Head and C spine injury

Question 1

What is normal ICP?

Answer 1

5-15 mmHg

Question 2

What is the equation for cerebral perfusion pressure?

Answer 2

CPP = mean arterial pressure - ICP

Question 3

What are signs of basilar skull fracture?

Answer 3

Blood in ear canal, hemotympanum, rhinorrhea, otorrhea, ‘battle’s sign’ (retro-auricular hematoma), ‘raccoon eye’ (periorbital ecchymoses)

Question 4

What is a basilar skull fracture?

Answer 4

basilar skull fractures include breaks in the posterior skull base or anterior skull base. The former involve the occipital bone, temporal bone, and portions of the sphenoid bone; the latter, superior portions of the sphenoid and ethmoid bones. The temporal bone fracture is encountered in 75% of all basilar skull fractures

Question 5

What tests can be used to assess brainstem function?

Answer 5

Look at respiratory pattern, pupil size and reactivity and eye function including the corneal reflex, Doll’s eye reflex (oculocephalic reflex), caloric test (oculovestibular test)

Question 6

What are the components of the GCS score?

Answer 6

E: 4 open, 3 open to command, 2 pain, 1 closed.
V: 5 normal, 4 confused, 3 wrong words, 2 incomprehensible, 1 nothing
M: 6 command, 5 localizes to pain, 4 withdraws pain, 3 decorticate, 2 decerebrate, 1 limp

Question 7

How is a head injury classified as mild, mod or severe based on GCS?

Answer 7

Mild: 14-15
Moderate: 9-13
Severe: 8 or less

Question 8

Which head injury patients are EXCLUDED from the CT head rules? (7)

Answer 8

1) penetrating trauma, 2) obvious depressed skull #, 3) acute neuro deficit, 4) seizure, 5) bleeding d/o or on anticoagulation, 6) pregnant pts, 7) <16 yrs

Question 9

Which pt population do the CT head rule guidelines apply to?

Answer 9

pts with ‘minor head injury’: Amnesia, LOC, disorientation, GC 13-15 as a result of HI in the past 24 hrs

Question 10

What are the ‘high risk’ (5) and ‘medium risk’ (2) criteria in the CT head rules?

Answer 10

High risk: GCS <15 2 hrs after injury, suspected open or depressed skull #, signs basilar skull #, vomiting >2x, Age >65.

Medium risk: amnesia >30 min, dangerous mxn (pedestrian struck by vehicle, occupant ejected, fall >3ft or 5 stairs).

Question 11

What is the sens and sp of the CT head rules?

Answer 11

for high risk criteria: sens 100%, sp 69%.

For all 7 factors: sens 98%, sp 50%

Question 12

What is a concussion?

Answer 12

Characterized by transient cognitive change or neurologic function with no CT findings.

Question 13

What symptoms may suggest concussion?

Answer 13

confusion, amnesia, disorientation, LOC, restlessness, lethargy, irritability, brief seizure immediately after insult.

Question 14

What is the SCAT2?

Answer 14

Sport cognitive assessment tool 2 which can be used for concussion assessment.

Question 15

When discharging a pt with a concussion, what symptoms should they return to the ED for?

Answer 15

Problems could arise over the first 24-48 hours. You should not be left alone and must go to a hospital at once if you:
• Have a headache that gets worse
• Are very drowsy or can’t be awakened (woken up)
• Can’t recognize people or places
• Have repeated vomiting
• Behave unusually or seem confused; are very irritable
• Have seizures (arms and legs jerk uncontrollably)
• Have weak or numb arms or legs
• Are unsteady on your feet; have slurred speech

Question 16

Describe stepwise return to play instructions

Answer 16

Athletes should not be returned to play the same day of injury. When returning athletes to play, they should follow a stepwise symptom-limited program, with stages of progression. For example:

1. rest until asymptomatic (physical and mental rest including no screens). Goal is recovery.
2. light aerobic exercise (e.g. stationary cycle, walking). Goal is to increase HR.
3. sport-specific exercise (e.g. running soccer, skating in ice hockey)
4. non-contact training drills (start light resistance training)
5. full contact training after medical clearance
6. return to competition (game play)

Question 17

What measures can be taken to prevent secondary brain injury that may occur as a result of primary moderate-severe head injury?

