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Trauma and Trauma Systems > Head Injuries > Flashcards

Head Injuries Flashcards

1
Q

head injuries

A
  • cause of 1.4 million ER visits are for traumatic brain injuries
  • 235,000 are hospitalized
  • 50,000 are fatal
  • TBIs (traumatic brain injuries) make up about half of all trauma victims
  • about 50-99% of patients who survive are left with some degree of permanent neurologic disability.
  • MVC are the leading cause of TBI’s of those 5-65 years of age
  • These injuries can be obvious and also extremely unnoticeable
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2
Q

scalp

A
  • strong flexible mass of skin, facia, muscular tissue
  • highly vascular
  • hair provides insulation
  • SCALP
  • Skin
  • Connective tissue
  • Aponeurotica
  • Layer of areolar tissue
  • Periosteum of skull
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3
Q

skull

A

-facial bones
-cranium
0vault for the brain
-strong, light, rigid spherical bone (flat)
-unyielding to increased intracranial pressure (ICP)
-Bones:
-Frontal
-Parietal
-Occipital
-Temporal

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4
Q

anatomy and physiology of the head

A
  • the interior of the cranial vault is not smooth -> not a lot of flexibility for trauma
  • This is problematic for any motion of the brain.
  • The only opening of the cranial vault is through the bottom called the Foramen magnum.
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5
Q

meninges

A
  • from the interior of the skull the brain is covered by 3 separate membranes
  • outer to inner
  • epidural space
  • dura mater
  • subdural space
  • arachnoid space
  • subarachnoid space
  • pia mater
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6
Q

epidural space

A

-under normal circumstance it does not exist, middle meningeal arteries follow grooves in the temporal bone here

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7
Q

dura mater

A
  • Made of rough fibrous tissue
  • Forms Tentorium:
  • Internal Support Structure that divides cerebrum and cerebellum
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8
Q

subdural space

A
  • Space that is spanned with Veins

- Low pressure

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9
Q

arachnoid space

A

Covering over the brains vasculature

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10
Q

subarachnoid space

A

Gap in which brains vasculature runs

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11
Q

pia mater

A

Thin covering Directly over the brain.

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12
Q

cerebrum

A

-Divided into left and right hemispheres
-four lobes:
-Frontal- Contains emotions, motor function, expression of
speech
-Parietal- Contains sensory function and spatial orientation
-Occipital- Contains vision
-Temporal- Reg. memory functions, are of speech
reception & integration

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13
Q

cerebellum

A

Involved in gross motor function

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14
Q

brainstem

A

Contains Midbrain, Pons, Medulla

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15
Q

medulla (oblongata)

A

-Acts as a path way for ascending and descending nerve tracts
-Controls several body functions
-Regulations of heart rate, blood vessel diameter,
breathing, swallowing, vomiting, coughing,
sneezing

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16
Q

pons

A 
-Contains ascending and descending nerve
tracts
-Relays information from the cerebrum to
cerebellum
-Houses the sleep center and respiratory
center
-Like medulla helps in the regulation of
breathing
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17
Q

midbrain (mesencephalon)

A

-Involved in hearing through audio pathways
in the CNS
-Responsible for visual tracking of moving
objects, turning the eyes
-Coordinates regulation of the automatic
functions that require no conscious thought .

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18
Q

cranial nerve

A

Head Contains 12 cranial nerves that originate from the brain and brain stem.

