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Surgery/ER Fall 2013 > ER- Head > Flashcards

ER- Head Flashcards

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1
Q

etiology of TBI

A

alcohol and drugs 70% of the time

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2
Q

leading cause of morbidity and mortality following trauma

A

head injury

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3
Q

patient lost consciousness, what must you do?

A

CT their head

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4
Q

TBI management

A

GCS, thorough neuro exam, CT head, drug screeen, maintain C-spine precautions. Consult- trauma, neurosurgery, opthalmology, plastic surgery, and speech therapy

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5
Q

Primary and secondary brain injuries

A

concussion-compression, sudden deceleration, rotational acceleration, systemic insults, intracranial insults, and cerebral ischemia-reperfusion injury

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6
Q

sudden deceleration can result in what kind of hematoma?

A

subdural hematoma- tearing of bridging veins on the side opposite the area of impact

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7
Q

most imp factor in generating parenchymal tears

A

rotational acceleration

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8
Q

what is though to be responsible for loss of consciousness with head trauma?

A

brain stem movement at the time of impact- (brain stem controls respiration)

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9
Q

what kind of injury would result in hypotension, decreased end organ perfusion, systolic BP less than 90 mmHg, anemia, electrolyte disturbances, hypoglycemia or hyperglycemia, and hyperthermia?

A

systemic injury

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10
Q

prolonged elevation in ICP a/w

A

poor outcome

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11
Q

Patient presents with acute subdural hematoma. What is mortality rate if operation occurs more than 4 hours after injury vs. less than 4 hours after injury?

A

90% mortality rate if operation MORE than 4 hours after injury, compared to 30% mortality rate if less than 4 hours after injury

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12
Q

what occurs in cerebral ischemia-reperfusion injury

A

transmembrane shift of sodium and calcium INTO cell and potassium OUT of cell, oxygen radical formation, lipid peroxidation

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13
Q

should you take a major scalp laceration seriouslY?

A

YES, can cause hemorrhagic shock

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14
Q

should you take trivial scalp injury seeriously?

A

YES, may overlie a penetrating skull injury that can cause meningitis or brain abscess

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15
Q

if laceration plus skull fracture-

A

neuro consult

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16
Q

if isolated laceration-

A

fix and discharge

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17
Q

Skull fracture types

A

stellate- occur with more force. Depressed fractures- still more force

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18
Q

most skull fractures are…

A

linear

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19
Q

basilar skull fracture can cause…

A

injury to cranial nerves. If fracture extends to paranasal sinuses or mastoid air cells, can cause CSF leak and meningitis

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20
Q

“racoon eyes” seen in

A

basilar skull fractures

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21
Q

penetrating skull injuries are at risk to develop

A

meningitis or brain abscess

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22
Q

what is prone to laceration type injury?

A

pontomedullary juction following hyperextension of the head on the neck

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23
Q

concussion=

A

transient loss of consciousness

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24
Q

concussion may result from..

A

temporary dysfunction of cortical hemispheric neurons bilaterally OR reticular activating system