Answer 17

Prevention of hypotension (sBP>90), hypoxia, anemia, glycemic extremes, hyperthermia. Reverse anticoagulations. Call interventionalists for evacuation of hematomas, burr holes or ICP monitoring. Prophylactic anti-seizure medications may reduce the incidence of early post-traumatic seizures (within 7d).

Question 18

What are signs of elevated ICP?

Answer 18

Aniscoria (unequal pupil sizes), labile BP, cushings reflex (HTN, brady, resp depression).

Question 19

What steps should be taken to intervene with impending herniation secondary raised ICP?

Answer 19

Elevated head, keep head midline, provide sedation, avoid unnecessary stimuli, provide analgesia, hypertonic saline or mannitol if deteriorating despite measures, neuromuscular blockade, mild hyperventilation (pCO2 30-35 mmHg).

Question 20

What are secondary therapies for refractory raised ICP?

Answer 20

Barbiturates or propofol to control elevated ICP.
HTN therapy.
Moderate hyperventilation (PCO2 C30).
Decompressive craniectomy.

Question 21

what are the 3 standard views for C spine radiographs?

Answer 21

AP, lateral, odontoid views. Consider flexion/extension views to look for ligamentous injuries after bony injuries are ruled out on standard 3 view.

Question 22

Which vertebrae should be visible on lateral C spine XR?

Answer 22

Should include C1-T1

Question 23

How should ‘A’ be assessed in the ABCS assessment of C spine radiographs?

Answer 23

A = alignment.
Follow the anterior and posterior contour lines. Translation of one vertebrae over another of >3.5 mm and an angulation of >11* is considered significant. The diameter between the posterior cortex and the spinolaminar line should be >18mm

Question 24

How should ‘B’ be assessed in the ABCS assessment of C spine radiographs?

Answer 24

Bone.

Follow bony contours of vertebrae looking for breaks in cortex.

Question 25

How should ‘C’ be assessed in the ABCS assessment of C spine radiographs?

Answer 25

Cartilage.
Look at disk spaces to ensure they are equal length throughout. Pre-dental space should be <3mm. Distance from lowest part of occiput base and dense <12 mm. Facet joints should be at 45*.

Question 26

How should ‘S’ be assessed in the ABCS assessment of C spine radiographs?

Answer 26

Soft tissue. Look at the retropharyngeal. C1/2, <7mm, Widens at C4.

Question 27

When should you consider intubating someone for a c spine injury?

Answer 27

If the injury is at or above C5.

Question 28

What are the components of the Canadian C spine rules?

Answer 28

Population: Alert (GCS 15) stable pts where cervical spine injury is a concern.

1) determine if high risk factors mandating radiography including either: age >65, dangerous mxn. if yes, radiograph.
2) determine if pt has low-risk factors that allow you to assess safe ROM, IF you can safely assess, ROM then if not able to actively rotate neck >45* L/R, then radiograph.

Question 29

what groups should the canadian C spine rules NOT be used for?

Answer 29

Non-trauma cases, GCS <15, unstable vitals, age <16, acute paralysis, known vertebral disease, prior C spine injury.

Question 30

What is considered a ‘dangerous mxn’ in the canadian c spine rules?

Answer 30

fall >3ft or 5 stairs, axial load to head, MVC high speed (>100km), roll over or ejection, motorized recreational vehicle, bicycle struck or collision.
MVCs that include rollover, large truck/bus, hit by high speed vehicle.

Question 31

What are low risk factors on the Canadian spine rules that would allow you to assess neck ROM?

Answer 31

simple rearend MVC, sitting position in ED, ambulatory any time, delayed onset neck pain.