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19
Q

mean arterial pressure

A
  • ensure circulation to brain tissue
  • diastolic pressure + (1/3 pulse pressure) = MAP
  • minimal value is 60 mmHg to profuse organs
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20
Q

cerebral perfusion pressure

A
  • amount of pressure that is needed to push blood through the cerebral circulation
  • accounts for cerebral pressure
  • CPP = MAP - ICP (intracranial pressure)
  • normal intracranial pressure = 7-15 mmHG
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21
Q

cerebral blood flow

A
  • most important factor for the brain

- brain retains this flow through autoregulation

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22
Q

traumatic brain injuries

A
  • are categories into 2 categories
  • primary- result of direct injury
  • secondary- result of on going injury process that is set in motion by the primary injury
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23
Q

cranial injury

A
  • trauma must be extreme to fracture skull
  • linear- crack
  • depressed- depressed and goes downward into brain
  • open- exposed to environment -> infection
  • impaled object- passing through the skull
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24
Q

basal skull

A
  • unprotected
  • bottom skull
  • spaces weaken structure
  • relatively easier to fracture
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25
Q

signs of basal skull fracture: battle signs

A
  • retroauricular ecchymosis - bruising behind ear

- associated with fracture of auditory canal and lower of skull

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26
Q

basal skull fracture signs: racoon eyes

A
  • bilateral periorbital ecchymosis

- associated with orbital fractures

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27
Q

basilar skull fracture

A
  • may tear dura
  • permit CSF to drain through an external passageway
  • may mediate rise of ICP
  • evaluate for target or halo sign
  • clear part of the CSF will be on the outside ring of a blood drop coming from the ear
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28
Q

brain injury

A
  • as defined by the national head injury foundation
  • a traumatic insult to the brain capable of producing physical, intellectual, emotional, social and vocational changes
  • classification:
  • Primary- caused by forces of trauma
  • Secondary- caused by factors resulting from the primary injury
29
Q

direct brain injury types

A
  • coup- injury at site of impact (usually more severe)

- contrecoup- injury on opposite side from impact -> brain sloshes back

30
Q

direct brain injury categories: focal

A
  • occur at a specific location in brain
  • differentials:
  • cerebral contusion
  • intracranial hemorrhage
  • > epidural hematoma
  • > subdural hematoma
  • intracerebral hemorrhage
31
Q

direct brain injury: diffuse

A
  • concussion
  • moderate diffuse axonal injury
  • severe diffuse axonal injury
32
Q

cerebral contusion: focal injury

A
  • blunt trauma to local brain tissue
  • capillary bleeding into brain tissue
  • common with blunt head trauma
  • confusion
  • neurologic deficit
  • personality changes
  • vision changes
  • speech changes
  • result from coup-contrecoup injury
33
Q

intracranial hemorrhage: epidural hematoma: focal injury

A
  • bleeding between dura mater and skull
  • blood is where the brain should be -> herniation
  • involves arteries - middle meningeal artery most common
  • rapid bleeding and reduction of oxygen to tissues
  • patients will have lucid interval
  • unconscious goes unconscious again
34
Q

intracranial hemorrhage: subdural hematoma: focal injury

A
  • bleeding within meninges
  • beneath dura mater
  • above arachnoid
  • slow bleeding- superior sagittal sinus
  • signs progress over several days
  • slow deterioration of mentation
  • blood is displacing the brain
35
Q

intracranial hemorrhage: intracerebral hemorrhage: focal injury

A
  • ruptured blood vessel within the brain
  • presentation similar to to stroke symptoms
  • Signs and symptoms worsen over time
36
Q

intracranial perfusion

A
  • cranial volume is fixed
  • 80% = cerebrum, cerebellum, and brainstem
  • 12% blood vessels and blood
  • 8% CSF
  • increase in size of one component diminishes size of another
  • inability to adjust = increased ICP
  • increase in any one of these things will displace CSF and eventually brain and eventually herniation
37
Q

compensating for pressure building up

A
  • compress venous blood vessels
  • reduction in free CSF
  • pushed into spinal cord
  • pressure builds
38
Q

decompensation for pressure

A
  • increase in ICP
  • rise in systemic BP to perfuse brain
  • further increase in ICP
  • dangerous cycle !
39
Q