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25
difference between concussion and contusion
concussion= little of no apparent tissue damage. contusion= tissue injury with capillary damage and interstitial hemorrhage
26
classifications of contusion
coup, intermediate, and contrecoup
27
contusion can produce neurologic deficit d/t tissue injury, but more often exert their major effect as...
a nidus for hemorrhage, swelling, or post-traumatic epilepsy
28
What can mark Diffuse axonal injury?
petechial hemorrhages at the interface of gray and white matter
29
preferred scan for Diffuse axonal injury?
MRI , but can also see on CT
30
diffuse axonal injury triad of damage involving:
corpus callosum, dorsal lateral quadrant of the midbrain, microscopic damage within the subcortical white matter
31
diffuse axonal injury result from
strain-shear forces in deceleration or rotational acceleration injury
32
difference between intracerebral hemorrhage vs. contusion
contusion- rupture of capillaries. intracerebral hemorrhage-rupturing of blood vessels
33
management of small vs. large intracerebral hemorrhage
small-non-surgical, control ICP, maintain perfusion. large- surgical decompression
34
types of intracranial hematomas
intracerebral hematomas, subdural, epedural hematomas, subarachnoid hemorrhage
35
epidural hematoma- rupture of
middle meningeal artery
36
subdural hematoma- damage to
cortical bridging veins
37
subarachnoid hemorrhage- damage to
saccular aneurysm
38
tx of subdural hematoma
acute- craniotomy. chronic- burr hole evacuation
39
tx of epidural hematma
emergency craniotomy and evacuation, IV mannitol and hyperventilation to PCO2 of 25-30 mmHg to buy some time
40
difference in subdural and epidural appearance radiographically?
subdural- crescent shaped. epidural- lens shape
41
epidural hematoma usually a/w
temporal bone fracture
42
How to decrease ICP in ER?
IV mannitol and hyperventilation to PCO2 of 25-30 mmHg, elevate head of bed
43
patient presents with concussion accident followed by period of lucidity, followed by headaches, loss of consciousness again, and progressive neurologic deterioration
epidural hematoma
44
effects of mannitol in managing cerebral blood flow
given as bolus- increases intravascular volume, SBP, CPP
45
what happens if mannitol given too rapidly?
can cause hypotension
46
hyperventilation in managing cerebral blood flow
reduces ICP by constricting pial and cerebral arterioles, causes alkylosis
47
herniation of medulla through foramen magnum
cushing response
48
herniation of cerebellar tonsils through foramen magnum
further brain stem compression and medullary ischemia
49
herniation of medial portion of temporal lobe
midbrain compression, LOC, decerebrate rigidity
50
herniation of cerebellum upward through tentorial hiatus
bilateral decerebrate rigidity
51
clinical sign seen when herniation has occured through foramen magnum?
ICP falls very fast, to 0
52
control of agitation and seizures
avoid electrolyte imbalance, hypoxia, fever. sedatives, paralytics, dilantin, diazepam
53
third leading cause of death worldwide
cva
54
CVA etiology
brain ischemia from hypoperfusion as a result of ischemia (thromboembolic- occlusion of vessel), hemorrhage, or systemic hypotension
55
ischemic stroke can occur as a result of
carotid circulation obstruction, vertebrobasilar obstruction, lacunar infarction
56
carotid artery circulation obstruction causing ischemic stroke may be caused by
either cardiac (a. fib, rheumatic heart disese, infectious endocarditis) or vascular (giant cell arteritis, SLE) cause
57
what has higher risk of early mortality and reinfarction - cerebral infarction or lacunar infarc?
cerebral infarction
58
patient presents with CVA and you are trying to determine the source- ischemic or hemorrhagic. presentation includes contralateral pure motor or sensory deficit, ipsilateral ataxia with crural paresis, dysarthria with clumsiness of hand
lacunar infarct causing ischemic stroke
59
prognosis of lacunar infarct
good- recovery in 4-6 weeks
60
what kind of hemorrhagic stoke can HTN cause?
intraparenchymal hemorrhage
61
HTN can cause microaneurysms most commonly in..
basal ganglia
62
"worse headache in my life"
subarachnoid hemorrhage caused by AVM's, saccular aneurysm rupture
63
indication for promp surgical decompression
