Clinical Care- Closed head injury (including aneurysm)

Question 1

overview/definition of a concussion

Answer 1

Concussion is cognitive impairment brought on by diffuse brain injury after exposure to impact forces.

With or W/O LOC

Mildest subset of TBI

Question 2

who is the most accident prone population?

Answer 2

young men (15-34), male, and drunk are most accident prone

Question 3

pathophysiology of concussions

Answer 3

during accelerate, force is applied to brain and it creates shear force at white/grey matter junction.

severe enough may rupture axons. mild damage leads to swelling and inflammation.

Question 4

what is the term for when an injury is present at site of impact as well as opposite side from rebound motion?

Answer 4

“coup-contrecoup”

Question 5

Hallmarks of concussion

Answer 5

confusion and amnesia

Question 6

clinical features of concussions

Answer 6

w/ or w/o LOC

may be immediate or delayed

lack of recall is red flag

Question 7

early SX of concussion (min to hours)

Answer 7

headache, dizziness, vertigo, imbalance, nausea, vomiting

Question 8

Delayed SX (hours to days)

Answer 8

mood/cognitive disturbance, light/noise sensitivity, sleep disturbance

Question 9

COMMON signs of concussion

Answer 9

1) Vacant stare (befuddled facial expression)
2) Delayed verbal expression (slower to answer questions)
3) Inability to focus attention (easily distracted)
4) Disorientation (walking in the wrong direction, not A&O)
5) Slurred or incoherent speech (making disjointed statements)
6) Gross observable incoordination (stumbling)
7) Emotionality out of proportion to circumstances (appearing distraught, crying for no apparent reason)
8) Memory deficits (exhibited by patient repeatedly asking the same question that has already been answered or inability to memorize and return three of three words and three of three objects for five minutes)

Question 10

LESS common sign of concussions?

Answer 10

1) Seizures
a) If seizures occur within one week of head injury, much more likely to be related to TBI than epilepsy
b) Occur in 5% of TBI patients, more common with severe injury

Question 11

what is defined as a complicated concussion?

Answer 11

any concussion with concomitant hemorrhage. may preset as acute, subacute or chronic.

usually arterial in origin.

Question 12

Acute evaluation of a concussion

Answer 12

HX and MACE w/ in 48 hrs

focus on neuro exam to detail extent of damage (more cognitive sx means more severe)

facial fractures are concerning for occult injury

Question 13

management of concussions

Answer 13

Direct observation for 24 hrs

awake pt every 2 hrs.

low level of activity for 24 hrs.

No Alcohol, sedatives, or pain relievers other than NSAIDS for 48 hrs.

Question 14

Immediate Referral/MEDEVAC for concussion

Answer 14

(a) Inability to awaken the patient
(b) Severe or worsening headaches
(c) Somnolence or confusion
(d) Restlessness, unsteadiness, or seizures
(e) Difficulties with vision
(f) Vomiting, fever, or stiff neck
(g) Urinary or bowel incontinence
(h) Weakness or numbness involving body part

Question 15

5 possible complications of concussion

Answer 15

Second impact syndrome 
post concussion syndrome 
posttraumatic headaches 
sleep disturbances 
Chronic traumatic encephalopathy

Question 16

what is second impact syndrome?

Answer 16

cerebral swelling that can develop in setting of a second concussion

2nd concussion when still symptomatic from 1st.

rare, potentially fatal

Question 17

what is post concussion syndrome?

Answer 17

Headache, dizziness, cognitive impairment, psych symptoms that develop in
the first few days after mild TBI and resolve in weeks to months

Question 18

what is chronic traumatic encephalopathy (CTE)?

Answer 18

1) Repeated concussions can lead to cumulative neuropsychologic deficits
a) Behavior changes, personality changes, depression, increased suicidality
b) Parkinsonism
c) Speech and gait abnormalities

Question 19

Cranial traumas are likely to be what kind of fracture?

Answer 19

linear fractures, less risk for underlying damage

Question 20

clinical features of a skull fracture

Answer 20

if open, look for CSF leakage
high likelihood of infection
scalp will bleed, must be cleaned
presence of tissue swelling, hematoma, palpable fracture, crepitus

Question 21

thin areas of the skull

Answer 21

temporal region

nasal sinuses

Question 22

what does it mean that force must be large for skull fracture

Answer 22

large impact or small area.

