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Trauma Flashcards

(85 cards)

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1
Q

What is a penetrating (missile) injury

A

When an object travels through the head to cause injury

Can be at high or low velocity

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2
Q

What are the effects of a penetrating (missile) injury

A

Focal damage - affects region the object strikes
Lacerations in the brain
Haemorrhage

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3
Q

What is cavitation

A

Where a high velocity object causes low pressure

Leads to short term cavity forming which then collapses causing damage

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4
Q

Describe high vs low velocity penetrating head injury’s

A

The speed an missile is travelling when it hits the head often determines the extent of the damage
Fast moving projectiles often cause more damage
Important in gun shot wounds

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5
Q

What is a non-missile (blunt) injury

A

When there is a sudden acceleration/deceleration of the head
Brain moves within the cranial cavity and makes contact with the inside of the skull

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6
Q

What are the common causes of blunt/ non-missile injury

A

RTAs
Falls
Assault
Alcohol

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7
Q

What is the primary head injury

A

The injury that occurs on impact/trauma
Includes the injury to the neurons
Irreversible - brain tissue has limited repair capacity

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8
Q

What is the secondary brain injury

A

Haemorrhage, oedema, infection, hypoxia etc
Occurs as a result of the primary one
Usually leads to a lack of oxygenation of the brain
Potentially treatable

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9
Q

What are the main effects of scalp lesions

A

Bruising
Can cause extensive bleeding
Route of infection

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10
Q

What are the types of skull fracture

A

Linear - straight fracture line that may cross sutures
Compound - open fracture with scalp laceration
Depressed - bones displace inwards (often also compound)

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11
Q

Why should base of skull fractures be considered open fractures

A

Because they usually create an opening into the paranasal sinuses which gives a route for infection

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12
Q

What is the difference between coup and contra-coup injury

A

Coup injury occurs at the point of impact – brain will impact the skull at the point the head has been struck
Contra-coup occurs at the opposite point oof the skull

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13
Q

What tends to be the worse injury - coup or contra-coup

A

Contra-coup
Could either be due to movement of CSF which gives it higher impact
OR
Cavitation - bubbles of low pressure damage the tissue

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14
Q

What is diffuse axonal injury

A

Widespread disruption of axons due to tearing force
Mainly affects central structures
Occurs at the moment of injury
Can lead to a vegetative state, coma and reduced consciousness

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15
Q

What causes diffuse axonal injury

A

Blunt force trauma to the head

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16
Q

What causes cytotoxic oedema

A

Intoxication

Severe hypothermia

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17
Q

What causes ionic oedema

A

Hyponatremia

Excessive water intake - SIADH

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18
Q

What causes vasogenic oedema

A

Trauma, tumours, inflammation, infection

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19
Q

What is more common, intradural or extradural haemorrhage

A

Intradural

Includes subdural and subarachnoids

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20
Q

What causes a traumatic extradural haematoma

A

Occurs when middle meningeal artery is damaged usually after fracture of squamous part of temporal bone
Minimal immediate damage but if untreated can cause midline shift, compression and herniation

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21
Q

What causes a subdural haemorrhage

A

Disruption of the bridging veins that extend into the subdural space
Occurs after trauma
Common in the elderly

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22
Q

What happens in an acute subdural haematoma

A

Clear trauma history
Brain swells and the haematoma has a mass effect
Can cause shifts and herniations

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23
Q

What happens in a chronic subdural haematoma

A

Very subtle presentation
Often present to GP or very late to hospital
older haemorrhage so will have a yellow appearance
Associated with brain atrophy

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24
Q

What is the definition of a traumatic brain injury

A

A non-degenerative, non-congenital insult to the brain from an external mechanical force, possibly leading to temporary or permanent impairment of cognitive, physical and psychosocial functions