role of carbon dioxide

A
  • increase of CO2 in CSF
  • cerebral vasodilation
  • encourage blood flow
  • reduce hypercarbia
  • reduce hypoxia
  • contribute to increased ICP
  • causes classic hyperventilation and hypertension
  • reduced levels of CO2 in CSF -> cerebral vasoconstriction -> cerebral anoxia
40
Q

factors affecting ICP

A
  • vasculature constriction
  • cerebral edema- swelling
  • systolic blood pressure
  • low BP- poor cerebral perfusion
  • high BP- increased ICP
  • carbon dioxide
  • reduced respiratory efficiency
41
Q

cascade

A

-cranial insult -> tissue edema -> increased ICP -> compression of arteries -> decrease cerebral blood flow -> decrease O2 with death of brain cells -> edema around necrotic tissue -> increase ICP with compression of brain stem and respiratory center -> CO2 accumulates -> vasodilation -> increase ICP due to increased blood volume -> death

42
Q

increased pressure

A
  • compresses brain tissue
  • herniates brainstem
  • compromises blood supply
43
Q

signs and symptoms of upper brainstem displace (from pressure)

A
  • vomiting
  • Altered mental status
  • Pupillary dilation
44
Q

signs and symptoms of medulla oblongata displace (from pressure)

A
  • Respiratory
  • Cardiovascular
  • Blood pressure disturbances
45
Q

diffuse brain injury

A
  • Due to stretching forces placed on axons
  • Pathology distributed throughout brain
  • Types:
  • Concussion
  • Moderate diffuse axonal injury
  • Severe diffuse axonal injury
46
Q

diffuse brain injury concussion

A
  • Mild to moderate form of diffuse axonal injury (DAI)
  • Nerve dysfunction without anatomic damage
  • Transient episode of Confusion, disorientation, event amnesia
  • Suspect if patient has a momentary loss of consciousness
  • Frequent reassessment of mentation
  • ABCs
47
Q

diffuse brain injury moderate diffuse axonal injury

A
  • “Classic Concussion”
  • Same mechanism as concussion
  • Additional: minute bruising of brain tissue
  • Unconsciousness -> confusion
  • If cerebral cortex and RAS involved
  • May exist with a basilar skull fracture
  • Signs and Symptoms
  • Unconsciousness or persistent confusion
  • Loss of concentration, disorientation
  • Retrograde and antegrade amnesia
  • Visual and sensory disturbances
  • Mood or personality changes
48
Q

diffuse brain injury severe diffuse axonal injury

A
  • Brainstem Injury
  • Significant mechanical disruption of axons
  • Cerebral hemispheres and brainstem
  • High mortality rate
  • Signs and Symptoms:
  • Prolonged unconsciousness
  • Cushing’s reflex
  • Decorticate (flexion) or decerebrate (extension) posturing
49
Q

altered mental status

A
  • altered orientation
  • alteration in personality
  • amnesia
50
Q

cushing’s reflex (triad)

A
  • increased BP
  • bradycardia
  • erratic respirations
  • these 3 symptoms are really only ever seen together for brain injury
51
Q

vomiting

A
  • without nausea

- projectile

52
Q

body temperature changes

A
  • changes in pupil reactivity (maybe dilated)

- decorticate posturing

53
Q

blood glucose

A

-obtain blood glucose level on all patient with AMS if there is a altered mental state

54
Q

brain injury: things to look for

A
  • cushings reflex
  • body temperature changes
  • vomiting
  • altered mental status
55
Q

pathophysiology of changes

A
  • frontal lobe injury- alterations in personality
  • occipital lobe injury- visual disturbances
  • cortical disruption- reduced mental status or amnesia
  • > retrograde- unable to recall events before injury
  • > antegrade unable to recall events after trauma -> repetitive questioning
  • focal deficits- Hemiplegia, weakness, or seizures
56
Q

upper brainstem compression

A
  • Increasing blood pressure
  • Reflex bradycardia
  • Vagus nerve stimulation
  • Cheyne-Stokes respirations
  • Pupils become small and reactive
  • Decorticate posturing
  • Neural pathway disruption
57
Q

