  • meninges
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2
Q

What does SCALP stand for and help you remember?

A

It is for the layers of ski protecting the scalp

Skin
Connective tissue
Aponeurotica
Layer of subaponeurotica (areolar) tissue
Pericranium (the skills periosteum)
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3
Q

What are the two main components of the cranium?

A

The cranium or cranial vault (where the brain is)

and the facial bones

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4
Q

What are the 3 layers of the meninges? describe them

A

Dura Mater - furthest from brain, has 2 layers: outer called periosteum and is attached to bone, inner is tough connective tissue that forms partial structural divisions

Pia Mater - closest to brain, highly vascular

Arachnoid membrane - covers inner dura matter and suspends brain with collagen and elastin fibers. Beneath is is the Subarachnoid Space that contains cerebrospinal fluid

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5
Q

What is cerebrospinal fluid and where does it come from?

A

It is a clear, colorless solution of water, proteins, and salts made to absorb shock.

It is made by the choroid plexus within the ventricles of the brain.

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6
Q

How much space does the brain, blood/vessels, and CSF take up in the cranial vault? What are the 3 main sections of the brain?

A

brain - 80%
Blood/vessels - 12%
CSF - 8%

  • cerebrum
  • cerebellum
  • brainstem
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7
Q

What makes up the cerebrum and what does it control?

A

It is the largest nervous system element and takes up the most space

It has an exterior which directs motor, sensory, memory, and emotions

the Occipital region controls sight

the Temporal region controls long term memory, hearing, speech, taste, and smell

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8
Q

What structure divides the brain into right and left hemispheres?

A

the Falx Cerebri

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9
Q

What separates the cerebrum from the cerebellum?

A

the Tentorium Cerebelli

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10
Q

What does the cerebellum control?

A

fine motor movements and balance/maintenance of muscle tone

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11
Q

What 3 structures make up the brain stem?

A
  • Midbrain (hypothalamus, and thalamus)
  • Pons
  • Medulla Oblongata
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12
Q

What does the hypothalamus control? Thalamus?

A

Hypothalamus : endocrine function, vomit reflex, hunger, thirst, kidney function, body temp, emotions

Thalamus : switching center between pons and cerebrum and is critical for the system that controls consciousness

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13
Q

What does the Pons do?

A

controls sleep

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14
Q

What 3 major centers does the medulla oblongata control?

A
  • Respiratory Center
  • Cardiac Center
  • Vasomotor Center
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15
Q

What 4 major vessels supply blood to the brain?

What is the Circle of Willis?

A

2 Internal Carotid arteries and 2 Vertebral arteries (the 2 vertebral combine to form the basilar artery)

The circle of Willis is at the base of the brain and is where the carotid and basilar arteries interconnect

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16
Q

What is the blood brain barrier?

A

it refers to the fact that the nervous system capillary walls are thicker so that it is less permeable because if blood or other things leaked through it acts as an irritant to CNS tissue and can cause inflammation and edema

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17
Q

What is normal ICP?

A

Less than 10 mmHg

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18
Q

What is the Monroe-Kelly Doctrine?

A

the formula for the relationships that form ICP

Intracranial Volume = Brain Volume + CSF Volume + Blood volume

and states that if any of these go up, others must go down you you will have an increased ICP

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19
Q

What are the 12 cranial nerves?

A 
CN-I = Olfactory (smell)
CN-II = Optic
CN-III = Oculomotor
CN-IV = Trochlear (keep eyes moving together)
CN-V = Trigeminal (facial senses and chewing)
CN-VI = Abducens (downward eye movement)
CN-VII = Facial
CN-VIII = Acoustic
CN-IX = Glossopharyngeal (swallowing, baroreceptors)
CN-X = Vagus (PNS, heart, respiration)
CN-XI = Spinal Accessory (neck,swallowing,vocal chords
CN-XII = Hypoglossal (voluntary control of toungue)
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20
Q

What is the Ascending Reticular Activating System?

A

controls the sleep-wake cycle and plays a role in regulating respirations, heart rate, and peripheral vascular resistance

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21
Q

In the ear, what is responsible for hearing and what is responsible for sensing position/motion?

