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Emergency Medicine Module 3 > Head Injury > Flashcards

Flashcards in Head Injury Deck (27):
1

ABCDEs of obtunded/altered head injured patient

  • Airway,
  • Breathing,
  • Circulation, and.......
  • C-spine: You must evaluate, or protect the cervical spine
  • Disability, your neuro exam
  • Exposure, complete secondary survey

2

pupil evaluation

3

Evaluation and management of head injured patient

  • The Glasgow coma scale
  • *Standardized evaluation of neurological   status
  • *Reproducible - can be performed by        multiple examiners at different levels of care
  • *Predictive of morbidity/mortality
  • Eye opening:
    • 4: Spontaneous eye opening.
    • 3: Eye opening in response to speech - that is, any   speech or shout.
    • 2: Eye opening in response to pain.
    • 1: No eye opening.
  • Best verbal response
    • 5: Oriented - patient knows who and where   they   are, and why, and the year, season and month.
    • 4: Confused conversation - patient responds   in conversational manner, with some   disorientation and confusion.
    • 3: Inappropriate speech - random or   exclamatory speech, with no   conversational exchange.
    • 2: Incomprehensible speech - no words   uttered, only moaning.
    • 1: No verbal response.
  • Best motor response
    • 6: Carrying out request ('obeying command') -  patient does simple things you ask.
    • 5: Localising response to pain.
    • 4: Withdrawal to pain - pulls limb away from   painful stimulus.
    • 3: Flexor response to pain - pressure on nail   bed causes abnormal flexion of limbs   (decorticate posture).
    • 2: Extensor posturing to pain - stimulus causes limb extension (decerebrate posture).
    • 1: No response to pain.
  • •GCS 13-15: Mild Head Injury
  • •GCS 9-12: Moderate Head Injury
  • •GCS 3-8: Severe Head Injury
  • A.V.P.U.
    • Alert, or responsive to
    • Verbal stimuli, or to
    • Painfull stimuli, or
    • Unresponsive

4

Trauma eval. Secondary survey and AMPLE history

  • A -> Allergies
  • M -> Medications (especially anticoagulants/anti-platelets)
    • Meds we are worried about are anticoagulants (warfarin, coumadin)

  • P -> Past medical history 
  • L -> Last meal (especially if surgery is indicated emergently)
  • E -> Events (what happened just before..?)
  • ●Vital Signs
    • −Bradycardia+ hypertension+ irregular respiration= Cushing's Triad
    • −Increased ICP and impending Herniation
  • ●Pupilary response to light
    • −Mydriasis ipsilateral to site of 3rd nerve injury in herniation events
  • ●Motor deficits usually contralateral to the sight of injury
  • ●Heent exam
    • −Battle sign, Racoon eyes, hematotympanum
  • ●CT without contrast

5

immediate actions

  • ●IV, Labs: cbc, electrolytes, stat glucose, coags, tox screen, ETOH level
  • ●Monitor, HR, O2 sat,BP
  • ●Oxygenate, ventilate, intubate if indicated
    • − (GCS<8), hypoxia, hypoventilation,need to sedate for trip to the scanner
  • ●Treat presumpively for increased ICP if:
    • −(GCS<8), fixed and dilated pupil(s),decorticate or decerebrate posturing, bradycardia, hypertension or respiratory depression
    • −Initial treatment is HOB up 30degrees and Manitol 1g/kg iv
  • ●Non-contrast Head CT

6

epidural hematoma

  • *2% of all serious head injuries
  • *Uncommon in infants
  • *Associated with skull fracture in 40-85%
  • *Laceration of dural vessels from skull fracture (91%),   usually the middle meningeal artery
  • *Avulsion of venous vessels from points of   calvarial perforations
  • *Disruption of dural sinuses (major cause in   kids)
  • *Transient loss of consciousness; lucent   interval
  • *3rd nerve palsy (sign of cerebral herniation)
  • *Somnolence 24-96 hrs after accident
  • *Hematoma expands
  • *Increased ICP, decreased CBF
  • *Herniation, ipsilateral CN-3 dysfunction and contralateral   paralysis or posturing

7

subdural hematoma

  • * Incidence: 5% of head trauma patients
  • * Age: infants and elderly (large subarachnoid space   with freedom to move)
  • * Cause: damage to subdural veins ("bridging veins")
  •  Acute Subdural Hematoma:
    • Manifests hours after injury
    • Hyperdense (<1 week); isodense (1-3 weeks);    hypodense (3-4 weeks)
    • Underlying brain injury (50%)
    • Worse long term prognosis than epidural   hematoma
  • *May be acute, like epidural hematoma
  • *May have delayed course, days to weeks
  • *Increased ICP, edema, herniation
  • *ETOH increases cerebral edema by increasing the permeability of the blood brain barrier
  • Chronic Subdural Hematoma:
    • Following minor injury, rarely parenchymal injury
    • Convex configuration
  • Interhemispheric Subdural Hematoma:
    • Usually posterior
    • Most common acute finding in child abuse
      • (whiplash injury)

