Head Injury

Question 1

A traumatic brain injury is any injury to the head. There are 2 types of traumatic head injury, open and closed. What is a closed head injury?

1 - damage to the head but no penetration of skull
2 - damage to the skull and membranes of skull and brain are compromised
3 - skull damaged leading to PTSD
4 - skull damaged and infection follows

Answer 1

1 - damage to the head but no penetration of skull

• range form toddler bumping head to a severe car accident

Question 2

A traumatic brain injury is any injury to the head. There are 2 types of traumatic head injury, open and closed. What is a open head injury?

1 - damage to the head but no penetration of skull
2 - damage to the skull and membranes of skull and brain are compromised
3 - skull damaged leading to PTSD
4 - skull damaged and infection follows

Answer 2

2 - damage to the skull and membranes of skull and brain are compromised

• more common in the military settings

Question 3

A traumatic brain injury is any injury to the head. There are 2 types of traumatic head injury, open and closed. Which one is more common?

Answer 3

• closed

Question 4

During a closed loop traumatic injury we can hurt our heads from the initial impact (coup) followed by the rebound to the back of the head (contrecoup). During the initial head trauma there are three things that are damaged in the brain, what are they?

1 - neuronal, vascular and/or hearing injury
2 - neuronal, cardiac and/or axonal injury
3 - neuronal, vascular and/or axonal injury
4 - vision, vascular and/or axonal injury

Answer 4

3 - neuronal, vascular and/or axonal injury

Question 5

During a closed loop traumatic injury we can hurt our heads from the initial impact (coup) followed by the rebound to the back of the head (contrecoup). During the initial head trauma there may be injury to neuronal, vascular and/or axons. What generally follows this?

1 - metabolic and inflammatory process (oedema)
2 - metabolic and cardiac changes
3 - vision and cardiac changes
4 - inflammatory process and blood clot formation

Answer 5

1 - metabolic and inflammatory process (oedema)

Question 6

During a closed loop traumatic injury we can hurt our heads from the initial impact (coup) followed by the rebound to the back of the head (contrecoup). During the initial head trauma there may be injury to neuronal, vascular and/or axons, followed by metabolic and inflammatory process (oedema). What does this then cause in the CSF?

1 - increased amounts
2 - decreased amounts
3 - impaired regulation in CSF flow
4 - blocked CSF flow

Answer 6

3 - impaired regulation in CSF flow

Question 7

Following a traumatic brain injury we can damage the brain which can lead to hypo-perfusion. Which of the following does NOT occur due to the hypo-perfusion?

1 - insufficient oxygen
2 - anaerobic glycolysis
3 - aerobic glycolysis
4 - build up of lactic acid

Answer 7

3 - aerobic glycolysis

Question 8

Following a traumatic brain injury we can damage the brain which can lead to cytotoxic & inflammatory processes, altered cerebral microcirculation and hypoperfusion and failure to deliver vital metabolites. Does this lead to a decrease or increase in excitatory neurotransmitters?

Answer 8

• increase excitatory neurotransmitters

Question 9

NMDA receptors are now understood to critically regulate a physiologic substrate for memory function in the brain. Following a traumatic brain injury we can damage the brain which can lead to cytotoxic & inflammatory processes, altered cerebral microcirculation and hypoperfusion and failure to deliver vital metabolites. Are the NMDA levels and pathways affected?

Answer 9

• yes

Question 10

Following a traumatic brain injury we can damage the brain which can lead to cytotoxic & inflammatory processes, altered cerebral microcirculation and hypoperfusion and failure to deliver vital metabolites. What happens to Ca2+ and Na+ levels and what does this lead to?

1 - both increase increasing neuronal excitation
2 - both increase leading to neuronal and axon destruction
3 - both decrease leading to neuronal and axon destruction
4 - both decrease increasing neuronal excitation

Answer 10

2 - both increase leading to neuronal and axon destruction

Question 11

Following a traumatic brain injury we can damage the brain which can lead to cytotoxic & inflammatory processes, altered microcirculation and hypoperfusion and failure to deliver vital metabolites. This can lead to different types of oedema, vasogenic and cytotoxic oedema. What is vasogenic oedema?