A

The inner ear receives sounds and the semicircular canals sense position and motion

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22
Q

What major blood vessels run along the neck?

A

The carotid arteries and the jugular veins

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23
Q

What are the three zones of the neck?

A

Zone 1 is below the cricoid ring (highest mortality rate)

Zone 2 is above the cricoid ring but below the angle of the jaw (more commonly injured)

Zone 3 is is above the angle of the jaw (injuries may be hidden but serious)

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24
Q

What are the 5 sections of the spine and how many vertebra are in each?

A 
Cervical - 7
Thoracic - 12
Lumbar - 5
Sacrum - 5 (fused)
Coccyx - 4 (fused)
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25
Q

What structure separates each vertebra?

A

Intervertebral disks

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26
Q

What is the first cervical vertebra called and why is it special?

A

It is the Atlas, it has no spinous process or vertebral body and permits nodding of the head (not twisting)

(this joint is called the atlantoocipital joint)

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27
Q

What is the 2nd cervical vertebra called and why is it special?

A

It is called the Axis and allows the head to swivel side to side

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28
Q

What are the 3 important ascending (sensory) tracts in the spinal column?

A
  • Fasciculus Gracilis
  • Fasciculus Cutaneous
  • Spinothalamic

the first two relay sensory light touch, vibrations, positional sense from the skin, muscles, tendons, and joints to the brain.

Spinothalamic has two parts: the anterior tract conducts pain and temperature. the lateral tract conducts touch and pressure sensation

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29
Q

What is the important descending (motor) spinal nerve?

A

The Corticospinal Tract and is responsible for voluntary and fine muscle movement

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30
Q

Where does the spinal cord get its blood supply?

A

1 anterior spinal artery and 2 posterior spinal arteries

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31
Q

What are the two types of brain injurie categories?

A

Direct (primary) or indirect injury to the tissues of the cerebrum, cerebellum, or brain stem

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32
Q

What is the difference between coup and contrecoup brain injury

A

Coup is when the brain hit the front of the head (assuming impact came from the front) as the skull is moving backwards

Contrecoup is when the brain hit the back of the skull once the head stops going back but the brain continues and thus hits the back of the head which then stops the brain from moving

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33
Q

What are the two types of direct brain injuries? what are they?

A

Focal : injuries that occur at specific locations

Diffuse (DAI - diffuse axial injury): generalized mechanism of injury

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34
Q

What are 2 types of (direct) focal brain injuries? describe them.

A

Cerebral Contusion :
- when blunt trauma occurs it can produce capillary bleeding into the brain’s substance (often to frontal lobe which can cause personality changes)

Intracranial Hemorrhage :
- Can be an epidural hematoma, subdural hematoma, and intracerebral hemorrhage

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35
Q

Explain where an epidural hematoma is and describe it

A

It is between the dura mater and the skull.

These typically involve arteries and will develop and worsen fast

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36
Q

Explain where an subdural hematoma is and describe it

A

It is between the dura mater and the arachnoid space

This occurs very slowly because they involve small venous vessels, since it is still above the pia mater it does not touch the brain tissue and cause irritation, inflammation and ultimately swelling like in intracerebral bleeding

suspect this with Pts who have not had recent trauma but present neurological deficiencies, take through history looking for previous trauma over some time ago

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37
Q

Explain where intracerebral hemorrhage occurs and describe it

A

Occurs when bleeding is directly on the brain surface which causes irritation, inflammation and ultimately swelling. This will happen fast because it usually involves and artery and will present much like a stroke

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38
Q

What is hydrocephalus?

