Head Trauma

Question 1

Describe the neurological presentation of concussion? What does head CT show?

Answer 1

No focal neurological abnormalities.

Normal CT scan.

Question 2

What is the neurological presentation of contusion? What does head CT show?

Answer 2

Occasionally (rarely) has focal abnormalities.

Ecchymoses found on CT (seen as blood mixed in with brain parenchyma but not collected in a way that allows drainage).

Question 3

How are epidural and subdural hematoma compare and contrast in terms of etiology, LOC, and neurological exam?

Answer 3

• Both are usually associated with more severe trauma than a concussion, even though epidural hematoma is more frequently associated with fracture.
• Both may or may not present with LOC, as well as a second LOC minutes or hours later, with a lucid interval in between.
• Both may or may not present with focal neurological findings

Question 4

How can you determine the difference between epidural and subdural hematoma?

Answer 4

Head CT without contrast is the only way to distinguish them.

• Epidural hematomas are seen as a lens-shaped hemorrhage on CT.
• Subdural hematomas are seen as a crescent-shaped hemorrhage.

Question 5

Which vessels are damaged in epidural hematomas? In subdural hematomas?

Answer 5

Epidural - middle meningeal artery

Subdural - bridging veins

Question 6

What is the treatment of concussion?

Answer 6

No need to hospitalize or treat. Observe at home for altered mental status.

Question 7

What is the treatment of contusion?

Answer 7

Rarely any treatment needed. Surgical debridement if necessary.

Question 8

What is the treatment of small hematomas? Large hematomas?

Answer 8

Small hematomas: No therapy needed.

Large hematomas:

• Intubation and hyperventilation
• Mannitol
• Surgical drainage (definitive treatment)

Question 9

What are the criteria for a “large” intracranial hemorrhage?

Answer 9

• Compression of ventricles or sulci
• Herniation with abnormal breathing and unilateral dilation of the pupil
• Worsening mental status or focal findings

Question 10

For management of large intracranial hemorrhages, why in addition to surgical drainage do we use hyperventilation and mannitol?

Answer 10

• Hyperventilation works by decreasing pCO2. Normally, cerebral circulation constricts when the pCO2 is low. A small decrease in volume results in a large decrease in pressure. Hyperventilation briefly slows herniation and is a bridge to surgery.
• Mannitol is an osmotic diuretic that is used to decrease intravascular volume; this decreases intracranial pressure but only has limited benefit.

Question 11

What else are given to head trauma victims as a preventative measure?

Answer 11

PPIs to prevent stress ulcers.

Question 12

What is the first step in any head trauma resulting in loss of consciousness?

Answer 12

Head CT withOUT contrast

*Do without contrast to detect blood. Contrast detects mass lesions such as cancer and abscess.