Head Injury Flashcards
(181 cards)
1
Q
How do you classify head injuries?
A
- mechanism
- severity
- morphology
2
Q
What are the 2 mechanisms to get a head injury?
A
- closed
- penetration
3
Q
What are the 3 ways to state severity of head injury?
A
- mild
- moderate
- severe
4
Q
What are the morphologies of head injury? (whats there and where is it)
A
- skull fracture
- intracranial lesions
5
Q
What are the two ways of getting closed injuries?
A
high velocity (auto accidents) low velocity (falls, assault)
6
Q
Do you want contrast in CT of the brain for a head injury?
A
NO!
7
Q
What are the 2 ways to get a penetrating head injury?
A
gun shot wounds
-other open injuries
8
Q
What are some common closed head injuries?
A
- falls
- auto accidents
- assaults
- sports
9
Q
On the glascow coma scale what does a 14-15 denote?
A
MILD Severity
talking, a little confused
10
Q
On the glascow coma scale what does a GSC 9-13 denote?
A
moderate severity
-may have neuro defects, may be repetitive or not talking
11
Q
On the glascow coma scale what does a GSC of 8 or less denote?
A
Severe!
comatose and usually a bad CT
12
Q
Is a low GCS good or bad?
What is the lowest score you can get?
What is the highest score you can get?
A
low is bad
high is good
3 is lowest
15 is highest
13
Q
What should you combine with a GCS to establish a neurological baseline?
A
eye/pupil exam
14
Q
(blank) may be beneficial in head trauma.
A
cooling (only in healthy tissue)
15
Q
What do you want to keep the intracranial pressure at? How do you idecrease ICP?
A
below 20
mannitol
16
Q
When should you test the patient with the GCS and eye/pupil exam?
A
- after BP and O2 normalize
- before sedative meds or paralyzing meds
17
Q
Why do you want to use the GCS test after a patient’s BP and O2 normalize?
A
Because low BP and low O2 can cause decrease level of consciousness (LOC)
18
Q
Why do you want to use the GCS test BEFORE sedative medications or paralyzing meds are given?
A
because you cant evaluate a paralyzed patient for head injury
19
Q
A normal response to cold water in the ear is…?
A
eyes move to same side and have nystagymus to the opposite side
20
Q
What is a battle sign a sign of (brusingin behind the ears)?
A
a basilar skull fracture or CSF leakage
21
Q
In basilar skull fracture, if cranial nerve injuries are present, it usually involves CN (blank)
A
7 or 8
22
Q
What are all the signs of a basilar skull fracture?
A
- battle sign (brusining behind the ears)
- Raccoon eyes
- Hematoympanum (blood behind the ear drum)
23
Q
(blank) is the presence of air or gas within the cranial cavity.
A
pneumocephalis
24
Q
(blank) will be lenticulate and lay on top of the dura
A
epidural hemorrhage (between skull and dura)
25
(blank) will lay on top of the brain and under the dura
subdural hemorrhage
26
What patients on the ASIA score can walk out of the hospital?
C,D,E (E is the best)
27
If you are decerebrate (extensor) you likely have a (blank)
brain injury
28
If a patient is comatose and the CT scan is negative, then you can do what to the patient?
take them out of their collar
29
Who can do a GCS?
doctor, nurse, VS in ICU
30
THe lower the GCS the more likely you will die. What score shows marked increase in survival?
6 and up
31
What are the three components of the GCS?
```
Eye opening (1-4 pts)
Motor response (1-6 pts)
Verbal response (1-5 pts)
```
32
How do you score eye opening?
4 points for spontaneous eye opening
3 points for eyes opening in response to speech
2 points for eyes opening in response to pain
1 point if eyes dont open at all
33
How do you score motor response?
```
6=if they can obey commands
5= localizes
4= withdraws
3= abnormal flexor response
2= extensor response
1= nil (no response)
```
34
How do you score verbal response?
```
Physician asks what year is this:
5= oriented and state the correct year
4= confused conversation
3= inappropriate words
2= incomprehensible sounds
1= no response
```
35
How do you get the max number of points on the GSC?
- opens eyes spontaneously (4)
- obeys commands (6)
- oriented (5)
36
How do you get the worst possible score of GSC?