1 - fluid collects inside brain stopping transport across blood brain barrier
2 - fluid collects in space between the brain and skull stopping transport across blood brain barrier
3 - fluid collects inside brain stopping increasing across blood brain barrier
4 - fluid collects extracellularly between the brain and skull increasing permeability of the blood brain barrier

Answer 11

4 - fluid collects extracellularly between the brain and skull increasing permeability of the blood brain barrier

Question 12

Following a traumatic brain injury we can damage the brain which can lead to cytotoxic & inflammatory processes, altered cerebral microcirculation and hypoperfusion and failure to deliver vital metabolites. This can lead to different types of oedema, vasogenic and cytotoxic oedema. What is cytotoxic oedema?

1 - injured cells leak osmotic solutes that are taken up by other cells in the brain causing oedema
2 - injured cells absorb osmotic solutes that are released from healthy cells in the brain causing oedema
3 - blood brain barrier leaks allowing solutes into brain and causing oedema

Answer 12

1 - injured cells leak osmotic solutes that are taken up by other cells in the brain causing oedema

• generally Na+ and Cl-

Question 13

What is the most common cause of death and disability in those aged 1-40?

1 - stroke
2 - heart attack
3 - traumatic brain injury
4 - infection

Answer 13

3 - traumatic brain injury

• 40% have a skull fracture
• <1% arriving at ED die

Question 14

How would we assess a patient with suspected brain trauma?

1 - Mini mental state examination
2 - Glasgow comma scale
3 - Addenbrooke’s Cognitive Examination
4 - Montreal Cognitive Assessment

Answer 14

2 - Glasgow comma scale

Question 15

Which of the following is not a category of the GCS?

1 - verbal response
2 - eye opening
3 - reflex response
4 - motor response

Answer 15

3 - reflex response

Question 16

The GCS has 3 sections: verbal response, eye opening and motor response. What is the range of the scores?

1 - 0-15
2 - 1-15
3 - 3-15
4 - 5-15

Answer 16

3 - 3-15

• patients get a 1 for failure to complete a task

Question 17

What is defined as a mild GCS score?

1 - >14
2 - >13
3 - >12
4 - >8

Answer 17

3 - >12

Question 18

What is defined as a moderate GCS score?

1 - 12-14
2 - 10-13
3 - >10
4 - 9-12

Answer 18

4 - 9-12

Question 19

What is defined as a severe GCS score?

1 - <12
2 - <10
3 - >8
4 - <8

Answer 19

4 - <8

• patients are determined as unable to breathe independently
• major fatality patients have moderate or severe GCS

Question 20

Which of the following is NOT a common symptom of a traumatic brain injury?

1 - Headaches
2 - Dizziness
3 - Hypotension
4 - Nausea and vomiting
5 - Diplopia (double vision)
7 - Deafness
8 - Amnesia (antro and retrograde)

Answer 20

3 - Hypotension

Question 21

Which of the following is NOT a common sign of a traumatic brain injury?

1 - Bruises / lacerations / bleeding scalp, mouth, nose , ear
2 - Skull deformities
3 - sleepy, irritability altered consciousness
4 - disorientation
5 - psychosis
6 - seizures
7 - focal neurological signs eg hemiparesis
8 - IMPAIRED CONSCIOUSNESS – reduced wakefulness, not orientated (Time, Place and Person) Eyes can be open
9 - UNCONSCIOUS (=COMA) Absence of awareness of surroundings or self. GCS <8

Answer 21

5 - psychosis

Question 22

If a patient has had a suspected traumatic brain injury, there are indications set out by NICE indicating which patients need to be seen at a hospital for assessment. Which of the following is NOT an indication for assessment in a hospital?

1 - GCS < 15 on initial assessment
2 - loss of consciousness
3 - focal neurological deficit (hemiparesis)
4 - skull fracture / penetrating HI
5 - amnesia (before or after)
6 - vomiting
7 - loss of bowel function
8 - seizure
9 - previous brain injury
10 - high-energy head injury

Answer 22

7 - loss of bowel function

Question 23

If a patient has had a suspected traumatic brain injury, there are indications set out by NICE indicating which patients need to be seen at a hospital for assessment. Which of the following is NOT a risk factor and does not need assessment in a hospital?

