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Emergency Med Final > Head & Neck injury > Flashcards

Head & Neck injury Flashcards

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1
Q

pupil eval- pinpoint bilaterally

A

opiates

pontine lesion

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2
Q

pupil eval- right is nml, left is dilated

A

left hematoma-herniation or ocular globe trauma

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3
Q

pupil eval- dilated bilaterally

A

increased ICP w/ poor cerebral perfusion
drug effect
bilateral herniation
severe hypoxia

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4
Q

The Glasgow Coma Scale general info

A

standardized eval of neurological status
reproducible- can be performed by multiple examiners at different levels of care
predictive of morbidity/mortality

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5
Q

GCS eye opening

A

4: spontaneous eye opening
3: eye opening in response to speech- any speech/shout
2: eye opening in response to pain
1: no eye opening

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6
Q

GCS best verbal response

A

5: oriented- pt knows who & where they are, why, & yr, season, & month
4: confused conversation- pt responds in conversational manner, w/ some disorientation & confusion
3: inappropriate speech- random or exclamatory speech, w/ no conversation exchange
2: incomprehensible speech- no words uttered, only moaning
1: no verbal response

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7
Q

GCS best motor response

A

6: carrying out request (‘obeying command’)- pt does simple things you ask
5: localizing 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

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8
Q

decorticate posture

A

flexor response to pain-pressure on nail bed causes abnormal flexion of limbs

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9
Q

decerebrate posture

A

extensor posturing to pain- stimulus causes limb extension

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10
Q

GCS interpretation

A

13-15: mild head injury
9-12: moderate head injury
3-8: severe head injury

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11
Q

A.V.P.U.

A

Alert, or responsive to
Verbal stimuli, or to
Painful stimuli, or
Unresponsive

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12
Q

Trauma eval. secondary survey & AMPLE hx

A 
Allergies
Meds (esp. anticoags/antiplatelets)
PMH
Last meal (esp. if surgery is indicated)
Events (what happened just before)
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13
Q

bradycardia + HTN + irreg. respirations=

A

Cushing’s Triad

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14
Q

increased ICP may lead to

A

herniation

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15
Q

pupillary response to light in herniation

A

mydriasis ipsilateral to site of 3rd nerve injury

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16
Q

motor deficits usually_____________to sight of injury

A

contralateral

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17
Q

look for HEENT signs

A

battler sign
racoon eyes
hematotympanum

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18
Q

what imaging study for head injury

A

CT w/o contrast

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19
Q

immediate actions to be taken in head injury

A

IV
Labs: CBC, electrolytes, d-stick, coags, tox screen, ETOH level
monitor, HR, O2 sat, BP

HOB up 30 degrees & manitol 1g/kg IV
non contrast head CT

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20
Q

oxygenate, ventilate, intubate if indicated by

A

GCS<8
hypoxia
hypoventilation
need to sedate for trip to the scanner

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21
Q

tx presumptively for increased ICP if…

A 
GCS<8
fixed & dilated pupil(s)
decorticate/ decerebrate posturing
bradycardia
HTN
respiratory depression
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22
Q

epidural hematoma

A

bleeding between the inside of the skull & the outer covering of the brain
usually an arterial bleed
doesn’t cross sutures