- Does not open eyes (1)
- Flaccid (1)
- Doesn't talk or make sounds (1)
37
What responses are you looking for when you check someones eyes?
- dilated pupils that are unresponsive to light
- lost corneal reflex
- dolls eyes
- lost oculobestibular reflex (ice water in ear and eyes dont move)
38
What is a dolls eye response?
you move their head but their eyes remain facing straight forward
39
What is the cold caloric response?
you put water into ears an their eyes move to that side and cause nystagmus to the contralateral side.
40
If you loose the cold caloric response what happen?
ice water in ears, eyes move to that side but dont do nystagmus to opposite side.
41
What are the two types of skull fractures?
- vault
| - basilar
42
What is a vault fracture?
over the brain
43
What is a basilar fracture?
under the brain
44
What are the 2 types of vault fractures?
- linear or stellate
| - depressed or non depressed
45
What are the 2 types of basilar fractures?
- With/without CSF leak
| - With/without VII or other cranial nerve palsy
46
What are the 2 types of intracranial lesions?
- focal
| - diffuse
47
What are the 2 types of focal intracranial lesions?
- subdural
| - epidural
48
What are 2 types of diffuse intracranial lesions?
- concussions
| - diffuse axonal injury
49
What kind of imaging would you use to see a skull fracture?
CT scan (x-ray isnt that good)
50
When describing a skull fracture, you would say it is either (blank) or (blank) or (blank) or (blank)
linear or stellate
| depressed or non-depressed
51
What is a skull fracture you often see in newborns?
ping-pong ball fracture (depressed fracture)
52
What does a hematoma feel like?
| How do you know its not a depressed skull fracture?
soft center and hard edges-> feels like a depressed skull fracture
-need CT to see if there is a fracture present
53
Up to 25% of head injuries are (blank) skull fractures
basilar skull fractures
54
What are the best ways to see basilar skull fractures?
on CT scan (bone windows)
55
In basilar skull fractures, how often will you have CN injury?
HOw often will you have CSF leak?
5%
| 10%
56
Where do you often get basilar skull fractures?
- petrous bone
- anterior cranial fossa and cribiform plate
- clival fractures (less common)
57
In a basilar skull fracture, what are the three ways you can fracture it?
- longitudinal
- transverse
- anterior fossa
58
If you get a longitudinal fracture you can have (blank) percent chance of damaging the facial nerve.
20%
59
If you get a transverse fracture you can have a (blank) percent chance of damaging the facial nerve.
50%
60
What are the clinical indications of basilar skull fractures?
- pneumocephalis
- CSF leak out of nose or ear
- Cranial nerve damage
- hemotympanum
- battle's sign
- raccoon eyes
61
In 10% of basilar skull fractures what can you get?
CSF leak
62
What do you make people with CSF leaks do and how effective is this at treating it?
bed rest and head elevation
| 85% effective
63
Should you give antibiotics to people with CSF leakage?
no! (unless pt develops meningitis)
64
How do you treat persistent CSF leaks?
with lumbar drain
| small number require surgical repair
65
When testing CSF what are you checking for?
- glucose
| - beta-2 transferrin ( a protein found almost uniquely in CSF)
66
What is the most common cause of subarachnoid hemorrhage?
trauma
67
Traumatic SAH have a low risk for (blank) or (blank)
deterioration
| surgical intervention
68
What can traumatic SAH lead to?
vasopasm (19%-68%)
69
In traumatic SAH you can get clinical deficits in (blank) percent of patients and the clinical course tends to be milder than vasospasm from (blank)
4-16%
| aneurysm SAH
70
What are the four focal lesions (of the intracranial lesions)?