1 - history of bleeding or clotting disorders
2 - current anti-coagulant therapy
3 - drug or alcohol intoxication
4 - professional is “worried”
5 - no-one at home
6 - hypertension
7 - Safeguarding issues

Answer 23

6 - hypertension

Question 24

If a patient attends ED with a suspected traumatic brain injury, they would need to be assessed. Place the assessments in the correct order?

1 - analgesics
2 - ABCDE
2 - GCS
4 - head scan

Answer 24

2 - ABCDE
2 - GCS
4 - head scan
1 - analgesics

Question 25

If a patient attends ED with a suspected traumatic brain injury, they would need to be assessed. A score of what on the GCS would make you get ITU involved? 1 - <15 2 - <13 3 - <10 4 - <8

Answer 25

4 - <8

Question 26

If a patient attends ED with a suspected traumatic brain injury, they would need to be assessed. If a patient is high risk, what should they be assessed to have as soon as possible? 1 - fluids 2 - head CT scan 3 - analgesics 4 - head X-ray

Answer 26

2 - head CT scan - history of bleeding or clotting disorders - current anti-coagulant therapy

Question 27

If a patient attends ED with a suspected traumatic brain injury, they would need to be assessed. If a patient is high risk they should receive a head CT scan. Which of the following is NOT an indication for a head CT scan? 1 - GCS < 13 on initial assessment 2 - GCS < 15 at 2 hours 3 - suspected open or depressed skull fracture 4 - basal skull fracture – haemotympanum, “panda” eyes,, CSF leak, Battle’s sign 5 - diplopia (double vision) 6 - Seizure 7 - Focal neurological sign 8 - > 1 episode vomiting

Answer 27

5 - diplopia (double vision)

Question 28

If a patient attends ED with a suspected traumatic brain injury, they would need to be assessed. If a patient is high risk they should receive a head CT scan. In addition to normal indications for a head CT, there are 4 main times when you would do a CT head scan regardless of how the patient appears. Which of the following is NOT 1 of these 4? 1 - > 65 years 2 - bleeding or clotting disorder 3 - dangerous mechanism injury 4 - > 30 minutes retrograde amnesia before HI 5 - blood loss

Answer 28

5 - blood loss

Question 29

If a patient with a GCS <8 who has is suspected of having a having a traumatic brain injury, where should they be transferred to ideally? 1 - ED 2 - neuroscience centre 3 - walk in centre 4 - fracture clinic

Answer 29

2 - neuroscience centre - patient may need burr holes to help relieve intracranial pressure

Question 30

Should steroids be given to a patient with a suspected traumatic brain injury?

Answer 30

- no

Question 31

Which of the following can be given to a patient following a suspected traumatic brain injury if we suspect an increased intracranial pressure? 1 - steroids 2 - mannitol 3 - ramipril 4 - liraglutide

Answer 31

2 - mannitol - can also give hyperosmolar saline to draw solutes out of brain cells and fluid follows - usually affective for 1 hour

Question 32

Mannitol can be given to a patient following a suspected traumatic brain injury if we suspect an increased intracranial pressure. What is the mechanism of action of this drug in this setting? 1 - acts as analgesic increasing NMDA firing 2 - not absorbed by cell but draws fluid out of cells 3 - absorbed by cells and increases fluid absorption 4 - absorbed by cells and increases fluid release

Answer 32

2 - not absorbed by cell but draws fluid out of cells - reduces the pressure on the cells and shrinks brains - can also lower the size of RBCs

Question 33

If a patient is suspected of a traumatic brain injury with increased intracranial pressure, why can hyperventilation be useful? 1 - increases CO2 retention and vasodilates blood vessels in the brain 2 - decreases CO2 retention and vasodilates blood vessels in the brain 3 - decreases CO2 retention and vasoconstricts blood vessels in the brain 4 - increases CO2 retention and vasoconstricts blood vessels in the brain

Answer 33

3 - decreases CO2 retention and vasoconstricts blood vessels in the brain - vasoconstriction decreased cerebral blood flow, which reduces cerebral blood volume and, ultimately, decreases the patient's ICP

