Head trauma Flashcards by Thomas Eraifej

Primary goal of treatment for patients with suspected traumatic brain injury

Prevent secondary brain injury

Via ABCDE and controlling BP etc

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Cushing’s triad

(Aka Cushing’s response)

Hypertension
Bradycardia
Irregular breathing

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Implication of Cushing’s triad

Impending uncal herniation (coning)

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Uncus

Medial part of temporal lobe

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Compartments of the intracranial cavity

Supratentorial compartment
Infratentorial compartment

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Through which structure does the uncus herniate

Tentorial notch

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Consequence of uncal herniation

Compression of midbrain
Compression of CN III
Contralateral hemiparesis

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Implication of a blown pupil

Midline shift and impeding uncal herniation
eg from subdural haematoma

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Classical signs of (impending) uncal herniation

Ipsilateral blown pupil
Contralateral hemiparesis

Cushing’s response

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Monro-Kellie Doctrine

Total volume of intracranial contents must remain constant as it is a closed space

When intracranial volume increases, ICP rises

CSF and venous blood compressed out first
Once this compression has reached capacity, brain matter becomes compressed
Leads to herniation / hemispheric shift

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Cerebral perfusion pressure

Cerebral perfusion pressure = Mean arterial pressure - Intracranial pressure

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Intracranial consequence of low MAP

Ischaemia / infarct of brain tissue

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Intracranial consequence of high MAP

Brain swelling

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Layers of the meninges including vessels

Skull
Meningeal arteries
Dura mater (encloses large venous sinuses)
Arachnoid mater
Blood vessels and CSF
Pia mater
Grey matter
White matter

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Parts of the brainstem

Midbrain
Pons
Medulla

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Ventricular system in brain

Filled with and constantly produce CSF

CSF absorbed over brain surface

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Consequence of blood in CSF

Can impair reabsorption of CSF and increase intracranial pressure

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Normal intracranial pressure

10 mmHg

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Raised intracranial pressure associated with poor outcomes

20 mmHg

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Methods of classifying Traumatic brain injury

Severity

Morphology

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Severity of traumatic brain injury classification

Mild = GCS 13 - 15
Moderate = GCS 9 - 12
Severe (/ coma)= GCS 8 or less

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Morphology of traumatic brain injury classification

Skull fractures:
- Vault
- Basilar

Intracranial lesions:
- Focal
- Diffuse

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Signs of basilar skull fracture

Panda eyes
Battle’s sign
Oto/rhinorrhoea of blood or CSF
Facial paralysis
Hearing loss

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Focal intracranial lesion examples

Study These Flashcards

Epidural haemorrhage
Subdural haemorrhage
Intracranial haemorrhage

Diffuse intracranial lesion examples

Concussion Multiple contusions Hypoxic / ischaemic injury Axonal injury

Axonal injury mechanism of injury

High velocity impact or deceleration impact Multiple punctate haemorrhages throughout cerebral hemispheres Often poor outcome

Concussion definition

Transient, non-focal neurological disturbance Often LOC No CT changes

Classic presentation of extra-dural haematome

Lucid interval between injury and neurological deterioration

Concern with cerebral contusions

In hours to days can evolve to form intracerebral haematomas and may require surgery Repeat CT scans to assess progressive changes

Management of mild TBI (traumatic brain injury)

Often associated with concussion Usually make uneventful recovery

Indications for CT head

Initial GCS <13 GCS <15 after 2 hours Suspected open or depressed skull fracture Sign of basilar skull fracture Vomiting > 2 episodes LOC / amnesia and >65 yrs age LOC > 5 mins Amnesia > 30 mins prior to HI Anticoagulant use Dangerous mechanism of injury

Management of moderate TBI

CT head with follow up scan within 24 hours D/W neurosurgery Admit for observation in ITU

Management of severe TBI

Urgent Neurosurgical consult Intubate Treat hypotension and hypoxia Maintain pCO2 around 4.7 kPa (35 mmHg) Consider mannitol, pCO2 28-32 for deterioration Avoid pCO2 <28

Target for systolic BP in TBI

Age 50 to 69: SBP > 100 mmHg Age 15 to 49 or >70: SBP > 110 mmHg

Replacement of choice to manage hypovolaemia in TBI and why?

Isotonic fluids Intracranial haemorrhage cannot cause haemorrhagic shock

Best prognostic indicator in patients with variable response to stimulation

Best motor response

Focussed neurological examination in primary survey

Level of consciousness Pupil size and response Lateralising signs to each limb Signs of spinal cord injury when pt alert

Secondary survey neuro exam

Complete neurological examination

Reversal of antiplatelets (eg Aspirin, clopidogrel)

Platelets Consider Deamino-Delta-D-Arginine Vasopressin (Desmopressin acetate)

Reversal of warfarin

FFP Vitamin K

Reversal of unfractionated heparin

Protamine sulfate Monitor APTT

Reversal of low molecular weight heparin

Protamine sulfate

Reversal of direct thrombin inhibitors (Dabigatran)

Idarucizumab (Praxbind) May benefit from prothrombin complex concentrate

Reversal of rivaroxaban

No reversal agent May benefit from prothrombin complex concentrate

Use of mannitol

Reduces raised intracranial pressure in euvolaemic patients with raised ICP

Contraindication to mannitol

Systemic hypotension SBP < 90

Dose of mannitol

0.25 - 1 g/kg Use as bolus

Monitoring with mannitol use

ICP monitor (unless evidence of herniation) Maintain serum osmolality <320 Maintain euvolaemia

Mechanism of action of mannitol

Acts as osmotic diuretic

Use of hypertonic saline

Reduces raised ICP in euvolaemic patients

Concentration of hypertonic saline used

3% to 23.4%

When is hypertonic saline preferred to mannitol

With systemic hypotension Both provide equivocal effects to reduce ICP in euvolaemic patients

When to use anticonvulsants in TBI

Only when absolutely necessary to cease seizure activity Anticonvulsants can inhibit brain recovery

Which anticonvulsants are used in TBI and when

Phenytoin and Fosphenytoin in acute phase Benzodiazepines added if necessary until seizure stops

Management of intracranial mass lesions

Neurosurgery Rapidly expanding life threatening haematomas may warrant emergency craniotomy

Management of penetrating brain injury

CT head +/- angiography Prophylactic abx Leave partially exteriorised objects in place until definitive neurosurgical management

Determination of death by neurological criteria (Brain death)

1) GCS 3 2) Non reactive pupils 3) Absent brainstem reflexes 4) No spontaneous ventilatory effort on formal apnoea testing 5) No confounding factors eg EtOH, drugs, hypothermia

Brainstem reflexes

Oculocephalic (Doll's eyes) Corneal Gag reflex

Head trauma Flashcards

(58 cards)