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25
Head injury is the commonest cause of death and disability in people age 1-40 in UK - true or false
TRUE
26
Who is at high risk of traumatic brain injuries
Young men and the elderly Those with previous head injuries Alcohol and drug abuse Low income
27
What situations have high risk of traumatic brain injury
``` Alcohol - cause of almost half Assault Falls RTCs Sports ```
28
When do the majority of deaths from traumatic brain injury occur
Within the first hour | After that there is a second peak as the secondary complications start
29
How do you immediately manage a TBI
ABC - intubate to secure airway and use C-spine control GCS and pupil check Secondary survey for other injuries
30
What might be relevant in the drug history for a TBI
Anticoagulants
31
What are the 3 sections of the GCS
Eye opening - out of 4 Verbal - out of 5 Motor - most significant and out of 6 Minimum score is 3, max is 15
32
The lower the GCS the better the outcome - true or false
FALSE! | Lower the GCS the worse the outcome
33
Who needs a CT scan
``` GCS<13 on initial assessment in the ED GCS <15 at 2 hours after injury Suspected open or depressed skull fracture Any sign of basal skull fracture Post traumatic seizure Focal Neurological Deficit More than one episode of vomiting Suspicion of NAI Over 65 Coagulopathy ```
34
What are the signs of a base of skull fracture
``` Racoon eyes - bruising around orbit Battle's sign - bruise behind ears Blood or CSF leaking from ears or nose Haemotympanum Bump ```
35
How does an extradural haematoma present on CT
Occurs outside the dura and pushes inward - pressure | Gives a bi-convex/lens shape
36
How does a extradural haematoma present clinically
Usually due to an injury and they have loss of consciousness Recovery with a lucid interval They will then have a rapid deterioration - lowering GCS, possible hemiparesis, unilateral fixed and dilated pupil Will then go into apnoea and death
37
What is an intracerebral haematoma
Blood clot within the brain itself
38
What is the goal of treatment after a head injury
Cant undo the primary insult so focus is on preventing the secondary issues Avoid hypoxia – give oxygen Mass lesions – can these be removed so that ICP is reduced To get a good cerebral perfusion pressure you need to keep MAP up and ICP down
39
What is the monro-kellie principle
Skull is a closed box, and increased pressure means one component of the contents gets pushed out CSF will get pushed out into spine first Once this is exhausted, the brain and blood vessels get pressed on
40
Which type of herniation can be life threatening
Central | Brain gets pushed out of the foramen magnum which compresses the brain stem
41
Why do you sedate someone with a brain injury
It reduces the metabolic demand on the brain
42
Why should you intubate someone with a brain injury
You need to avoid hypoxia as this will cause further brain injury
43
How can you monitor ICP
Can place a wire inside the head to give a pressure reading | It sits in the ventricles to give accurate reading
44
How can you manage raised ICP medically
Sedation - benzos etc Maximise venous drainage - head of bed tilt, cervical collars etc Osmotic diuretics - mannitol CSF release - can put in drains
45
What position should you put the head in to reduce ICP
30’ position | Adjust the head of the bed to achieve this
46
What is a decompressive craniotomy
Surgical procedure to remove part of the skull to reduce pressure Risky operation – high infection risk Need to put an artificial plate in – cosmetic procedure
47
Should you give prophylactic anti-epileptics to those with head injury
Can cause secondary insult but little evidence that prophylaxis helps
48
Describe the process of excitotoxicity
Occurs after injury Excitatory amino acids (Glutamate) released Activates NMDA receptors Calcium mediated activation of proteases and lipases Further cell death
49
What is needed to confirm a brainstem death
``` No pupil response No Corneal reflex No Gag reflex No Vestibulo-ocular reflex No motor response No respiration No severe metabolic or endocrine disturbance No hypothermia No drugs ``` 2 doctors must carry out all test Basically a lack of all brain stem function/reflexes
50
How do you test vestibulo-ocular reflex
Inject ice cold water into ear and look for eye response | Would normally induce nystagmus
51
How do you confirm lack of respiration
Pre-oxygenate and then turn off the respirator – look for the CO2 to rise to at least 6Kpa If there is no attempt at spontaneous respiration then they are brain stem dead
52
What is a subarachnoid haemorrhage
When there is bleeding into the subarachnoid space - into the CSF Can be fatal
53
What usually causes a subarachnoid haemorrhage
