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Clin Med B 2 > (Enochs + some)Lecture 5: CNS Trauma > Flashcards

(Enochs + some)Lecture 5: CNS Trauma Flashcards

1
Q

What is a TBI?

A

Traumatic brain injury, which is an alteration in brain function.

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2
Q

What is a primary brain injury?

A

The insult that caused the TBI.

  • Explosion
  • MVC
  • Penetrating head trauma
  • etc
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3
Q

What is a secondary brain injury?

A

The cascade of molecular injury mechanisms initiated at time of trauma and continues. (Neuronal cell death)

electrolye imbalances, mitochondrial dysfunction, apoptosis, scondary ischemia from vasospasm, ect

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4
Q

What conditions do we need to avoid for TBI patients?

A
  • Hypotension
  • Hypoxia
  • Hyperglycemia
  • ICP
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5
Q

What is CPP?

A

Cerebral perfusion pressure = MAP - ICP

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6
Q

What two things result in decreased ICP?

A
  • Tachypnea/alkalosis (inducing hypocarbia)
  • HTN

causes vasoconstriction and therefore decreases ICP

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7
Q

What is goal MAP in TBI?

A
  • > = 80 in order to keep CPP high.

CPP = MAP - ICP

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8
Q

What physical exam triad helps us determine increased ICP?

A

Cushing reflex:

  1. HTN
  2. Bradycardia
  3. Decreased respiratory drive

HIB
HTN
Irregular breathing
Bradycardia

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9
Q

What happens to ICP in TBIs?

A

Increases, so we need to increase MAP to counteract it.

CPP = MAP - ICP

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10
Q

For a patient with increased ICP, what can we do to help lower it?

6

A
  • Elevate patient head
  • Glucose between 80-180
  • Prevent any fever (96.8-100.4)
  • Keep O2 > 90%
  • IV Lorazepam to treat seizures
  • IV phenytoin to prevent seizures (esp. for GCS < 10)
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11
Q

What is the trimodal age group for TBI?

A
  1. 0-4
  2. 15-24
  3. > 75
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12
Q

What is the ABCDE for trauma?

A
  • Airway (C-spine and maintain airway)
  • Breathing (ventilation)
  • Circulation (pulses)
  • Disability (GCS, neuro)
  • Exposure (undress pt and check injuries)

A patient that can communicate clearly is already cleared A-D

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13
Q

What are the 3 severity ratings for GCS?

A
  1. Mild = 13-15
  2. Mod = 9-12
  3. Severe = 8 or less

If it’s 8, then you intubate (mnemonic)

Most TBIs are mild (75%)

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14
Q

What is the inclusion criteria for Head CTs?

A
  • Age 16-66
  • Not on blood thinners (except baby asa)
  • No seizure after injury
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15
Q

What are the 4 high risk criteria that prompt a Head CT for head trauma?

A
  1. GCS < 15 2 hours post injury
  2. Suspected/confirmed skull fracture
  3. Signs of basilar skull fracture
  4. > = 2 eps of vomiting (brainstem injury)
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16
Q

What are the 2 medium-risk criteria that prompt a Head CT for head trauma?

A
  1. Retrograde amnesia >= 30 mins prior to TBI
  2. Dangerous mechanism (hit by car as a pedestrian, ejected from car, fell from >3 ft or 5 stairs)
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17
Q

What criteria is used for determing Head CT criteria for children < 16?

A

PECARN

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18
Q

How does a concussion typically present in terms of S/S?

A
  • Loss of memory prior to event
  • Confusion
  • HA, N/V, dizziness
  • Visual changes
  • LOC (rare)
  • AMS

Any neurological symptom can techincally occur

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19
Q

How does a concussion injury look like?

A

Coup contrecoup injury

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20
Q

What are the more alarming S/S in a concussion?

A
  • Focal neurologic deficit
  • Visual field deficit
  • Pupil abnormality
  • Horner syndrome

Stroke can be caused by traumatic hemorrhage

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21
Q

What is the ED treatment in a concussion

A
  • no less than 2 hr of obs after injury in ED setting and 24 hrs at home.
  • any change in neuro status = CT brain w/o

rest, no studying/TV/exercise or ETOH. NO NSAIDS.