A

It is a byproduct of intracerebral hemorrhaging where swelling or fluids block the arachnoid villi in the subarachnoid space that are responsible for allowing CSF to be reabsorbed back into the blood. This obviously causes increased ICP

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39
Q

What are 3 types of (direct) diffuse brain injuries? (DAI - diffuse axial injury)

A

Concussion : (mild DAI)
- is when there is nerve dysfunction without substantial anatomic damage. Pt usually has confusion, disorientation, and event amnesia

Moderate Diffuse Axial Injury (DAI): “classic concussion”
- caused by stretching, tearing, or shearing of nerve fibers with minute brain bruising. Pt may (usually) loose consciousness and have prolonged confusion, lack of concentration, disorientation, and amnesia

Severe Diffuse Axial Injury (DAI) :
- caused by significant mechanical disruption of multiple axons in both cerebral hemispheres and extends to brain stem. Pt will usually remain unconscious and many do not survive; of those who do they will have permanent neurological deficiencies

40
Q

What is indirect injury and what are 2 distinct ones?

A

Indirect injury (secondary) is the result of factors that occur because of the initial (primary) injury

  • Intracranial Perfusion
  • Pressure & Structural Displacement
41
Q

What are 2 major factors that affect brain perfusion?

A

ICP and hypotension

42
Q

Since veins are the first thing to compress when ICP goes up (the next being CSF being pushed into the spinal cord) what will take place in response to the low venous blood return?

A

It will cause a build up of CO2 (hypercarbia) which will cause vessels to dilate, increasing ICP even further. This increase in ICP and CO2 build up is the cause of hyperventilation and hypertension associated with head injuries.

The latter is for HYPERcarbia but HYPOcarbia can be just as dangerous because it will cause vasoconstriction but this will further decrease blood supply to the brain

43
Q

What symptoms would be present if the brain stem was herniated through the tentorium incisura?

what about the medulla oblongata through the foramen magnum

A

Brain stem herniation = vomiting, AMS, pupillary dilation

Medulla Oblongata herniation = disturbance in breathing, blood pressure, and heart rate

44
Q

What are 8 signs and symptoms of a brain injury?

A

1) Altered Mental Status
2) Altered personality
3) Amnesia (event, retro = before event, antero = after)
4) Cushing’s Triad
5) Vomiting
6) Body temp changes
7) Pupillary reaction change
8) Decorticate posturing

45
Q

What is Cushing’s Triad? Compression of what causes this?

A
  • Increased BP
  • slow pulse
  • Irregular respirations

compression of the brain stem

46
Q

What is the “central syndrome”?

A

The predictable progression of events caused by an expanding mass in the central cerebrum that puts pressure on the midbrain, then pons, then medulla oblongata

47
Q

What are some mechanisms of spinal injury?

A

Extreme range of motions including:

  • Hyperextension/flexion
  • rotational
  • lateral

Axial Stress:

  • loading (compression)
  • distraction (decompression)
48
Q

What are 6 types of spinal cord injuries?

A
  • Concussion (disruption but no damage)
  • Contusion (minor damage and bruising/fluid leakage)
  • Compression
  • Laceration
  • Hemorrhage
  • Transection (partial or full cut of the chord)
49
Q

What are 9 signs and symptoms of spinal chord injuries?

A
  • Paralysis of extremities
  • Pain w/out movement
  • Tenderness of spine
  • Impaired breathing
  • Spinal Deformity
  • Priapism
  • Posturing
  • Loss of bowel/bladder control
  • Nerve impairment to extremities
50
Q

What causes Anterior Cord Syndrome?
Central Cord Syndrome?
Brown-Sequard Syndrome?
Cauda Equina Syndrome

A

Anterior Cord Syndrome = flexion/extension injury and results from bony fragments or pressure compressing arteries that perfuse the anterior cord

Central Cord Syndrome = hyperextension of spine often with preexisting arthritis, affects 50+yo via incontinence and motor weakness in lower extremities

Brown-Sequard Syndrome = penetrating injury to one side of the chord that effects the ipsilateral side of the body to the injury

Cauda Equina Syndrome = is when the lower end of the spinal cord are compressed, interrupting sensation and motor control, especially bladder and bowel nerves

51
Q

What is spinal shock?

A

temporary insult to the spinal cord affecting body below the level of injury; the affected area becomes flaccid and loses feeling

52
Q

transient = ?

A

temporary

53
Q

What is a SCIWORA and who does it affect?