- epidural hematoma
- subdural hematoma
- contusions
- intracerebral hematomas
71
Epidural hematoma are commonly due to arterial bleeds caused by the (blank) artery and a fracture
middle meningeal artery
72
An epidural hematoma can be due to a artery or (blank)
vein or venous sinus
73
What is the classic presentation of an epidural hematoma patient?
alert patient that deteriorates as clot enlarges
74
What shape is an epidural hematoma?
lenticular shape
75
What is the most common location for an epidural hematoma?
| Where do they occasionally occur?
temporal fossa
- sub-frontal region
- posterior fossa
76
What is the most common location for an epidural hematoma in children?
posterior fossa
77
How do you get subdural hematomas?
due to tearing of veins or brain lacerations
78
Which is worse, a subdural hemorrhage or a epidural hemorrhage? Why?
subdural hemorrhage
| -due to the associated brain injury
79
What is the shape of a subdural hematoma?
spread out (i.e not lenticular)
80
A chronic subdural hematoma may show up (blank or blank) after head injury
weeks or months
81
Do you need a major head injury to cause a subdural hematoma?
no it can be a minor head injury
82
Does a subdural hematoma present with?
- headache
- focal neuro deficits
- decreased level of conc.
83
What will rotational forces result in?
shearing and twisting
84
What will contrecoup result in?
contusion, swelling, blood clots
85
What is a cerebral contusion?
area of focal injury-deficit depends on area injured
86
How do you typically get cerebral contusions?
coupe-contra coup pattern (frontal occipital)
87
20% of cerebral contusions expand into (blank)
surgical hematomas
88
If you have a patient with a cerebral contusions what should you do with the patient?
observe them in the ICU
89
How long should you monitor the ICP of a cerebral contusion patient?
monitor it until the patient becomes conscious and cooperative
90
After a patient has a cerebral contusion you give a CT, when do you repeat this CT? Why?
within 24 hours or sooner if deteriorates
91
Are cerebral contusions common?
yes 8% of all TBI
| and 13-35% of all severe injuries
92
Where do you typically get cerebral contusions?
frontal and temporal lobes (but any site possible)
93
What do cerebral contusions look like on a CT?
"salt and pepper"
94
You always do a follow up CT with cerebral contusions because they can develop into (blank)
hematomas
95
What is the treatment for a significant mass effect caused by a intracerebral hematoma?
surgical evacuation
96
What is the treatment for a intracerebral hematoma that does have signif mass effect?
conservative managmet
97
What should you do with a patient that has an intracerebral hematoma but is alert with no signs of ICP?
manage with intensive monitoring and serial imaging
98
What is this:
| short loss of consciousness or temporary neurological dysfunction
concussion
99
What is this:
| loss of consciousness from time of injury beyond 6 hours
diffuse axonal injury (may be mild, moderate or severe)
100
What does a severe diffuse axonal injury present as?
deeply comatose for prolonged periods of time and often remain severely disabled if they survive
101
Where do most diffuse axonal injuries occur?
| How do they happen?
at the gray-white matter junction
(injury is greatest in where density difference is greatest)
-extreme acceleration and deceleration
102
Whats wrong with using a CT to detect a diffuse axonal injury?
CT can look normal or have small hemorrhages but the exam findings can be worse than explained by CT
103
(blank) percent of head injuries are mild TBI (concussion)
80%
104
What is the GCS of a mild TBI?
14-15
105
What are some characteristics of TBI?
- AWAKE but may be amnesic about injury
- usually make uneventful recovery
- lingering mild neurologic symptoms
106
3% of mild TBI patients do what unexpectedly?
deteriorate :(
107
Concussion (blank and blank) determine the severity of head injury
symptoms and duration
108
Concussion may be associated with loss of consciousness in (blank) of patients
(minority 10%)
109
What are some symptoms of concussion?
- confusion
- amnesia
- dizziness
- visual disturbance
- headache
110
How do you manage concussions?
a symptoms free waiting period of physical and cognitive rest before returning to subsequent play
111
What is second impact syndrome?
2 events-> days, weeks or minutes apart
| Athlete has post-concussive symptoms after head injury and then returns later to play and sustains a second head injury.
112
In second impact syndrome you get loss of (blank). What does this result in?
autoregulation
| -diated blood vessels-> cerebral swelling-> increased ICP-> brain herniation and death
113
Who typically gets second impact syndrome?
rare-usually young healthy athletes less than 18 years old
114
What is repetitive head injury syndrome?
(AKA punch-drunk syndrome: its like boxers)
| ->repeatedly get hit in the head and you get a slow delcine in cognitive abilities, Chronic traumatic encephalopathy
115
Helmet accelerometers show high school and college athletes in contact sports sustain (blank) head impacts per season
several 100 to over 1000
116
What are subconcussions?