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23
Q

epidural hematoma uncommon in

A

infants

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24
Q

3rd nerve palsy is a sign of

A

cerebral herniation

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25
somnolence often occurs how many hours after an accident that causes an epidural hematoma
24-96 hrs
26
disruption of dural sinuses is a major cause of epidural hematoma in
kids
27
most common cause of bleed in epidural hematoma is
laceration of dural vessels from skull fracture (91%), usually the middle meningeal artery
28
often there is a transient_________then a lucent interval
LOC
29
course of an epidural hematoma
hematoma expands increased ICP, decreased CBF herniation, ipsilateral CN-3 dysfunction & contralateral paralysis or posturing
30
subdural hematoma
more common than epidural hematoma seen in infants & elderly d/t large subarachnoid space w/ freedom to move caused by damage to subdural veins "bridging veins"
31
acute subdural hematoma
``` manifests hrs after injury hyperdense (<1 wk) isodense (1-3 wks) hypodense (3-4 wks) underlying brain injury (50%) worse long term prognosis than epidural hematoma ```
32
course of a subdural hematoma
may be acute, like epidural hematoma may have delayed course, days-wks increased ICP, edema, herniation
33
EtOH increases__________________by increasing the permeability of the blood brain barrier
cerebral edema in a subdural hematoma
34
chronic subdural hematoma
following minor injury rarely parenchymal injury convex configuration
35
interhemispheric subdural hematoma
usually posterior | most common acute finding in child abuse (whiplash injury)
36
sub-arachnoid hemorrhage
bleeding from small vessels at site of coup/ contrecoup injury bleeding under arachnoid, spreads in CSF vasoactive substances in blood contribute to ischemia & ALOC often occurs directly below external injury direct rupture of intrinsic cerebral vessels
37
halo's sign
clear drainage that separates from bloddy drainage | suggests presence of CSF
38
basal skull fracture caused by
deceleration injury or occipital trauma seldom fatal (except for race car drivers) 4% of serious head injuries
39
basal skull fracture may involve
orbits or sphenoid bone | fracture near foramen magnum
40
basal skull fracture is a separation of suture between what
temporal & occipital bones
41
S&S of basal skull fracture
``` damage to CN III, VII CSF otorrhea, CSF rhinorrhea (danger of meningitis) battle's signs racoon eyes hematotympanum ```
42
tx of the seriously head injured pt
seizure prevention: IV phenytoin prevent fever ctrl bleeding, transfuse to HCT>30 Abx for penetrating injury or basal skull fx early neurosurgical sonsultation: ventriculostomy, craniotomy
43
tx hypotension in head injury pt
resucitate to MAP >90 SBP 120-140 w/ NS pressors PRN N.B. isolated head injury unlikely to be HoTN on initial presentation, so look for other injuries!!!
44
control excessive HTN in head injury pts with what
Labetolol to reduce BP 20-30%
45
other tx for head injured pt
tx hypoxia intubate & ventilate (increased CO2 dilates vessels & lowers cpp sedate if needed (NOT katamine)
46
treating increased ICP in head injury
target <20, cpp 70-80 raise HOB 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
47
head injury disposition of GCS 15 w/ resolved sx's
dispo to home w/ vigilant family members & return precautions
48
head injury disposition w/ GCS of 14-15 ("mild injuries")
``` admit for observation neuro exams q 1-4 hrs IV fluids analgesia anti-emetics repeat head CT if worsening pain, vomiting or adverse change in LOC ```
49
head injury disposition GCS of 9-13 ("moderate" injuries)
admit to ICU neuro exam q 1-2 hrs NPO repeat head CT 6 hrs after admission or promptly if pt worsens if pt is immobile, DVT prevention may be warranted
50
head injury disposition GCS of 8 or less ("severe" injuries)
``` admit to ICU w/ hourly neuro exams NPO intracranial pressure monitor analgesia & sedation tight ctrl of BP & intracranial pressure seizure prophylaxis DVT prevention ****expanding hematoma/signs of imminent herniation- to OR for craniotomy ```
51
eval of mild/moderate head injured pt
Hx: MOI, LOC-how long? observed by?, amnesia, pain PE: neuro & mental status, repeat PRN, HEENT consider non contrast head CT
52
high risk indications for CT scan
GCS 65 yo (some studies suggest >60) basal skull fx signs: hemotympanum, periorbital bruising (raccoon eyes), mastoid process ecchymosis (battle's sign), CSF leakage from ear/nose
53
moderate risk indications for head CT
``` pre-trauma amnesia lasting longer than 30 min high risk mechanism of injury pedestrian in MVA passenger ejected from vehicle fall from ht >3" or 5 stairs ```
54
additional head CT indications
``` drug/ alcohol intoxication physical findings of trauma above clavicle seizure coagulopathy focal neuro deficit ```
55
indications for head CT in awake, alert peds pts