A

it affects young children who have much more elastic spines and ligaments. A Spinal Cord Injury With Out Radiographic Abnormality (SCIWORA) occurs when there is a spinal cord injury but xrays show no sign of spinal column because they were unharmed thanks to their stretcher nature as opposed to the spinal cord

54
Q

What is retroauricular ecchymosis? What is it a sign of?

A

It is also called “Battle’s Sign” and it is a black and blue discoloration found just behind the ears and it is an indication of a Basilar Skull fracture

55
Q

What is bilateral periorbital ecchymosis? What is it a sign of?

A

It is also called “Racoon Eyes”, it is a severe discoloration around the eyes associated with orbital fractures and a classic sign of a Basilar Skull fracture

56
Q

What are 4 types of cranial fractures? Describe them,

A
  • Linear Nondisplaced Fracture: small cracks in the cranium, with no other associated injuries this is not particularly harmful for Pt.
  • Depressed Fracture : is an inward displacement of the skull
  • Open Fracture : involves the cranium and often the dura mater being broken and exposed
  • impaled object : self explanatory
57
Q

What is the thinnest most frequently fractured cranial bone?

A

Temporal

58
Q

What is the target or “halo” sign?

A

It is the yellowish ring around blood caused by CSF, commonly from the ears (though can also come from eyes, nose, or mouth), is a common sign of a basilar skull fracture, CSF leakage should not try to be stopped as it is often releasing ICP and helping lessen damage to the brain. The body reproduces CSF very quickly

59
Q

What are the 4 types of scalp injuries? describe them.

A
  • Hematoma : blow disrupts blood vessels causing blood to accumulate and swell making a bump
  • Depression : blow can tear fascial layers under neath causing a depression; this can often be confused with a depressed skull fracture but it is not
  • Normal Scalp Contour : blood may fill the space vacated by the torn fascia; basically a depression but blood fills the dent so it appears normal
  • Depressed fracture : Like the last two but this time a fracture is present but that blood still fills the dent, masking the skull fracture
60
Q

What are two immediate problems caused by a facial injury and what 2 associated injuries should be assumed?

A

A mass loss of blood because of high vasculature (hypovolemia) and a compromised airway

Assume a head and spinal injury to be associated

61
Q

What 4 places are facial fractures or dislocations often found?

A
  • Mandible
  • Maxillary
  • Orbital
  • Nasal
62
Q

What are Le Fort’s Facial Fractures? for what bone?

A

The classify maxillary damage

Le Fort I : slight instability to maxilla, no displacement

Le Fort II : Fracture of both maxilla and nasal bones

Le Fort III : Fracture involving entire face below brow ridge ( zygoma, nasal, maxilla)

** Le Fort II & III can cause CSF leakage

63
Q

Epistaxis (nosebleed) can be classified as either _____ or _____?

A

Anterior - comes out of the nasal septum, usually from damage to a network of vessels called Kiesselbach’s plexus

Posterior - goes down back of Pts throat and can cause nausea or vomiting

64
Q

What is hyphema?

What is subconjunctival hemorrhage?

What is enophthalmos?

A

Hyphema is the pooling or collection of blood over the iris or pupil (usually involves hospitalization and intervention)

Subconjunctival hemorrhage is when small blood vessels in the subconjunctiva rupture leaving a portion of the eye surface to turn blood red (not serious)

Enophthalmos - is the depression displacement injury of something like a racquet ball hitting the eye directly and pushing it back

65
Q

What is the Simplified Motor Score (SMS) and when is it done?

A

It is a simplified GCS that can be done early and very quickly in the primary assessment to assess possible brain injury

It only entails:
2 = obeys commands
1 = localizes pain (actually moves towards pain stim)
0 = withdrawals to pain or worse

a score of 1 means transport to neuro center
a score of 0 mean intubate

66
Q

If the heart rate is _____ and _____ then suspect brain injury

A

below 60 and strong/bounding

normal is 60-100

67
Q

If a Pt has a head injury WITH suspected herniation, adjust capnography goals from 35-40mmhg (normal) to _____?

