Head Trauma Flashcards
Define head trauma v. TBI
how is head trauma initially assessed
Head Trauma = a range of conditions from simple/superfiscial injuruies to severe TBI like subdural hematomas
TBI: tramatic brain injury; a physiologic disruptuion to the brain and its function as a resul of a mechanial force (“blow to brain”)
Initial Assessment = Glasgow Coma Scale (GCS)
GCS: 3-8 = severeTBI
GCS: 9-13 = moderate TBI
GCS 14-15 = mild TBI
normal GCS = 15
physiologica relationship between CPP and a TBI
CPP calculation
how does the injury impact perfusion pressure
CPP= cerebral perfusion pressure
a TBI can significantly alter the CPP because the brain is sensitive to cahnges to O2 and in perfusion (leading to infarct)
ICP = intracranail pressure (measured through a probe)
CPP = MAP -ICP (essentially, how much blood is getting to the brain)
normal ICP 10-15 mmHg adults and 3-7 mmHg for kids
thus, a minimum CPP is 60 to achieve adequate perfusion
under normal conditions, the body autoregulates the CPP
- so in a trauma, the ICP increases, thus decreasing the CPP: because of direct compression to the vessels and tissue within the brain as a reuslt of increased pressure
- so the body to compensate then would try to increase the blood pressure to try to get blood to the brain
if you cannot adequately measure ICp, ensure the MAP remiains > 80
Overview & Management of TBI
- address the primary injury; idenfity and treat the mass injury or other life-threatening injuries
- prevent any secondary injuries (edema, sweeling, increase ICP) though the following…
- correct hypoxia, hyperglycemia, hypotension, anemia, & evacuate any intracranial masses
- manage the airway: intubation often in the TBI
- aggressive fluid management to prevent hypotension and hypoperfusion
TBI ABCDE’s to watch
A: airway
- consider intubation
- if GCS < 8 = probably intubate
- RSI: rapid sequece with paralytic meds is often done to control the C-spine
Breathing: assess oxygenation and address breathing concerns
C: Circulation
- fluid resuscitation is indicated: keep that MAP at the right level!!
- use fluids or pressors to maintain BP; hypotension can lead to increase mortality/morbidity
D:Disability
- pupils: exam to indicate hematoma, trauma, drug, nerve injury
- GCS Scale!!!: correlated with outcomes (post-resuscitation score)
E: Expsoure
- posturing: to indicate how severe the CNS injury is
- Decorticate: the limbs are pointed inwards (upper limbs flexed, lower limbs extended): midbrain or above lesion
- Decerebrate: arms and legs extended and wrists extended/rotated): lower than midbrian lesion
Diagnostic Methods to use in a TBI
CT scan of the head is the test of choice
- sensitive to blood on film
CT Indications
- GCS < 15 (so literally anyone!!)
- lost consciousness
- changed mental status
- vomiting, seizure, amnesia before the event
- age > 65
- coagulopathies, HA
- intoxication
decision to CT can be guided by clinical suspicion too
Tools to Use for CT or Not?
- Canadian CT head Rule
- New Orleans Criteria
MRI: MRi can detect more subtle lesions than CT but less avalible and can delay treament
Epidural Hematoma
Etiology
Presentation
Treatment
Etiology
- a blood collection above the dura below the skull
- most common: usually after blunt trauma to the temporal/ temproalparietal area (skull is thin there)
- fracture here can disrupt the middle meningeal artery and thats where the bleed comes from (fast because its an artery)
Presentation
- blunt head trauma
- loss conciousness
- leucid inteval
- rapid deterioration
Signs
- hernation and rapid deterioration can happen if not caught early enough
- AMS
- unequal pupils
- neuro deficts
- CT: football shaped
Treatment
- neurosurg. consult for evacuation
- if done quickly: full recovery possible
Subdural Hematoma
Etiology
Presentation
Signs
Subdural Hematoma
Etiology
- a hematoma that is a blood collection under the dura between the dura and arachnoid
- usually a sudden acceleration-deceleration injury
- the bridging veins in the area are sheared
Presenation
- this will be an alcoholic or an eldery pt. = atrophy of brain = more space to bleed
- slower blood collection becasue these are veins
- subtle symptoms (HA)
- to a coma and death
Signs
- the hematoma will slowly increase ICP: leading to compression of the brain tissue
- this allows blood to leak into the tissue itself causing swelling and cell death
Subdural Hematoma: Types
Acute
presentation
CT scan findings
Treatment
types classified by time from onset & active hemorrhage
Acute Subdural Hematoma
- this is immediately following the injury; life threatening
Presentation
- AMS
- HA
- focal neuro deficts
- coma
CT scan
- hyperdense (white) crescen-shaped lesions
Managment
- neurosurg. evaluation
Subdural Hematoma: Types
Subacute
presentation
CT findings
treatment
Subacute
- may or may not have symptoms for days after the injury