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22
Q

what indicates need for admission in Concussions

6

A
  • GCS <15 at 2 hours post injury
  • Abnormalities on CT if obtained (at hospital with neurosurgery)
  • Seizure
  • Bleeding disorders or on anticoagulants
  • Recurrent vomiting
  • No family or friends able to observe for 24 hours
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23
Q

What is CTE and what makes it more likely?

A

Chronic traumatic encephalopathy: 3+ concussions (football)

presents w short term mem loss, early dementia, impulsive behavior and depression

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24
Q

How long does it typically take to recover from concussion?

A

Around 6 days

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25
What is post concussive syndrome
vage neuropsych s/s starting 7-10 days after injury that end within a year of injury. | get MRI if s/s are disabling.
26
What is the treatment for a linear skull fracture?
obs 4-6 hrrs in ED and dc w/ 24 hr obs if no s/s. | Little to no clinical significance
27
What is the treatment for a depressed skull fracture?
* Usually open, so give tetanus + ABX (vanco + rocephin) * If it is greater than the skull's thickness, surgery * Consult neurosurg | usually open because when youre depressed you open up to people
28
What bone is most commonly affected in a basilar skull fracture? what is the tx for this?
* Temporal bone trauma * admit ALL pts with this * surgery for underlying bleeds, look for CSF leak from ear/nose
29
What are the hallmark signs of a basilar skull fracture?
* Halo sign (CSF + blood from ear/nose) * Raccoon eyes * Battle sign (under the ear) * haemotympanum * bump on head
30
What is the treatment for an elevated skull fracture?
IV ABX + surgery
31
What is the ABX for all OUT PATIENT open fractures in general?
2g ancef/cefazolin | includes gunshots, stabbing, blasts
32
If we suspect a skull fracture, what additional scans should we order?
* Noncon CT brain and Cspine * Con CT chest + abd + pelvis | All of this ordered together is called a "Pan-Scan"
33
What should you never place in a patient with a basilar skull fracture?
Nasal airway, as the cribiform plate could be fractured.
34
what is a subdural hemorrhage
collection of blood below inner layer of dura but external to brain and arachnoid membrane
35
What is the MC type of traumatic intracranial mass lesion?
Subdural hematoma | Usually due to vein tearing
36
What are the 3 classifications for SDH?
1. Acute <= 2 days 2. Subacute <= 3-21 days 3. Chronic > 21 days | Darker on CT = older
37
What gender is SDH MC in?
Males
38
what does subdural hemorrhage indicate in a neonate
child abuse:(
39
If a patient has a new type of HA, what should be considered ASAP?
CT head w/o con | 90% subdurals present w HA worse w/straining = sus seizures not common
40
What is the criteria for surgical intervention of acute SDH?
* Symptomatic * Bleed thicker than 10mm * Midline shift > 5mm * GCS decrease >= 2 since injury * Fixed or dilated pupils | Craniotomy. if not surg candidate then obs and repeat CT in 6-8 hrs
41
When is surgery indicated for chronic SDH?
* Risk of herniation * > 10mm thickness or 5mm midline shift * Anyone that has the potential to recover | Burr holes to relieve
42
43
What are the 4 types of brain herniation?
1. Trans calvarial (going laterally) 2. Transtentorial (towards center?) 3. Tonsillar (downard) 4. Subfalcine (upward/towards face?)
44
What is the MC type of brain herniation?
Uncal transtentorial herniation
45
What is the common presentation of brain herniation?
Ipsilateral fixed and dilated pupil | brain mass pressing on parasympathetic fibers of CN III
46
what is an epidural hematoma
accumulation of blood between dura mater and skull
47
What is the primary cause of a epidural hematoma?
Middle meningeal artery rupture | usually d/t blow to temporal area
48
What does an epidural hematoma look like on CT?
Lens shaped
49