A

30-35mmHg to help prevent hypercarbia

68
Q

What set of vitals is the sign for a herniated brain injury?

as ICP goes up it will eventually cause herniation so it is also a sign of increased ICP as well

A

Cushing’s Triad:

  • increased systolic BP (strong and bounding pulse)
  • slow and decreasing pulse rate
  • Irregular respirations (typically cheyne-stokes respirations that is increasing then decreasing resp volumes followed by periods of apnea)

they will also typically have irregular pupil reactions, posturing (decorticate or decerebrate), or no movement at all

69
Q

Usually the affected pupil is on the _____ side as the brain injury side

A

Ipsilateral (same side)

70
Q

What is the Doll’s eye (oculocephalic) response?

A

Tests for a brain injury by rotating the head side to side. At normal the eyes will move slowly with the head, but if a brain injury is present the eyes will move with the head (or in other words not move at all, just point where the head is pointing)`

DO NOT do if there is suspected spinal injury

71
Q

The eyes can provide indications of problems with cranial nerves? (4)

A

CN - II (optic)
CN - III (oculomotor)
CN - IV (Trochlear) (keeps eyes moving together)
CN - V (Trigeminal) (sensations of face, teeth, gums, palate, and controls chewing)

72
Q

When doing a full body exam on a Pt you suspect has a brain/CNS injury and suspected paralysis or loss of feeling/function, what should you change?

A

Start from feet and move upwards, this sis to prevent the patient from realizing they have lost their ability to feel and may panick

Also be on the look out for where the line between sensation and no sensation is as well as where skin may go from cold and pale to warm and flush. This also indicates that CNS has lost its ability to control the vasculature there

73
Q

With a traumatic brain injury, it is critical to maintain a BP of at least _____ mmHg with aggressive fluid resuscitation?

A

90

74
Q

What does a GCS of 13-14 mean?
9-12?
Less than 8

A

3-15 is total range

13-14 means mild head injury
9-12 means moderate injury
Less than 8 means severe injury and usually means coma and probably intubation

75
Q

What are the 3 things GCS weighs?

If a pt has a score of anything less than ____ reassess every _____ minutes

A
  • Eye Response
  • Verbal Response
  • Motor Response

If a pt has anything less than a 15 (perfect score) reassess their GCS every 5 minutes

76
Q

What scores can you get for Eye Movement in GCS?

A

Eye Movement:

4 = Spontaneous
3 = to Verbal Command
2 = to Pain
1 = No Response
77
Q

What scores can you get for Verbal Response in GCS?

A

Verbal Response:

5 = Oriented and converses normally
4 = disoriented but converses
3 = Inappropriate words (random words)
2 = incomprehensible sounds
1 = no response
78
Q

What scores can you get for Motor Response in GCS?

A

Motor Response:

6 = Obeys verbal commands
5 = Localizes pain
4 = Withdrawals from pain (flexion)
3 = Abnormal flexion to pain (decorticate rigidity)
2 = Abnormal extension to pain (decerebrate rigidity)
1 = No response
79
Q

What is a priapism, what is it a sign of?

What is the “hold-up” position? What is it a sign of?

A

A priapism is an erection caused from unopposed parasympathetic stimulation; which happens when a brain injury blocks the sympathetic tone

The “hold-up” position is when the Pt holds their hands/arms above the shoulders and head because spinal injury has caused them to loose control over their adductor and extensor muscles but maintains control over their abductor and flexors

80
Q

In the event a traumatic brain injury causes seizures, what meds can you consider giving? (2)

A

Diazepam and lorazepam

81
Q

What is a eye(s) that looks dull and lackluster a sign of?

What does it mean when one pupil becomes sluggish, nonreactive, then dilated?

A

Cerebral hypoxia

increased ICP

82
Q

What should be kept aligned when moving a patient?

A

Nose, navel, and toes

83
Q

What 3 criteria must be met in order to discontinue spinal precautions?

A

1) Pt must be fully oriented, not intoxicated, has GCS of 15, and is not effected by the fight or flight response
2) The Pt is free of significant distracting injuries
3) Pt is free of any signs or symptoms of spinal injury

84
Q

According to the Maine spinal clearance protocol, what 4 things can individually or together suggest immobilization is necessary?