middle brainstem compression

A
  • Widening pulse pressure
  • Increasing bradycardia
  • Central Neurogenic Hyperventilation
  • Deep and rapid
  • Bilateral pupil sluggishness or inactivity
  • Decerebrate posturing
58
Q

lower brainstem injury

A
  • Pupils dilated and unreactive
  • Ataxic respirations
  • Erratic with no pattern
  • Irregular and erratic pulse rate
  • ECG changes
  • Hypotension
  • Loss of response to painful stimulus
59
Q

brain injury: eye signs

A
  • Indicate pressure on
  • CN-II, CN-III, CN-IV, and CN-VI
  • CN-III (Oculomotor nerve)
  • Pressure on nerve causes eyes to be sluggish, then dilated, and finally fixed.
  • Reduced peripheral blood flow
  • Pupil Size and Reactivity
  • Reduced pupillary responsiveness
  • Depressant drugs or cerebral hypoxia
  • Fixed and dilated
  • Extreme hypoxia
60
Q

recognition of herniation

A
  • cushings reflex- increasing blood pressure, decreasing pulse rate, respirations that become erratic
  • lower level of consciousness
  • GCS < 9 and dropping
  • singular or bilaterally dilated and fixed pupils
  • Decerebrate or decorticate posturing
  • No movement with noxious stimuli
61
Q

glasgow coma scale

A

-know this

62
Q

Trauma to the eye or Orbit

A
  • Eyelid laceration: Laceration to eyelid,
  • Cover Both Eyes with lose dressing. Lac of globe is possible.
  • Corneal abrasion: Scratch to epithelial covering of the cornea
  • Cover both eyes, to limit light and sympathetic movement
  • Blow out fracture: Increased pressure due to outside insult causes the base of orbital socket to fracture inward
63
Q

Trauma to Nasal

A

-Usually simplistic injury, Be ware of basilar skull injuries

64
Q

midface injuries

A
  • Le fort 1: Involves a horizontal detachment of the maxilla from the nasal floor
  • Le fort 2- Fracture of the right and left maxillae, medial orbital floor and nasal bones.
  • Le fort 3- Involves the facial bones being fractured off the skull “Craniofacial disjunction”
65
Q

head injury management: airway

A
  • Suctioning
  • Patient positioning
  • OPA and NPA use
  • Endotracheal intubation- Orotracheal; RSI
  • Cricothyrotomy
  • Oxygen
  • 15 LPM/NRB
  • Begin at 10-12 breaths/min
  • adjust breathing rate to maintain ETCO2 at 35–40 mmHg
  • Continuous waveform capnogrpahy
66
Q

head injury management: circulation

A
  • Hemorrhage Control
  • Blood pressure maintenance
  • Fluid resuscitation to SBP of 90 mmHg
67
Q

hypovolemia

A
  • Reduces cerebral perfusion and hypoxia.
  • Consider early management with 2 large bore IVs and isotonic fluids.
  • Prevents slower compensatory mechanism.
  • Maintain SBP 90 mmHg in an adult.
  • Maintain SBP 80 mmHg in a child.
  • Maintain SBP 75 mmHg in a young child.
  • Maintain SBP 65 mmHg in an infant.
68
Q

definitive care: nonsurgical candidates

A
  • Patients with small Hemorrhages Patients with minimal
  • Neurological deficits
  • Patients who have GCS less that or equal to 4 Unless emergent brain stem release
69
Q

definitive care: surgical candidates

A
  • Patient with hemorrhages greater than 3cm
  • Patients that are neurologically deteriorating
  • intracranial Hemorrhage associated with structural lesion
  • Improve chance of good outcome
  • Young Patients with a moderate lobar hemorrhage with deterioration

Trauma and Trauma Systems (18 decks)

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