Question 34

The tentorium is a reflex of the dural matter that separates the cerebellum and brainstem from the occipital lobes of the cerebrum. If a patient has a traumatic brain injury, this can cause tentorium herniation. What can then happen? 1 - cerebellum can protrude into the cerebrum 2 - increased ICP causes tentorium herniation and brain pushes down through the herniation 3 - increased ICP causes tentorium herniation and brain begins leading CSF

Answer 34

2 - increased ICP causes tentorium herniation and brain pushes down through the herniation

Question 35

What is a subdural haematoma? 1 - blood collects below the dura mater, and in the space between the dura and arachnoid mater 2 - blood collects in the ventricles of the brain 3 - blood collects between the cranium and the dura mater 4 - blood collects between the arachnoid mater and the pia mater

Answer 35

1 - blood collects below the dura mater, and in the space between the dura and arachnoid mater - normally a venous bleed, bridging veins

Question 36

What is a extradural (also known as an epidural) haematoma? 1 - blood collects below the dura mater, and in the space between the dura and arachnoid mater 2 - blood collects in the ventricles of the brain 3 - blood collects between the cranium and the dura mater 4 - blood collects between the arachnoid mater and the pia mater

Answer 36

3 - blood collects between the cranium and the dura mater - dura peels of the skull

Question 37

In a extradural (also known as an epidural) haematoma, which blood vessel is likely to have ruptured? 1 - middle meningeal artery 2 - middle cerebral artery 3 - vertebral artery 4 - internal carotid artery

Answer 37

1 - middle meningeal artery - normally an arterial bleed

Question 38

Patients can present with a variety of symptoms if they have a subdural bleed. Which of the following is not commonly present? 1 - Headache 2 - Drowsiness 3 - Confusion 4 - Seizure 5 - Focal neurological signs 6 - Personality change

Answer 38

4 - Seizure

Question 39

Do subdural haemorrhage always present acutely?

Answer 39

- no typically present later, but can also be acute - treatment is typically conservative

Question 40

Which one of these groups of patients is NOT at a greater risk of subdural haemorrhage? 1 - alcoholics 2 - elderly 3 - obese 4 - anti-coagulant medication

Answer 40

3 - obese

Question 41

In a subdural haemorrhage, will the blood appear white or dark on a CT scan?

Answer 41

- dark

Question 42

When looking at CT brian scans, if you are trying to distinguish if a haemorrhage is subdural or extradural you can remember this: - extra-dural haematoma is lentiform like a lemon - subdural haematoma is sickle shaped like a banana

Answer 42

- extra-dural haematoma is lentiform like a lemon

Question 43

In the image attached, is this a subdural or extradural haemorrhage?

Answer 43

- subdural - subdural haematoma is sickle shaped like a banana - can also see: a) With midline shift b) Compressed right lateral ventricle

Question 44

In a patient with a suspected extradural haemorrhage, why do we need to monitor them closely?

Answer 44

- can be lucid, before deteriorating rapidly

Question 45

In patients with mild to moderate traumatic head injuries 1 year following the injury, what % return to work? 1 - 10% 2 - 30% 3 - 50% 4 - 75%

Answer 45

4 - 75% - but 85% will have symptoms such as headache, irritability, poor concentration, forgetfulness and fatigue

Question 46

What is the best outcome marker following a mild to moderate head injury? 1 - NEWS2 score 2 - initial GCS 3 - CT scan 4 - post traumatic amnesia

Answer 46

4 - post traumatic amnesia - how long from head injury before you can remember anything

Question 47

In a patient who has had a severe traumatic brain injury, what % are able to return to their jobs? 1 - 5% 2 - 25% 3 - 50% 4 - 75%

Answer 47

3 - 50% - but 38% will have a reduced salary

Question 48

In a patient who has had a severe traumatic brain injury, which of the following has the largest drop in functionality? 1 - Balance 2 - Headaches 3 - Cognitive complaints 4 - Anxiety 5 - Depression

Answer 48

3 - Cognitive complaints - 20-33% will have disabilities