Presentation
- mild to severe neurological deficts
CT Findings
- isodense (similar to other tissue) lesions
- this shows the hematoma is resolving on its own &/or the tissue is dying
Treatment
- neurosurgical evaluation
- MRI
- Serial CT + observation usually
Subdural Hematoma: Type
Chronic Subdural
Presentaion
CT findings
treatment
Chronic Subdural
- +/- presentation of a head injury
- this is a bleed: that has since stopped
Presentation
- vague complaints
- AMS
- eldery and alcoholics sicne more room to blled
CT Findings
- hypodense (darker than the surrounding tissue) lesions
Treatment
- Neurosurg. eval. for observation
Cerebral Contusion
etiology
Coup & CounterCoup
Symptoms & treatment
Etiology
- Contusion = “bruise”
- a blood vessel leaks = pooling of blood into the tissue + swelling
a non-space occupying lesion of the brain matter itself
Coup = the sight of the blunt injury (commonly the front)
CounterCoup = the area directly opposite of the coup; like whiplash of the brain from getting hit, going backwards and hitting back of skull
Symptoms
- anywhere from mild
- to hemorrhage
- to death
Treatment
- surgical intervention usually not needed
Subarachnoid Hemorrhage
etiology
presentation
CT Findings
Etiology
- usually a nontraumatic bleed in the subarachnoid space between arachnoid and pia
- spontaneous: rupture of an aneurysum or AV malformation or from a subarachnoid vessel
Presentation
- HA (severe, thunderclap!)
- photophobia
- meningial signs (since CSF runs in this space)
- stupor/coma
- more likley to evolve quicker
CT Findings
- active blood bleed = hyperdense (white) in the basilar cisterns and suci/fssures of the hemispheres
- a CT scan 6-8 hours is most senstive because at initial presentation you can miss the bleed (cant see it yet!)
Treatment & Dx.
- LP is indicated in these pt.: to see for significant blood in CSF (xanthochrosma)
- early neuro evaluation to decompress/lower ICP
- high morbidity and mortality
Diffuse Axonal Injury (DAI)
Etiology
Presentation
Ct/MRI Imaging
Treatment
Etiology
- a disruption in the axonal fibers in teh white matter and brainstem of the brain
- usually shearing forces from blunt trauma can cause injury scattered throughout the brain’s white matter
- MVA, shaken baby
Presentatino
- edema, increase ICP
- can result in post-tramatic coma
- mild, moderate, serve neuro deficts
CT Findings
- CT can look normal OR
- CT can show hemorrhages along the grey-white matter interface
- typically a blurring of the grey/white matter edge seing punctate hemorrahges
DAI: MRI is often more sensitive
Treament
- decrease edema and ICP to prevent secondary injury
Concussion
Define
Symptoms
Diagnosis
Presentation
Concussion = a milde TBI (GCS 14-15) + associated symptoms following a blunt trauma
Symptoms
- loss of consciousness (doest NEED to happen though)
- memory loss
- altered mental status or personality
- foacl neurologica deficts
- dizzy, HA
Diagnosis
- made on history of the mental status at time of injury
- injure + neuro signs + no imaing signs = concussion
- do not have gross lesions or hemorrhages
lost consciousness not needed for the dx. but if they do lose consciousness, a CT is warreneted
Presentation
- neuro assessment often times will be normal
- anything like seizures, gait issues, etc. are more liekly something serious
- they will have subtle “feeling dizzy or out of it” on exam
Concussion
pathology
Define the vulnerable period
Pathology
- thought to be a metabolic insult > strucutral
- thus, the brain is super sensitve during this time and any further injury can be detrimental with bad effects
- increased metabolic damande = can worsen the concussion (metabolic = school, sports, etc.)
- since there is not obvious lesion, as its ametabolic issue CT is poor to show anything
Vulnerable Period
- time after concussion where brain i shypersensitive to changes
- minor injury can result in “second-impact syndrome”
- think about this causing seconday injury (more inflammation, edema, etc.)
Who would get a CT?
- lost consciousness
- intoxicated pt.
- those > 65
- those on anticoags.
- those who cannot be observed if d/c
- again us candian and new orleans score
Concussion
Treatment
Graded Return to Activity
ImPACT
Mild TBI (14-15) + no Imaging
- 4-6 hours of observation
- d/c with info about when to come back if worse
- rest + avoid alcohol
- graded return to activity
Graded Return to Activity
- recovery program for athetes to return to playsafely
- wait 24 hours between each step, any return of sympotms they go back to beginning
- 1. no activty until symptom free
- 2. light aerobic activity
- 3. sport training, noncontact
- 4. noncontract drill
- 5. contact drills
- 6. game play
ImPACT: a congitive test to see pre and post test scores to identify concussion
- helps determine return to play
- 20 minute test for age 10+