What is the mnemonic for epidural hematoma S/S?
* Epidural hematoma * Luc E (lucid interval) * Looks like an Eye on CT * Middle meningEEEal artery ## Footnote Blunt trauma to the temple with likely LOC followed by a “Lucid Interval” where the patient’s neuro exam would be normal. Compensation is occurring. This is followed by quick decompensation with significant worsening of Sx/Sx.
50
What is the treatment for epidural hematomas?
* Surgical hematoma evacuation * Monitoring with serial CT scans
51
what is a subaracnoid hemorrhage
blood flowing into the subarachnoid space between pia and arachnoid membranes
52
What is the classic symptom of SAH?
Thunderclap headache/worst HA of their life
53
What are the S/S of a SAH?
* N/V * Nuchal rigidity * Back pain * BL leg pain * Seizures 25% dt sudden rise in pressure * Sudden LOC at onset 45% | s/s may take 6 hours to present
54
What is the first step in working up a SAH?
CT w/o con | most reliable in first 6 hrs
55
When would we do an LP for SAH and what would we see?
* get LP if high suspicion and CT negative * Increased opening pressure * Increased RBC count in all tubes * Xanthochromic (yellow) CSF
56
What is the gold standard imaging for a SAH?
CTA of Brain
57
What meds do we use to reduce MAP < 130 in SAH?
* Esmolol * Labetalol | Short half-lives
58
For a patient with increased ICP and SAH, what interventions do we do?
* Intubate and hyperventilate to REDUCE PCO2 to 30-35. * Consider mannitol to reduce ICP * Lasix to reduce IVP * Surgical clipping/coiling of aneurysm * Neuro ICU
59
What is the can't miss condition in spinal cord injuries?
Cauda Equina syndrome
60
What is the most commonly injured area of the spine?
Cervical
61
What is NEXUS criteria used for?
Determination of whether a C-spine injury requires imaging
62
What is the NEXUS criteria?
* Midline posterior Spinal tenderness present * Painful distracting injury present * Intoxication present * Focal Neurological Deficits present * Encephalopathy (or ALOC) present | All must be negative to clear a patient without imaging.
63
What exam should we not neglect in testing the spinal cord's motor function?
DRE to test sphincter tone
64
For significant trauma, what CTs do we order?
* Brain * C-spine * Chest w/ con * Abd/Pelvis w/ con | Con for organs ## Footnote Can add thoracic and lumbar if needed. Cranium to coccyx
65
How do we treat a C1/atlas fx?
Rigid-C collar | Often associated with a C2 facture and without deficits
66
How do you treat torticollis/C1 rotary subluxation?
* Pain control (NSAID, opioid, benzo, muscle lax) * Restrict motion with SOFT collar * Refer ## Footnote Soft collar because we don't want to forcefully correct it.
67
What are the two types of a C2 facture? How is it treated?
* Odontoid fx * Posterior element/hangman's | Tx w/ pain control and rigid cervical brace
68
What is the most common cervical fx in adults? How do we treat cervical fx and dislocation
C5 | tx w pain control and rigid cervical brace
69
What is the most stable part of a vertebrae?
Anterior
70
How do thoracic fx typically occur?
* Anterior wedge/compression: Axial loading with flexion * Burst/chance/fracture = dislocation
71
How do you manage anterior wedge/compression of the thoracic spine?
TLSO brace and pain meds
72
what suggests complete v incomplete spinal cord injury
* Complete - no demonstrable sensory or motor function below a certain level * Incomplete - some degree of motor or sensory function remains (Much better prognosis for recovery)
73
What is the treatment for a spinal cord injury?
* Restrict via rigid c-collar * No backboard * IV fluids * Pain meds * Transfer
74
What S/S might suggest cauda equina syndrome?
* Saddle anesthesia * Urinary retention * Difficulty walking * LBP * Poor rectal tone * Change in bowel or bladder in anyway
75
What scan should we order for cauda equina syndrome?
MRI | tx with pain meds and urgent surg consult.
76
good review pic

Clin Med B 2 (44 decks)

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