Usually a berry aneurysm rupturing Sometimes AVM Sometimes its spontaneous Rarely trauma
54
How does a SAH present
``` Sudden onset severe headache - explosive/thunder-clap, worst they've ever had Collapse Vomiting Neck pain Photophobia May have a reduce consciousness ```
55
What are the differentials for a sudden onset headache
SAH Migraine - usually people know what this is but could be their first presentation Benign coital cephalgia - severe sudden headache after exertion (often during sex)
56
What is the gold standard test for a SAH
CT scan of the brain | May be negative in some though- follow up LP in case
57
When is it safe to do an LP
Safe in alert patient with no focal neurological deficit and no papilloedema, or after normal CT scan
58
What should you do if someone with a suspected subarachnoid haemorrhage has a normal CT
Lumbar puncture | Look for bloodstained or xanthochromatic (yellow) CSF
59
What is the gold standard for looking for brain vessel abnormalities
Cerebral angiography | Travel up via femoral artery
60
What are the potential complications of a SAH
Can be immediately fatal or lead to brain damage Can re-bleed - often the cause of death as missed Delayed ischaemic deficit Hydrocephalus Hyponatraemia Seizures
61
How can you prevent re bleeding after a SAH
Endovascular techniques - can place coils into the aneurysm so that blood cannot feel Surgical clipping - place metal clip across aneurysm to occlude it
62
How can you treat the delayed ischaemia associated with SAH
Nimodipine - CCB | High fluid intake
63
How can you treat the hydrocephalus associated with SAH
CSF drainage | Can be done LP or EVD (shunt into brain)
64
How does SAH cause hydrocephalus
Blood can clog the CSF pathways – either block its reabsorption in the sinuses or block its movement through the ventricles This increased the pressure in the brain Causes headache or altered consciousness
65
How do you treat hyponatremia caused by SAH
Supplement the sodium intake Fludrocortisone DO NOT fluid restrict as this can lead to cerebral ischaemia which is worse
66
SAH lowers your seizure threshold - true or false
TRUE | 10% 5 year risk
67
What commonly causes a intracerebral haemorrhage
Hypertension - 50% of cases | Aneurysm or AVM
68
How does an intracranial haemorrhage present
Headache Focal neurological deficit - feature dependant on location of bleed Decreased consciousness level
69
How do you investigate an intracerebral haemorrhage
CT - urgent if decreased consciousness | Angiography if there is a suspected vascular anomaly
70
How do you treat and intracerebral haemorrhage
Surgical evacuation of the haematoma | Treatment of underlying anomaly if needed
71
What areas have a poor prognosis for intracerebral haemorrhage
Large basal ganglia or thalamic clots | Can lead to major focal deficits or deep coma
72
What causes an intraventricular haemorrhage
Occurs after rupture of a subarachnoid haemorrhage or if there is an intracerebral bleed into a ventricle
73
How can you treat AVM
Surgery Endovascular embolization Stereotactic radiotherapy Conservative - have to weigh up risk/benefit
74
How do you open someones airway if they have a head/neck injury/trauma
You should only do a jaw thrust to open the airway in order to keep C-spine still Head tilt chin lift cause too much movement
75
What is the main contraindication to using a Guedel airway (oropharygeal)
Conscious patient as it will make them gag | Otherwise pretty safe to use
76
What is the main contraindication to using a nasopharygeal airway
Base of skull fracture | The tube can pass through the fracture into the brain
77
When can you use a full anaesthetic airway
Only if patient is unconscious under GA or in cardiac arrest
78
What is the definition of unconscious
Not awake and aware of/responding to environment
79
What is the definition of coma
A state of unarousable unconsciousness | GCS of 8 or less is a definition of coma
80
At which GCS should you consider intubation
8 or less | This suggests a loss of protective airway reflexes
81
What is the usual cause of a subdural haematoma
Tearing of the bridging veins under the dura | Usually due to trauma
82
What is the normal cerebral perfusion pressure
around 70-100
83
Why is raised ICP an issue
No where for it to go | The heart has to overcome this pressure in order to perfuse the brain (nutrients, oxygen etc.) - maintain CPP
84
What is the Cushing's reflex
High BP and low HR in context of brain injury BP rises to try and overcome the raised ICP and perfuse the brain Heart rate is lowered - reflex bradycardia triggered by baroreceptors in the neck
85
How do you calculate CPP
CPP = MAP-ICP

Neurology (18 decks)

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