- asymptomatic (no outward or visible signs or syptoms of neurological dysfunction)
- functional impairment found on neuropsychological testing and MRI
- axonal injury (even though asymptomatic)
117
T or F
athletes without history of concussions have pathology consistent with traumatic encephalopathy
What do we call this?
T
subconcussion
118
What are the three choices to be made with a TBI?
- street em-> send them home
- keep em-> admit for 24 hour observation
- ship em'-> transfer to neuro trauma center
119
What is a category 0 TBI?
```
GCS=15
alert
no LOC (loss of consciousness)
no PTA (post traumatic amnesia)
(no risk factors)
```
120
What do you do with a category 0 TBI?
send the patient home
121
What is a category 1 TBI?
GCS= 15
LOC < 30 min
PTA < 60 min
(no risk factosr)
122
What do you do with a category 1 TBI?
CT scan recommended
123
What do you do with a patient who is a category I TBI with a normal CT scan?
- discharge home with head injury warning instructions
| - admit if coagulation or other disoders (multi trauma) present
124
What do you do with a patient who is a category I TBI with a abnormal CT scan?
-no indication for surgery
(observe for 24 hours, consult neurotrauma center, repeat CT scan before discharge)
-indication for surgery
(transfer to neurotrauma center)
125
What is a category 2 TBI?
GCS=15 (alert) with risk factors
126
What are the risk factors associated with a category 2 TBI?
```
AMBIGUOUS ACCIDENT HISTORY
HEADACHE
VOMITING
FOCAL NEUORLOGICAL DEFICIT
SEIZURE
AGE YOUNGER THAN 2 YEARS OR OLDER THAN 60 YEARS
COAGULATION DISORDER OR ON ANTICOAGULANTS
HIGH-ENERGY (SPEED) ACCIDENT
```
127
What is a category 3 TBI?
CGS=13-14 (with or without risk factors)
128
What do you do with a category 3 TBI?
- CT scan mandatory
| - admit
129
What do you do with a category 3 TBI that has a normal CT?
observe for 24 hours
consult neurotrauma center
repeat CT scan before discharge
130
What do you do with a category 3 TBI that has an abnormal CT and there is no indication for surgery?
- Observe for 24 hours or until normal
- consult neurotrauma center
- repeat CT scan before discharge
131
What do you do with a category 3 TBI that has an abnormal CT and there is indication for surgery?
admit to neurotrauma center
132
10% of head injury patients seen in ER have (blank) TBIs
moderate
133
What GSC level are moderate TBI patients?
9-13
134
What are the symptoms of moderate TBI?
confused or somnolent, can follow simple commands, may have focal neuro deficits
135
(blank) percent of moderate TBIs will deteriorate and result in a coma
10%
136
What is the death rate of moderate TBIs?
9% death reate
137
With moderate TBI patients you should assure (blank) stability
cardiopulmonary
138
When you CT scan the head with moderate TBIs, how often will you see abnormalities and what percent require surgery?
40%
| 8%
139
What is a severe TBI?
GSC=8 or less
| -cannot follow simple commands
140
(blank) percent of severe TBI patients have a major systemic injury
50%
141
(blank) percent of severe TBI patients will die
35-40%
142
In severe TBI, you should make sure to prevent/correct hypotension and hypoxia?
because 35% of patients arrive hypotensive
| -systolic BP less than 90mm increases mortality rate from 27% to 50%
143
In severe TBI, how should you treat this?
- Establish airway, breathing and circulation.
- Establish a venous access
- volume replacement
144
T or F, hypotension is rarely caused by the brain injury
T
145
What is the cause of hypotension?
- may be severe blood loss
- spinal cord injury
- cardiac contusion or tamponade
- tension pneumothorax
146
THe patient's neurological exam is (blank) when hypotensive
meaningless
| cuz you can go from unresponsive to near normal after BP is restored
147
If you have a severe TBI with a normal CT, what three factors are associated with a poor outcome?
- hypotension on admission
- age over 40
- motor posturing (decerebrate)
148
What is a severe TBI workup?