cerebellar hemorrhage
64
ischemic stroke tx
tpa 0.9 mg/kg. 10% given over 10 minutes. remaining given over 1 hour. give within 3-4.5 hours
65
berry aneursyms grade I-5
I- Neurologically intact, HA. II- HA, CN involvement. III- decreased LOC. IV-stupor. V- coma, brainstem involvement
66
tx of hemorrhagic stroke
supportive/conservative tx. mannitol and elvate head to decrease intracranial pressure. If SBP over 220, lower wtih IV labetolol to range of 170-200 mmHg. CPP maintained between 70-90 mmHg
67
when to consider carotic endarterectomy
in stoke patients who have nearly recovered but have carotid artery stenosis more than 70% in ipsilateral carotid a
68
how to prevent second stroke or MI from occuring after first stroke?
preventative therapy includes statins, antiplatelet therapy with ASA and dipyridamole, or clopidogrel
69
prognosis for CVA
survival for ischemic infarcts is beter than for hemorrhagic
70
BP management in hemorrhagic stroke
should not be brought down to normal in first 2 weeks after stroke. if SBP over 220, then lower to 170-200 with IV labetolol
71
correlation between stroke and TIA
risk of stroke highest in the 48 hours after TIA and declines to baseline by 3 months
72
TIA cuased by
emboli, cardiac or vascular
73
patient presents with vertigo, diplopia, weakness and numbness on ALTERNATING sides of body
TIA in vertebrobasilar distribution
74
patient presents with weakness and sensory deficits on contralateral side, amaruosis fugax if opthalmic artery involved
TIA in carotid distribution
75
gold standard in diagnosing TIA
Standard arteriography. can also do CT/MRI of head to r/o small CVA and tumor, carotid duplex ultrasonography
76
Hospital if the following TIA symptos:
within 48 hours of attack, attacks are crescendo, symptoms lasting more than 1 hour, symptomatic carotid stenosis, KNOWN cardiac source, or hypercoagulable state
77
Patient with TIA, do a standark arteriography that shows high -grade stenosis. next course of action?
surgery or stenting indicated
78
when is medical tx indicated in TIA
if poor surgical candidate or if vascular disease is extensive or vertebrobasilar
79
medical tx for TIA that is cardiac source-
warfarin INR 2-3. If Warfarin CI, then ASA 325 mg/day
80
medical tx for TIA that is non-cardiac source
Warfarin or ASA (used alone or with dipyridamole). clopidogrel
81
symptoms and signs of infectious meningitis
HA, fever, neck and back stiffness, kernig and brudzinski's sign positive, sensory disturbance, and CSF abnormalities
82
organisms responsible in purulent meningitis
18-50: s. pneumonia, Neiseeria meningitis. over 50- listeria, gram negatives
83
dx and tx in purulent meningitis
dx- gram stain or culture of CSF. Tx- Vanco and cefotaxime or ampicillin
84
aseptic meningitis cause
viral usually- HSV
85
defining feature of aseptic meningitis
benign and self limited course
86
aseptic meningitis can resemble___ on CSF exam
partially treated bacterial meningitis
87
drug induced aseptic meningitis caused by
NSAIDS, sulfonamids, solid organ transplant agents
88
CSF examination on non-infectious meningeal irritation
pleocytosis, increased protein, low or normal glucose
89
organisms in health care associated meningitis
pseudomonas, staph, coag negative staph
90
encephalitis causes
viral- herpesvirus, arbovirus, rabies virus, flavivirus
91
CSF with RBC's=
HSV encephalitis
92
diagnosis of encephalitis
CT head and LP. CSF may be normal or show lymphocytes
93
classic triad CNS infection
fever, stiff neck, altered mental status
94
nearly all patients with bacterial meningitis have 2 of the following
FEVER, STIFF NECK, ALTERED MENTAL STATUS, HEADACHE
95
if patient has papilledema, seizures of focal neurologic findings, do CT before LP to r/o
intracranial mass lesions
96
dx CNS infection
CBC, blood culture, LP, CSF analysis, CXR, latex agglutination test
97
tx meningitis
abx given prior to LP, LP should be done within 4 hours of abx start. Dexamethasone also given with first abx (most effective when causative agent is strep). to decrease ICP- mannitol, hyperventilation, ventriculostomy catheter placement
98
heache behind 1 eye, a/w drinking. treated with oxygen.WANDER.
CLUSTER ha
99
bilateral headache, have stress
tension ha

Surgery/ER Fall 2013 (11 decks)

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