A

1) Unreliable Pt
2) Distracting injury is present
3) Abnormal sensory/motor exam
4) Sine pain/tenderness

85
Q

According to the Nexus spinal clearance protocol, what 5 things can individually or together suggest immobilization is necessary?

A

1) if mid-line C-spine is tender
2) if any neurological deficient are present
3) if Pt has anything less than a 15 GCS
4) if Pt is intoxicated
5) if the Pt has distracting injury or pain

86
Q

What is different about the Canadian C-spinal clearance protocol, in contrast to Maine or Nexus?

A

It weighs the mechanism of injury, not the pain/injury

87
Q

If you have a Pt that is hypertensive and has a suspected brain injury, what is the only thing you can do?

A

Elevate the head 30 degrees

88
Q

What kind of drug is Diazepam (Valium)?
What is it good for?
How long does it last?
Diazepam, Lorazepam, and Midazolam can be reversed by giving what drug?

A

Diazepam:

Is a benzodiazepine; it has antianxiety and muscle relaxant qualities

It is often used for PREMEDICATION for INTUBATION and as a potent ANTICONVULSANT

It is fast acting, taking peak effectiveness in 15 minutes and lasting up to 60 minutes

**Diazepam, Lorazepam, and Midazolam can be reversed by giving FLUMAZENIL

89
Q

How does Lorazepam (Ativan) differ from Diazepam?

A

It is one of the most potent benzodiazepines; however, has a shorter lasting sedation effect but longer anti-seizure effect

Other than those regards it is very similar to diazepam

90
Q

Of the three Analgesics WITH sedative properties discussed, which one is the best for a head trauma Pt and why?

  • Morphine
  • Fentanyl
  • Ketamine
A

Fentanyl is the best for a head injury, it is an opiate narcotic (easily reversible with Naloxone (narcan), it has a faster onset action than morphine so lower dosages are needed but most importantly it does NOT cause hypotension as badly as morphine

Morphine is not a good candidate mostly because it has side effects such as: HYPOtension, respiratory depression, and possible nausea and vomiting. It is an opium alkaloid and does relieve pain, sedates, and reduces anxiety. (hypotension is caused by a reduction in cardiac preload caused by an increase in venous capacitance) (i.e. it blows up veins which decreases pressure of veins pushing blood back to the heart, effectively decreasing preload and thus output of the heart)

Ketamine is an analgesic and sedative but adversely causes HYPERtension and tachycardia which can be contraindicated for head trauma Pts that typically can already have hypertension (this will just increase ICP further)

91
Q

What meds were previously used and now no longer used in spinal cord injuries?

A

Corticosteroids, they use to combat the inflammation but had too many side effects

92
Q

How can you medicinally combat the hypovolemia and slow heart rate often found with brain injuries?

A

Hypovolemia is combated with fluid therapy and if needed vasopressors such as dopamine, norepinephrine, or phenylnephrine

Bradycardia is combated with Atropine, via reducing parasympathetic stimulation

93
Q

What effects can Mannitol have that would be helpful or hurtful for a brain injury pt?

A

Mannitol is a osmotic diuretic, so it draws in water from the interstitial spaces and into the cardiovascular system.

This can be beneficial for a Pt with high ICP that is herniating or that has cerebrum edema because it will draw in fluids from the cerebrum

CONTRAINDICATIONS however are if a Pt has lower than 90mmHg as it will further reduce blood pressure and for Pts with kidney problems as the kidneys have to flush out and filter all the reabsorbed water

94
Q

Cerebral Perfusion Pressure (CPP) =

A

CPP = MAP - ICP

95
Q

For the patient with suspected traumatic brain injury, the ideal positioning of the patient for transport is:

A

on a long backboard with the head of the backboard elevated 15 to 30 degrees.

96
Q

The spinal cord is continuous from the brain to the level of?

A

L1 to L2

97
Q

What is the desired range of end tidal CO2 on capnography for Pt WITH suspected herniation?

A

30-35

PC1-2 (23 decks)

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