8

Sub-arachnoid hemorrhage

  • *Bleeding from small vessels at site of coup   or contrecoup injury
  • *Bleeding under arachnoid, spreads in CSF
  • *Vasoactive substances in blood contribute   to ischemia and altered level of   consciousness
  • *Often occurring directly beneath an   external injury
  • *Can also occur as a contrecoup injury
  • *Direct rupture of intrinsic cerebral   vessels.
  • *Traumatic SAH diagnosed without LP. Consider LP if “Trival Trauma”

9

Basal skull fracture

  • *Caused by deceleration injury or occipital   trauma
  • *4% of serious head injuries
  • *Seldom fatal (except for race car drivers)
  • *Separation of suture between temporal and   occipital bones
  • *May involve orbits or sphenoid bone, or   fracture near foramen magnum
  • *Damage to Cranial nerves III, VII or  
  • *CSF otorrhea, CSF rhinorrhea   (danger of   meningitis!) 
  • *Battle’s sign
  • *Racoon eyes
  • *Hematotympanum

10

treatment of seriously head injured pt

  • *Seizure prevention: IV Phenytoin
  • *Prevent fever
  • *Control bleeding, transfuse to HCT>30
  • *Antibiotics for penetrating injury or basal skull fracture
  • *Early neurosurgical consultation: ventriculostomy,   craniotomy
  • •Treat hypotension, resucitate to MAP>90 (SBP   120-140 with NS. Pressors as needed. N.B. isolated head injury is unlikely to be hypotensive on initial presentation, so look for other injuries!
  • •Control excessive hypertension.
    • Labetolol to reduce BP 20-30%
  • •Treat hypoxia, intubate and ventilate (increased CO2 dilates vessels and lowers cpp)
  • •Sedate if needed (not ketamine)‏
  • *Treat increased ICP (target <20, cpp70-  80)‏
    • *Raise head of bed to 30 degrees
    • *IV mannitol boluses once euvolemic
    • (serum osmolality 280-300)‏
    • *Hyperventilate PCO2 to 26-30? Consider   only if other measures ineffective
    • *Steroids not proven to have benefit in head trauma

11

cerebral perfusion pressure

12

head injury, disposition

  • ●GCS of 15 with resolved symptoms:, dispo to home with vigilant family members and return preacautions
  • ● GCS of 14-15 (ie: "mild" injuries)
    • −Admit for observation. Neurological exams every 1-4 four hours. IV fluids, analgesia, anti-emetics.
    • −Repeat head CT if worsening pain, vomiting or adverse change in level of consciousness
  • ●GCS of 9-13 (ie: "moderate" injuries)
    • −Admit to ICU. Neurological exams every 1-2 hours.
    • −NPO
    • −Repeat head CT six hours after admission or promptly if  pt worsens
    • −If pt is immobile, DVT  prevention may be warranted.
  • ∙GCS of 8 or less (ie: "severe" injuries)
    • ∙Admit to ICU with hourly neurological exams.
    • ∙NPO.
    • ∙intracranial pressure monitor
    • ∙Analgesia and sedation.
    • ∙Tight control of BP and intracranial pressure
    • ∙Seizure prophylaxis
    • ∙DVT prevention
  • ∙Expanding Hematoma or signs of imminent herniation
  • ∙To OR for craniotomy
  • ∙Admit to ICU

13

evaluation of the mild/moderate head injured patient

  • ●History
    • −Mechanism of Injury
    • −LOC? How long? Observed by?
    • −Amnesia?
    • −Pain
    • ●Exam
    • −Complete neuro and mental status exam, repeat as needed
    • −Head,ENT ,Neck
  • ●Consider non contrast head CT

14

indications for CT scan

  • Protocol: Canadian CT Head Rule (for mild Head Injury)
    • *High risk indications for Head CT
      • •Glasgow Coma Scale <15 at 2 hours after injury
      • •Open or depressed skull fracture
      • •Vomiting (Two or more episodes)
      • •Age 65 years or over (other studies suggest age   60)
      • •Basal skull fracture signs:
        • –Hemotympanum   Periorbital Bruising (Raccoon Eyes)
        • –Mastoid process Ecchymosis (Battle's Sign)
        • –Cerebrospinal fluid leakage from ear or nose
  • *Moderate risk indications for Head CT
    • •Pre-trauma amnesia lasting longer than 30 minutes
    • •High risk mechanism of injury
    • •Pedestrian in motor vehicle accident
    • •Passenger ejected from vehicle
    • •Fall from height over 3 feet or 5 stairs

15

ACEP clinical policy indications for head CT

  • LOC or Amnesia+any of:
    • *    Headache
    • *    Vomiting
    • *    Age>60
    • *    Drug/alcohol intoxication
    • *    Short-term memory deficits
    • *    Evidence of trauma above the clavicles
    • *    Posttraumatic seizure
    • *    GCS<15
    • *    Focal neurological deficit
    • *    Coagulopathy
  • No LOC or amnesia
    • *    Severe headache
    • *    Vomiting
    • *    Age>65
    • *    GCS<15
    • *    Physical signs of a basilar skull fracture
    • *    Focal neurological deficit
    • *    Coagulopathy
    • *    Dangerous Mechanism
      • •ejection from a motor vehicle, pedestrian struck, a fall >3 feet or 5 stairs