- intubation (ventilator)
- IV access
- Foley catheter (look for hematuria)
- NG tube (beware of frontal floor fx)
- CT brain
- Cervical spine films or a CT scan (better!)
- chest film
- KUB abdominal film
- pelvic film
- Better: CT scan of head, neck, chest, abdomen and pelvis (after eval and stabilization)
149
What do you use a computed tomography angiography (CTA) for?
pts with skull base fx, cervical fx through transverse foramen at risk for artery dissection
150
When do you use an MRI?
- help with dx in those w/ non specific CT
- contraindicated unless absolutely certain patient has no incompatible device, implant, or foreign body
* *****usually done late if needed*****
151
When do you use ICP monitoring?
-if pt isnt following simple commands (cant be monitored clinically)
152
What is the normal ICP in relaxed patients?
10 mmg hg
| 10-20 is ok
153
It useful to follow (blank) rather than ICP
CPP (cerebral perfusion pressure)
154
What is cerebral perfusion pressure (CPP)?
mean arterial bp minus the ICP
155
What should the minimum CPP be?
60 mm Hg
156
Where do you put the transducer for ICP monitoring?
at the level of the foramen of monro
157
What are the different methods for monitoring ICP?
- epidural
- subdural
- subarachnoid
- intra parenchymal
- ventricular
158
What should you do if your ICP is increased (greater than 20 mm or CPP greater than 70 mm Hg)?
make sure its for real:
- check neck is in neutral position (veins)
- check calibration of system
- make sure transducer is at level of foramen of Monro
159
How do you conservatively treat increased ICP?
- sedation or chemical paralysis (esp. if patient restless or fighting ventilator)
- head of bed elevated 30 degrees
- euthermia
- make sure pCO2 not elevated
- mild hyperventilation
160
What happens if you treat the elevated ICP but it wont lower?
Repeat CT to rule out mass leasion that should be removed
161
What are the three methods for treating increased ICP?
- ventricular drainage
- hyperventilation
- hyperosmolar therapy
162
How does ventricular drainage work?
remove CSF if ventr. catheter
163
Why do you utilize hyperventilation to treat increased ICP?
reduces IC blood flow and volume through vasoconstriction
| -if prolonged can cause ischemia
164
What is hyperosmolar therapy ?
```
mannitol-> 48-72 hours
hypertonic saline-> longer (monitor blood chem)
loop diuretics (furosemide) adjunct to mannitol
```
165
What is a decompressive hemicraniectomy?
a "robust craniotomy" from frontal to occipital lobe including the temporal lobe and opening the dura (patch graft)
166
What is a barbituate coma?
last resort management of ICP
| -lowers cerebral metabolism and reduces cerebral blood flow
167
Whats the downside of barbituate coma?
-can cause hypotension requiring vasopressors and can cause hypotension
168
Do you use steroids to improve ICP?
No
169
What do you use to improve ICP?
anti seizure meds:
| Dilantin and Keppra (levetiracetam)
170
What is this:
- head compressed between two forces
- may cause failure of cranium
crush
171
What is this:
| recently added after experience with IED devices in recent combat situations
blast
172
How long is mannitol effective for?
| How much do you give?
48-72 hours
| 0.25 g to 1 g/kg at 4-6 hours
173
What is a hypertonic saline made up of and how do you give it?
23.4 % NaCl 30 cc boluses, central line over 15 minutes
174
How do hypertonic saline solutssions work?
they creat osmotic gradients
175
Mannitol has a reflective coefficient less than 1, what does this mean?
it will slowly leak into the interstitial fluid/brain parenchyma
176
Hypertonic saline has a coefficient of 1, what does this mean?
it will not accumulate in interstitial space/brain parenchyma if bbb is intact
177
(blank) with mannitol-has a synergistic effect
furosemide
178
Furosemide with mannitol works primarily on the (Blank) and is not dependent on intact (blank). This may reduce CSF production.
kidney
| BB
179
The (blank) in semipermeable membranes relates to how such a membrane can reflect solute particles from passing through.
reflection coefficient
180
A reflection coefficient of zero results in a (blank) particles passing through
all
181
A reflection coefficient of 1 results in (blank) particles that can pass.
no
