Chapter 6- Head Trauma Flashcards by Meg Dolohanty

should obtaining a CT scan in a head injury delay transfer to a trauma center?

No, patient should be transferred to a trauma center capable to definitive neurosurgical intervention as first priority

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Things to include in OCP of patient with TBI

Age
MOI and time
BP and Oxygen saturation
GCS score, emphasis on motor response/ pupils
focal neuro deficits
associated injuries
results of CT scan 
treatment of HPOTN/ hypoxia

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what fossa houses the frontal lobe

anterior fossa

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what fossa houses the temporal lobes

middle fossa

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what fossa houses the lower brain stem and cerebellum

posterior

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what are the three layers of the meninges

dura mater
arachnoid mater
pia mater

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meningeal layer that adheres firmly to the internal surface of the skull

dura mater

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layer that is firmly attached to teh brain

pia mater

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what fills the space between the arachnoid mater and pia mater

cerebrospinal fluid (CSF)

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what separates the hemispheres

falx cerebri

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which side of the brain typically contains the language center

left hemisphere

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contained in the midbrain and upper pons, responsible for the state of alertness

reticular activating system

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where is the vital cardiorespiratory center

medulla

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this divides the intracranial cavity into the supratentorial and infratentorial compartments

tentorium cerebelli

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what type of herniation may compress the oculomotor nerve which may lead to pupillary dilation (blown pupil)

temporal lobe herniation

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part of the brain that usually herniates through the tenorial notch

medial part of the temporal lube (uncus)

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classic sign of uncal herniation

ipsilateral pupillary dilation and contralateral hemiparesis

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What is the normal ICp at resting state

10 mm Hg. Pressures >20 mm Hg are associated w/ poor outcomes

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states that the total volume of the intracrnail contents must remain constant because the cranium is a rigid, nonexpansible container

monro-kellie doctrine

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CPP (cerebral perfusion pressure) =

MAP- ICP

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What MAP is “autoregulated” to maintain constant cerebral blood flow

50-150

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GCS score associated w/ coma or severe brain injury

8 or less

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GCS for a moderate brain injury

9-12

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GCS for minor brain injury

13-15

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Max GCS score for eye opening

4 (spontaneous)

eye GCS score for opening eyes to pain

eye GCS score for opening eye to speech

eye GCS score for no eye opening

Verbal GCS score for confused conversation

Verbal GCS score for inappropriate words

verbal GCS score for no speech

verbal GCS score for incomprehensible sounds

verbal GCS score for oriented

motor GCS score for extension (Decerebrate)

motor GCS score for localizes pain

motor GCS score for flexion withdrawal to pain

motors GCS for abnormal flexion (decorticate)

Biconvex or leticular hematoma that push adherent dura away from inner table of the skull. Often in temporal region

Epidural hematoma

are subdural or epidural hematomas more common

subdural

where do the majority of cerebral contusions occur

frontal and temporal lobes

why do patients with cerebral contusions need repeat CT scans w/i 24 hours

evolve to form an intracerebral hematoma and have a mass effect so they may need surgical evacuation

History of disorientation, amnesia, or transient loss of consciousness.

minor brain injury (GCS 13-15)

amnesia before the event

retrograde

amnesia after the even

anterograde

Whom should CT scan be obtained in with minor brain injury

open skull fracture, sign of basilar skull fracture, >2 episodes of vomiting, >65 years old, LOC > 5 minutes, retrograde amnesia for >30 minutes, severe HA, focal neuro deficit

Are patients with a GCS of 9-12 discharge home?

No, they should be admitted to the ICU and ahve frequent repeat neuro checks and consider f/u CT in 24 hours

One thing to especially monitor with moderate brain injury

airway/ breathing- can have hypoventilation. want to avoid hypercapnia. may need to intubate if they deteriorate

patient is unable to follow simple commands

severe brain injury (GCS 3-8)

priorities with severe brain injury

ABCDEs once BP normal- GCS and pupillary rxn Establish cause of HPOTN if not >100 (may need laparotomy- CT after this/ or Burr hole in OR)

Can intracranial hemorrhage cause hemorrhagic shock?

What should be done prior to sedating a patient with a brain injury

GCS score and pupillary exam

What is a well known early sign of temporal lobe (uncal) herniation

dilation of the pupil and loss of pupillary response to light

A shift of ___ mm or greater on head CT is often indicative of the need for surgery to evacuate the blood clot or contusion causing the shift

5 mm

medical therapies for brain injuries

IV fluids, temporary hyperventilation, mannitol, hypertonic saline, barbiturates, anticonvulsants

what type IV fluids should be used in a TBI

ringer's lactate or normal saline

what is the preferable level for PaCO2

35 mm Hg (low end of normal which is 35-45) a this promotes vasoconstriction

how does hyperventilation help

will low ICP in a deteriorating patient with expanding intracranial hematoma until emergent craniotomy can be performed

indications for administration of mannitol in a euvolemic patient

acute neuro deterioration (dilated pupil, hemiparesis, LOC)

how much mannitol should be given

1g/kg bolus over 5 minutes then transport patient to CT or OR

What is mannitol used for?

reduce elevated ICP

why can't mannitol be given to patients with hypotnesion

it doesn't lower ICP w/ hypovolemia and is a potent osmotic diuretic

Preferable agent to reduce ICP in a hypotensive patient

hypertonic saline

used when need to reduce ICP when other methods are ineffective

barbiturates

when should barbiturates not be used

presence of hypovolemia or hpotn

why are barbiturates rarely used

lead to HPOTN long 1/2 life prolong time to brain death determination

why should anticonvulsants only be used when necessary

may inhibit brain recovery | early anticonvulsant doesn't change long term seizure outcome

agents of choice in acute phase of seizures

phenytoin and fosphenytoin (Loading dose is 1 g phenytoin IV no faster than 50 mg/min)

phenytoin maintence dose

100 mg/8 hours

meds frequently used in addition to phenytoin until seizure stops

diazepam or lorazepam

Do muscle relaxants (like succinylcholine or vecuronium) control seizures?

No, the only mask the tonic/ clonic aspect of them. try to control seizures before initiating these drugs

What does CSF leakage with a scalp wound indiate

there is a dural tear

tx for depressed skull fractures

operative elevation if depression is greater than the thickness of the adjacent skull

Brain death

GCS=3 nonreactive pupils absent oculocephaic, corneal, doll's eyes, no gag reflex no spontaneous ventilatory effort

what are the C's of increased density on head CT

contrast, clot, cellularity (tumor), calcification (pineal gland, choroid plexus)