Question 23

signs of basilar skull fracture

Answer 23

battle sign 
"racoon" eyes 
hemotympanum 
CSF rhinorrhea/otorrhea 
cranial nerve deficits

Question 24

Acute management of skull fracture

Answer 24

• orogastric tube may be more appropriate than nasogastric
• watch for signs of swelling
• other fracture care as needed
• oxygen, C Spine, MEDEVAC ASAP
• serial neuro
• IV fluid

Question 25

signs of ICP

Answer 25

decreased mental status dilated pupils or anisocoria papilledema Cushing's Triad (bradycardia, hypertension, respiratory irregularity)

Question 26

if signs show rapid increase of ICP or herniation what are our actions

Answer 26

open airway elevate head of bed ventilate, avoid hyperbarbia iv fluids (NS or LR) DO NOT USE GLUCOSE OF HYPOTONIC SOLUTIONS.

Question 27

management of ICP

Answer 27

osmotic therapy (mannitol: 1g/kg 15-20% solution, repeat .25-.5 g/kg every 6-8 hrs OR 7.5% Hypertonic NaCL 250cc bolus) consider hyperventilation as last resort. if seizure, diazepam (10mg IV q10min max dose of 30mg)

Question 28

3 major types of ICH sites

Answer 28

epidural hematoma subdural hematoma subarachnoid hematoma

Question 29

Epidural Hemorrhage - Pathophysiology

Answer 29

85% of the time, skull fracture leads to arterial injury Middle meningeal artery commonly affected Normally the epidural space is a potential space, with the dura tightly attached to the skull, Under arterial pressure, the dura slowly peels away and a blood pocket forms

Question 30

how will a epidural hemorrhage present?

Answer 30

immediate LOC “Lucid interval” with recovery of consciousness, after a period of hours increasing headache with deteriorating neuro function may see seizure, coma, anisocoria, respiratory collapse

Question 31

what is the acute management of someone with epidural hematoma

Answer 31

oxygenation, GCS <8, intubate neurosurgical consultation monitor for increased ICP/herniation

Question 32

complications of epidural hematoma

Answer 32

coma respiratory depression death unless treated surgically

Question 33

disposition of epidural hematomas

Answer 33

MEDEVAC ASAP

Question 34

who is more at risk for subdural hemorrhage?

Answer 34

elderly, alcoholics, anticoagulated at risk may occur without impact, dismal prognosis

Question 35

what's happening during a subdural hematoma?

Answer 35

Acceleration in the lateral direction tears bridging veins draining the brain blood to the dural sinuses Lower pressure blood, but more actual rather than potential space

Question 36

clinical manifestation of a subdural hematoma

Answer 36

(a) May or may not have history of head trauma (b) Acute subdural hematoma presents 1-2 days after onset 1) May have lucid interval after injury (c) Chronic subdural hematoma presents 15 days or more after onset (d) Insidious onset of headaches, light headedness, cognitive impairment, apathy, somnolence are typical symptoms

Question 37

patient management of subdural hematoma

Answer 37

managed same as epidural

Question 38

SAH hemorrhage epidemiology

Answer 38

over 80% are usually rupture of aneurysm high pressure bleeding into the subarachnoid space

Question 39

SAH clinical presentation

Answer 39

Hallmark-thunderclap, worst headache of my life sudden onset of headache, possible meningeal irritation patient may have been doing something strenuous to increase intrathoracic pressure some activities like cocaine, amphetamines, smoking, hypertension, alcohol use (all put stress on Cardio system)

Question 40

treatment of SAH

Answer 40

rest analgesia with tylenol avoid anticoagulation drugs MEDEVAC

Question 41

Complications of SAH

Answer 41

Rebleeding (7%) only eliminated by treating underlying cause Cerebral ischemia (30-40%) either by loss of blood flow or vasospasm Increase ICP (54%) includes due to increase blood volume and swelling from inflammation Seizures (7%), Hyponatremia, Cardiac arrhythmia