L4

Question 1

Scalp injury

Answer 1

• Hematomas below the over covering of the skull is usually reabsorbed and does not require any treatment
• Laceration撕裂 should be clean and remove foreign substances before sutured縫合 to reduce risk of infection

Question 2

Battle’s signs

Answer 2

1) Postauricular ecchymosis
(Post: behind; Auricular: pinna; Ecchymosis: bruise)
2) Periorbital ecchymosis
(Peri: surround; Orbital: eye)
3) Rhinorrhea: CSF leak from the nose
4) Otorrhea: CSF leak from the ear

Question 3

Meningitis 腦膜炎

Answer 3

• higher risk if have CSF leakage
• antibiotics as a preventive measure

Question 4

Testing for clear CSF leaking fluid

Answer 4

Destrostix (glucose testing strip),
CSF give a positive reading for glucose

Question 5

Test for blood stained CSF leaking fluid

Answer 5

Drip the CSF onto a white gauze pad,
CSF will give a halo sign
*Halo sign: blood coalesces眾合 into the centre, with yellow fluid encircles the blood, within a few minutes

Question 6

Contractions with basilar skull fracture

Answer 6

NG tube insertion

Question 7

Pathophysiology of traumatic brain injury

Answer 7

1) Brain bleeding or swelling after the injury, increasing the intracranial pressure (ICP)
(Rigid cranium顱骨 allows no room of expansion)
2) Increased ICP compress the cerebral blood vessels —> decrease cerebral blood flow
3) Cerebral hypoxia and ischemia occur
4) Herniation may occur
5) Cerebral blood flow ceases停止

Question 8

Diffuse brain injuries

Answer 8

Generalised, e.g. concussion腦震盪

Question 9

Focal brain injuries

Answer 9

Localised

Question 10

Classification of severity of brain injuries

Answer 10

• Minor: GCS 13-15
• Moderate: GCS 9-12
• Severe: GCS 3-8

Question 11

Nursing care for increased ICP

Answer 11

1) Monitor vital signs, report cushing’s traid
2) Monitor neurological and respiratory status
3) Elevate bed head to 30 degree or above
—> promote cerebral venous output to decrease ICP
4) Limit suction passes within 10s
5) Give sedation and decrease stimulito reduce agitation and hyperactivity
6) Maintain normothermia to prevent increased ICP caused by cerebral metabolism

Question 12

Factors affecting cerebral blood flow

Answer 12

1) Increased PaCO2:
relax smooth muscles—>dilate cerebral vessels—>reduce cerebrovascular resistance—>increase CBF
2) constrict cerebral vessels—>increase cerebrovascular resistance—>decrease CBF

Question 13

Osmotherapy: Mannitol

Answer 13

A potent diuretic
Draw fluid from intracellular and interstitial spaces to the vascular compartment
—> hemodilution —> reduce blood viscosity —>increase cerebral blood flow and O2 delivery

Question 14

Sedation

Answer 14

Xxx for mild head injury
For severe head injury, sedation reduce agitation, discomfort and pain —> reduce ICP

Question 15

Anti-seizure drugs

Answer 15

Use prophylactically預防性;
Manage seizure activity to prevent elevation of cerebral metabolic rate and CBF, and hypoxia

Question 16

Complications of head injury

Answer 16

• Cerebral edema: 48-72 hours after the injury
• Intracranial bleeding or hematoma
  —> Increased ICP and herniation of the brain stem
  —> May lead to irreversible brain anoxia缺氧 and brain death

Question 17

Ventriculostomy

Answer 17

Insert ventricular catheter to control ICP by draining out CSF

Question 18

Clinical manifestations of brain tumour

Answer 18

• dull and constant headache, worsen at night
• nausea and vomiting
• cognitive dysfunction, muscle weakness, sensory loss, etc

Question 19

Treatments for brain tumor

Answer 19

• Surgery: craniotomy
• Radiation: 5 days a week for 6 weeks
• Chemotherapy: build a Ommaya reservoir between the scalp and the skull to get drugs across the blood-brain barrier

Question 20

Purpose for lumber puncture

Answer 20

• Diagnosis of subarachnoid haemorrhage
• Measuring of CSF pressure
• Injection of medication
• Removal of CSF; or collection of CSF for biochemical, microbiological and cytological細胞學 analysis
• radiological visualisation by injecting dye

Question 21

Contradictions of lumber puncture

Answer 21

• Patient with high ICP and intracranial tumour
• Patient receiving anticoagulant or antiplatelet

Question 22

Procedure of lumber puncture

Answer 22

• Obtain signed, informed consent
• Instruct the patient to void before procedure
• Check coagulation profile
• Position the patient lying laterally with back facing the physician, knee flexed closest to the head
• Inject local anesthetic between L3 and L4
• Neddle interned to subarachnoid space between 3-4 or 4-5 lumber interface

Question 23

After care for lumber puncture

Answer 23

• Cover the wound with gauze and tensoplast to prevent leakage of CSF
• Monitor vital signs and conscious level to observe for brain herniation
• Observe and record the opening pressure and colour of CSF
• Dispatch the labelled CSF