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Flashcards in Head Trauma Deck (19):

What types of brain injury are there?

1) Primary brain injury
- Focal pathology
- Lesions of the scalp, skull and dura, lacerations
- Surface contusions: coup, contrecoup
- Intracranial haematoma: extradural, intradural (SAH, subdural, intracerebral)

- Diffuse axonal injury (DAI) associated with acceleration-deceleration injuries

- Secondary brain injury
- Raised ICP
- Hypoglycaemia and hyperglycaemia
- Seizures
- Hypoxic damage
- Hypotension
- Hypoxia and hypercarbia
- Anaemia
- Cerebral oedema


Give some examples of symptoms associated with head trauma.

Physical symptoms
- Headache
- Vomiting* (continuing vomiting)
- Drowsiness/fatigue* (difficulty waking)
- Bleeding/discharge from ear or nose*
- Fits/seizures/twitching/convulsions*
- Blurred/double vision*
- Poor coordination/clumsiness/weakness*
- Difficulty swallowing, coughing when eating or drinking*
- Noise sensitivity

Behavioural and emotional symptoms
- Irritable/frustrated/mood swings
- Anxiety/fear
- Changed sleep patterns

Cognitive or communication symptoms
- Cognitive fatigue: difficulty concentrating, slower
- Memory problems/confusion/loss of orientation*
- Slurred speech*


Aside from the GCS, what can you use to assess conscious state of a patient?

- A Alert
- V Responds to voice
- P Responds to pain - use firm supraorbital pressure/jaw thrust as stimulus
- Purposefully
- Non-purposefully    
□ Withdrawal/flexor response
□ Extensor response
- U Unresponsive

+ Assess pupil size, equality and reactivity 


Secondary survey: what might you look for in the eyes?

○ Pupil size
○ Equality
○ Reactivity
○ Fundoscopy for retinal haemorrhage (may indicate non-accidental injury)
○ Dilated non-reactive pupil


What are some signs of a base of skull fracture?

- Raccoon eyes
- Battle's sign: bruising behind ear
- Blood behind ear drum
- CSF leak - ears, nose


What does a dilated non-reactive pupil indicate?

3rd nerve palsy from ipsilateral intracranial haematoma until proven otherwise


What are definite indications for a CT brain and C-spine in head trauma?

• Any sign of basal skull fracture on secondary survey
• Focal neurological deficit
• Suspicion of open or depressed skull fracture
• Unresponsive or only responding non-purposefully to pain
• GCS persistently < 8
• Respiratory irregularity/loss of protective laryngeal reflexes


What are relative indications for a CT brain and C-spine in head trauma?

•  Loss of consciousness lasting more than 5 minutes (witnessed)
• Amnesia (antegrade or retrograde) lasting more than 5 minutes
• Persistent vomiting
• Clinical suspicion of non-accidental injury
• Post-traumatic seizures (except a brief ( <2 min) convulsion occurring at time of the impact)
• GCS persistently less than 14, or for a baby under 1 year GCS (paediatric) persistently less than 15
• If under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head
• Dangerous mechanism of injury
• high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant,
• fall from a height.

• Known bleeding tendency


Other than imaging, what are some investigations that are always done for head trauma?

- VBG and blood sugar level (especially in small children and in adolescents who have been drinking alcohol)
- ECG (query arrhythmia as cause of fall)


Minor head injury:
- Conscious state
- Other features

• AVPU ~ GCS 13-15
• No LOC, stable and alert conscious state

• Up to one episode of vomiting
• May have scalp bruising or laceration


Moderate head injury:
- Conscious state
- Other features

• AVPU ~ GCS 9-12
• Brief LOC at time of injury
• Currently alert or responds to voice
• May be drowsy

• Two or more episodes of vomiting
• Persistent headache
• Up to one single brief ( <2min) convulsion occurring immediately after the impact
• May have a large scalp bruise, haematoma or laceration
• Visual disturbance


Severe head injury:
- Conscious state
- Other features

• AVPU ~ GCS 3-8
• Decreased conscious state – responsive to pain only or unresponsive

• Localising neurological signs (unequal pupils, lateralising motor weakness)
• has a second seizure, convulsion or fit, other than a single brief one when the injury happened
• Signs of increased intracranial pressure
• Penetrating head injury
• CSF leak from nose or ears


What are some signs of increased ICP?

- Uncal herniation: Ipsilateral dilated non-reactive pupil due to compression of the oculomotor nerve

- Central herniation: Brainstem compression causing bradycardia, hypertension and widened pulse pressure (Cushing's triad)

- Irregular respirations (Cheynes-Stokes)

- Decorticate: arms flexed, hands clenched into fists, legs extended, feet turned inward
- Decerebrate: head arched back, arms extended by the sides, legs extended, feet turned inward


When do you intubate a trauma patient?

○ Child unresponsive or not responding purposefully to pain
○ GCS persistently <8
○ Loss of protective laryngeal reflexes
○ Respiratory irregularity


What kind of feeding tube should you give a head trauma patient?

OGT (NGT to avoid in case it is a base of skull fracture!)


What must you anticipate during intubation?

Hypoxia (max pre-oxygenation) and hypotension (don't give sympatholytics)


How do you manage a minor head injury?

- Adequate analgesia, can be discharged from ED


How do you manage a moderate head injury?

- Observe for up to 4h with 30mins neuro obs - D/C if back to normal conscious state and no further vomiting
- Adequate analgesia
- Can consider anti-emetics, but longer period of obs needed


How do you manage a severe head injury?

- Urgent CT brain and c-spine - maintain c-spine immobilisation even if imaging normal
- Urgent neurosurgical opinion

- Sufficient analgesia (more sensitive to opioids)
- Nurse 20-30 degrees head up (after correction of shock) and head in midline position to help venous drainage.

- Maintain Normothermia
- Avoid hypo/hyperglycaemia
- Avoid hyponatraemia(?Hypertonic saline)
- Control seizure

- Ventilate to a pCO2 35mmHg 4-4.5 kPa (consider arterial catheter).
- Ensure adequate blood pressure with crystalloid infusion or inotropes (e.g. noradrenaline) if necessary.
- Consider mannitol (0.5-1 g/kg over 20-30 min i.v.) or hypertonic saline (NaCl 3% 3 ml/kg over 10-20 min i.v.).
- Consider phenytoin loading dose (20 mg/kg over 20 min i.v.)