16

nexus II rule

  • *    Head CT not required if ALL of the following are absent:
    • *    Age ≥ 65yr
    • *    Evidence of significant Skull Fracture
    • *    Scalp hematoma
    • *    Neurologic deficit
    • *    Altered Level of Alertness
    • *    Abnormal behavior
    • *    Coagulopathy
    • *    Recurrent or forceful vomiting

17

New orleans rule: inclusion criteria

  • GCS 15, LOC,amnesia or disorientation
  • Head CT not required if ALL of the following are absent:
    • *    Headache
    • *    Vomiting
    • *    Age >60yr
    • *    Drug or Alcohol Intoxication
    • *    Persistent anterograde amnesia (deficits in short-term memory)
    • *    Visible trauma above the clavicles
    • *    Seizure

18

indications for head CT in awake, alert pediatric patients

  • CT of head indicated for all high risk patients
    • * Age under 3 months
    • * Skull fracture, less than 24 hrs old
      • (intracranial injury in 15-30%)
    • * Scalp hematoma predicts skull fracture - 80% sensitive
    • * Basal skull signs, scalp depression
    • * Depressed mental status
    • * Focal neurologic deficits
    • * Bulging fontanelle
    • * Irritability after head injury

19

concussion: grading scale

  • *Grade 1 Concussion
    • Transient confusion without amnesia.
    • No loss of consciousness
    • Mental status abnormalities resolve within 15 minutes
    • Most common
  • *Grade 2 Concussion
    • Transient confusion or amnesia lasting greater than 15   minutes.
    • No loss of consciousness
    • Patient may have retrograde amnesia of events   preceding the injury
  • *Grade 3 Concussion 

    • Loss of consciousness for any amount of time

    • Mental status change and/or amnesia is not   included in the definition

20

Postconcussion syndrome

  • *Physical findings: nystagmus, cranial nerve abnormalities, asymmetric muscle reflexes, abnormal plantar reflexes,   asymmetric hearing loss, electroencephalographic abnormalities.
  • *Exertion and stress can aggravate the   symptoms.
  • *Treatment is analgesia and outpatient   neurology or primary care. No modality of   treatment clearly shown to alter course.
  • *Physical findings: nystagmus, cranial nerve abnormalities, asymmetric muscle reflexes, abnormal plantar reflexes,   asymmetric hearing loss, electroencephalographic abnormalities.
  • *Exertion and stress can aggravate the   symptoms.
  • *Treatment is analgesia and outpatient   neurology or primary care. No modality of   treatment clearly shown to alter course.

21

treatment of minor head injury

  • *Discharge for home observation
  • *Diminished LOC is predictive of more serious injury
  • *Waking patient Q2 hours not proven, poor compliance
  • *Analgesics

22

second impact syndrome

  • *An acute, usually fatal swelling of the brain that   occurs when a second impact concussion occurs before the symptoms of a previous concussion have fully cleared.
  • *Symptoms can include paralysis, mental   disabilities and epilepsy.
  • *Death occurs in over 50% of cases.
  • *Controversial

23

gradual return-to-play protocol

● Day 1: light aerobic exercise (walking, swimming , or stationary cycling) keeping exercise heart rate less than 70% of maximum  predicted heart rate.  No resistance training

●Day 2: sport-specific exercise, any activities that incorporate sport-specific skills.  No head impact activities.

●Day 3: non-contact training drills

●Day 4: full contact practice, participate in normal practice activities         

●Day 5: return to competition

●If any concussion symptoms return during any of the above activities, the athlete should return to the previous level, after resting for 24 hours.

24

evaluating the neck injured patient

  • ●ABCDE
    • −Look for neurological impairment before directly examining the neck
    • −Maintain inline stabilization of the neck as you remove pt from back board. Protect the C-spine until done evaluating it.
  • ●Risk factors for more severe injury
    • −MVC, higher speeds, air bag deployment, intrusion into vehicle or car totaled
    • −Sports: diving, horseback riding, football, gymnastics, skiing, hang gliding
    • −Age over 65, arthritis, osteoporosis

25

ED treatment of cervical injury

  • ●Protect from further injury
  • ●IV steroids
  • ●Traction for unstable fractures
  • ●Treat shock

26

Spinal cord injury without radiographic abnormality

27

Central cord, anterior cord, and brown-sequard syndrome

  • Central
    • ●Forced hyperextension injury
    • ●Flacid paralysis of upper extremities
    • ●Variable sensory loss
    • ●May extend to lower extremities
  • Anterior
    • ●Forced Hyperflexion, disk herniation or fracture
    • ●Loss of distal motor function and pinprick, pain and temperature sense
    • ●Vibration, pressure, light touch sensation preserved
  • Brown-Sequard
    • ●Penetrating trauma
    • ●Complete ipsilateral motor paralysis and loss of vibration, pressure, and all proprioception.
    • ● Contralateral loss of pinprick, pain, and temperature sensations.