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Lecture 5: CNS Trauma Flashcards

1
Q

What is a TBI?

A

Traumatic brain injury, which is an alteration in brain function.

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2
Q

What is a primary brain injury?

A

The insult that caused the TBI.

  • Explosion
  • MVC
  • Penetrating head trauma
  • etc
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3
Q

What is a secondary brain injury?

A

The cascade of molecular injury mechanisms initiated at time of trauma and continues. (Neuronal cell death)

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4
Q

What conditions do we need to avoid for TBI patients?

A
  • Hypotension
  • Hypoxia
  • Hyperglycemia
  • ICP
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5
Q

What is CPP?

A

Cerebral perfusion pressure = MAP - ICP

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6
Q

What breathing pattern results in decreased ICP?

A

Tachypnea/alkalosis (inducing hypocapnia)

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7
Q

What is goal MAP in TBI?

A

> = 80 in order to keep CPP high.

CPP = MAP - ICP

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8
Q

What physical exam triad helps us determine ICP?

A

Cushing reflex:

  1. HTN
  2. Bradycardia
  3. Decreased respiratory drive

HIB
HTN
Irregular breathing
Bradycardia

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9
Q

What happens to ICP in TBIs?

A

Increases, so we need to increase MAP to counteract it.

CPP = MAP - ICP

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10
Q

For a patient with increased ICP, what can we do to help lower it?

A
  • Elevate patient head
  • Glucose between 80-180
  • Prevent any fever (96.8-100.4)
  • Keep O2 > 90%
  • IV Lorazepam to treat seizures
  • IV phenytoin to prevent seizures (esp. for GCS < 10)
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11
Q

What is the trimodal age group for TBI?

A
  1. 0-4
  2. 15-24
  3. > 75
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12
Q

What is the ABCDE for trauma?

A
  • Airway (C-spine and maintain airway)
  • Breathing (ventilation)
  • Circulation (pulses)
  • Disability (GCS, neuro)
  • Exposure (undress pt and check injuries)

A patient that can communicate clearly is already cleared A-D

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13
Q

What are the 3 severity ratings for GCS?

A
  1. Mild = 13-15
  2. Mod = 9-12
  3. Severe = 8 or less

If it’s 8, then you intubate (mnemonic)

Most TBIs are mild (75%)

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14
Q

What is the inclusion criteria for Head CTs?

A
  • Age 16-66
  • Not on blood thinners (except baby asa)
  • No seizure after injury
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15
Q

What are the 4 high risk criteria that prompt a Head CT for head trauma?

A
  1. GCS < 15 2 hours post injury
  2. Suspected/confirmed skull fracture
  3. Signs of basilar skull fracture
  4. > = 2 eps of vomiting (brainstem injury)
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16
Q

What are the 2 medium-risk criteria that prompt a Head CT for head trauma?

A
  1. Retrograde amnesia >= 30 mins prior to TBI
  2. Dangerous mechanism (hit by car as a pedestrian, ejected from car, fell from >3 ft or 5 stairs)
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17
Q

What criteria is used for determing Head CT criteria for children < 16?

A

PECARN

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18
Q

How does a concussion typically present in terms of S/S?

A
  • Loss of memory prior to event
  • Confusion
  • HA, N/V, dizziness
  • Visual changes
  • LOC (rare)
  • AMS

Any neurological symptom can techincally occur

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19
Q

What is the physical description of what happens in a concussion injury?

A

Coup contrecoup injury

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20
Q

What are the more alarming S/S in a concussion?

A
  • Focal neurologic deficit
  • Visual field deficit
  • Pupil abnormality
  • Horner syndrome

Stroke can be caused by traumatic hemorrhage

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21
Q

What is CTE and what makes it more likely?

A

Chronic traumatic encephalopathy: 3+ concussions (football)

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22
Q

How long does it typically take to recover from concussion?

A

Around 6 days

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23
Q

What is the treatment for a linear skull fracture?

A

Generally just obs

Little to no clinical significance

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24
Q

What is the treatment for a depressed skull fracture?