``` CT of head indicated for ALL high risk pts age < 3 months skull fxs, < 24 hrs old (intracranial injury in 15-30%) scalp hematoma predicts skull fx basal skull signs, scalp depression depressed mental status focal neuro deficit bulging fontanelle irritability after head injury ```
56
grade 1 concussion
transient confusion w/o amnesia no LOC mental status abnormalities resolve w/in 15 min most common
57
grade 2 concussion
transient confusion/amnesia lasting >15 min no LOC pt may have retrograde amnesia of events preceding the injury
58
grade 3 concussion
LOC | mental status change &/or amnesia is not included in the definition
59
Postconcussion syndrome
PE: nystagmus, CN abnormalities, asymmetric m. reflexes, abnormal plantar reflexes, asymmetric hearing loss, electroencephalographic abnormalities. Exertion & stress can aggravate the sx's
60
tx for postconcussion syndrome
analgesia & outpatient neuro/ primary care. No modality of tx clearly shown to alter course
61
postconcussion syndrome sx's
onset 1 day to wks after injury HA, dizziness, irritability, insomnia, anxiety, impaired attention, impaired memory, sound sensitivity, vertigo, tinnitus, decreased hearing, blurred vision, diplopia, photophobia, reduced taste & smell, depression, change in personality, fatigue, sleep disturbances, reduced libido, decreased appetite, decreased attention, increased info processing time
62
tx of minor head injury
d/c for home observation diminished LOC is predictive of more serious injury waking pt Q2 hrs not proven, poor compliance analgesics
63
second impact syndrome
an acute, usually fatal swelling of the brain that occurs when a 2nd impact concussion occurs before the sx's of a previous concussion have fully cleared. Sx's can include paralysis, mental disabilities & epilepsy. Death occurs in >50% of cases. Controversial
64
return to play protocol day 1
light aerobic exercise (walking, swimming, stationary cycling) keeping exercise heart rate <70% of max predicted heart rate. No resistance training
65
return to play protocol day 2
sport-specific exercise, any activities that incorporate sport-specific skills. No head impact activities
66
return to play protocol day 3
non-contact training drills
67
return to play protocol day 4
full contact practice, participate in nml practice activities
68
return to play protocol day 5
return to competition *If any concussion sx's return during any of the above activities, the athlete should return to the previous level, after resting 24 hrs
69
evaluating neck injured pt
- ABCDE - look for neuro impairment before examining neck - maintain inline stabilization of neck - protect C-spine until done evaluating
70
Risk factors for more severe neck injuries
MVC, higher speeds, air bag deployment, intrusion into vehicle/ car totaled sports: diving, horseback riding, football, gymanstics, skiing, hang gliding age > 65, arthritis, osteoporosis
71
neck injury- xray vs no xray
if yes to the following questions= no xray 1. no posterior midline C-spine tenderness 2. no evidence of intoxication 3. a normal level of alertness 4. no focal neuro deficit 5. no painful distracting injuries if no to any=xray
72
examples of dangerous mechanisms in neck injuries
``` fall from >/= 3 ft. or 5 stairs an axial load to the head MVA (>100 km/hr, rollover, ejection) motorized recreational vehicle accident bicycle collision ```
73
SCIWORA Syndrome
Spinal Cord Injury w/o Radiologic Abnormality
74
SCIWORA
occurs most often in peds pop ~2/3 of cervical injuries < 8yo -elasticity in peds cervical spine is reason
75
causes of SCIWORA
-transverse atlantal ligament injury -fx thru cartilaginous end plates -unrecognized interspinous ligamentous injury -for above 2 injuries, take flexion & extension views -adult w/ acute traumatic disc prolapse -cervical spondylosis
76
problems in cervical spondylosis
C-spine tramua occurs w/ hyperextension injury to spine w/ vertebral canal whose diameter is already compromised by spondylosis excessive ant. buckling of ligamentum flavum into canal already compromised by post. vertebral body osteophyts- probably the cause of central cord syndrome
77
what is central cord syndrome (another card is coming up for this)
- motor loss in arms > than in legs, variable sensory loss | - typically pts are managed nonsurgically w/ orthosis & their neuro status is carefully monitored
78
ED tx of cervical injury
protect from further injury IV steroids traction for unstable fx's treat shock
79
central cord syndrome
forced hyperextension injury flaccid paralysis of upper extremities variable sensory loss may extend to lower extremities
80
anterior cord syndrome
forced hyperflexion, disk herniation or fx loss of distal motor function & pinprick, pain & temperature sense vibration, pressure, light touch sensation preserved
81
Brown-sequard syndrome
penetrating trauma complet ipsilateral motor paralysis & loss of vibration, pressure, & all proprioception contralateral loss of pinprick, pain, & temp sensations

Emergency Med Final (9 decks)

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