A
  • Usually open, so give tetanus + ABX (vanco + rocephin)
  • If it is greater than the skull’s thickness, surgery
  • Consult neurosurg
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25
What bone is most commonly affected in a basilar skull fracture?
Temporal bone trauma
26
What are the hallmark signs of a basilar skull fracture?
* Halo sign (CSF + blood) * Raccoon eyes * Battle sign (under the ear)
27
What is the treatment for an elevated skull fracture?
IV ABX + surgery
28
What is the ABX for all open fractures in general outside of da hospital?
2g ancef/cefazolin
29
If we suspect a skull fracture, what additional scans should we order?
* Noncon CT brain and Cspine * Con CT chest + abd + pelvis
30
What should you never place in a patient with a basilar skull fracture?
Nasal airway, as the cribiform plate could be fractured.
31
What is the MC type of traumatic intracranial mass lesion?
Subdural hematoma | Usually due to vein tearing
32
What are the 3 classifications for SDH?
1. Acute <= 2 days 2. Subacute <= 3-21 days 3. Chronic > 21 days | Darker on CT = older
33
What gender is SDH MC in?
Males
34
If a patient has a new type of HA, what imaging should be considered ASAP?
CT head w/o con
35
What is the criteria for surgical intervention of acute SDH?
* Symptomatic * Bleed thicker than 10mm * Midline shift > 5mm * GCS decrease >= 2 * Fixed or dilated pupils | Craniotomy
36
When is surgery indicated for chronic SDH?
* Risk of herniation * > 10mm thickness or 5mm midline shift * Anyone that has the potential to recover | Burr holes to relieve
37
38
What are the 4 types of brain herniation?
1. Trans calvarial (going laterally) 2. Transtentorial (towards center?) 3. Tonsillar (downard) 4. Subfalcine (upward/towards face?)
39
What is the MC type of brain herniation?
Uncal transtentorial herniation
40
What is the common presentation of brain herniation?
Ipsilateral fixed pupil
41
What is the primary cause of a epidural hematoma?
Middle meningeal artery rupture
42
What does an epidural hematoma look like on CT?
Lens shaped
43
What is the mnemonic for epidural hematoma S/S?
* Epidural hematoma * Luc E (lucid interval) * Looks like an Eye on CT * Middle meningEEEal artery
44
What is the treatment for epidural hematomas?
* Surgical evacuation * Monitoring with serial CT scans
45
What is the classic symptom of SAH?
Thunderclap headache/worst HA of their life
46
What are the S/S of a SAH?
* N/V * Nuchal rigidity * Back pain * BL leg pain * Seizures * Sudden LOC at onset
47
What is the first step in working up a SAH?
CT w/o con
48
When would we do an LP for SAH and what would we see?
* Neg CT * Increased opening pressure * Increased RBC count in all tubes * Xanthochromic (yellow) CSF
49
What is the gold standard imaging for a SAH?
CTA of Brain
50
What meds do we use to reduce MAP < 130 in SAH?
* Esmolol * Labetalol | Short half-lives
51
For a patient with increased ICP and SAH, what interventions do we do?
* Intubate and hyperventilate to REDUCE PCO2 to 30-35. * Consider mannitol to reduce ICP * Lasix to reduce IVP * Surgical clipping/coiling of aneurysm * Neuro ICU
52
What is the can't miss condition in spinal cord injuries?
Cauda Equina syndrome
53
What is the most commonly injured area of the spine?
Cervical
54
What is NEXUS criteria used for?
Determination of whether a C-spine injury requires imaging
55
What is the NEXUS criteria?
* Midline posterior **S**pinal tenderness present * **P**ainful distracting injury present * **I**ntoxication present * focal **N**eurological Deficits present * **E**ncephalopathy (or ALOC) present | All must be negative to clear a patient without imaging. ## Footnote SPINE
56
What exam should we not neglect in testing the spinal cord's motor function?
DRE to test sphincter tone
57
For significant trauma, what CTs do we order?
* Brain * C-spine * Chest w/ con * Abd/Pelvis w/ con | Con for organs ## Footnote Can add thoracic and lumbar if needed. Cranium to coccyx
58
How do we treat a C1/atlas fx?
Rigid-C collar | Often associated with a C2 facture and without deficits
59
How do you treat torticollis/C1 rotary subluxation?
* Pain control * Restrict motion with SOFT collar * Refer ## Footnote Soft collar because we don't want to forcefully correct it.
60
What are the two types of a C2 facture?
* Odontoid fx * Posterior element/hangman's
61
What is the most common cervical fx in adults?
C5
62
What is the most stable part of a vertebrae?
Anterior
63
How do thoracic fx typically occur?
* Anterior wedge/compression: Axial loading with flexion * Burst/chance/fracture = dislocation
64
How do you manage anterior wedge/compression of the thoracic spine?
TLSO brace and pain meds
65
What is the treatment for a spinal cord injury?
* Restrict via rigid c-collar * No backboard * IV fluids * Pain meds * Transfer
66
What S/S might suggest cauda equina syndrome?
* Saddle anesthesia * Urinary retention * Difficulty walking * LBP * Poor rectal tone * Change in bowel or bladder in anyway
67
What scan should we order for cauda equina syndrome?
MRI

Neuro (17 decks)

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