Term
| Head injury has the highest mortality in people ages __ years old. |
|
Definition
|
|
Term
| #1 cause of death for those less than 45 years old? |
|
Definition
| Injury- TBI (traumatic brain injury) is the most common injury |
|
|
Term
| Glasgow coma scale assesses what 3 features? |
|
Definition
|
|
Term
| The highest possible score with the Glasgow coma scale is a __, while the lowest score is a __. The ___ the score the better. |
|
Definition
- 15
- 3
- higher the score the better |
|
|
Term
| ___% are considered mild TBI. |
|
Definition
|
|
Term
|
Definition
| MVC> falls > job accidents > assaults |
|
|
Term
| male to female ratio for TBI: |
|
Definition
|
|
Term
| 50% of TBI are in pts between ages of _ and __ years old. |
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Definition
|
|
Term
| There is a higher risk of injury in those younger than __ and those older than __. |
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Definition
|
|
Term
| __ of TBI are associated with c-spine injury. |
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Definition
|
|
Term
| 4 aspects of immediate management of head injuries: |
|
Definition
1. Airway- all should receive 100% O2 NRB, hypoxia increases mortality
2. Breathing- should palce ET if no gag reflex, GCS <8, or inability to control secretions
3. Circulation- maintain SBP>90, hypotension increases mortality
4. Cushing response- increase bp, bradycardia, and decreased respirations due to increased intracranial pressure |
|
|
Term
| __ and __ increase mortality with brain injury. |
|
Definition
|
|
Term
| When should you place an ET tube in a brain injury patient? |
|
Definition
- no gag reflex
- GCS < 8
- inability to control secretions |
|
|
Term
| In brain injury patients, their systolic blood pressure needs to be maintained above __. |
|
Definition
|
|
Term
| Cushing response is a late finding seen with severe brain injury due to __ __ __. This usually means they are __. Symptoms of this include __ blood pressure, __cardia, and __ respiratory effort. |
|
Definition
- increase intracranial pressure
- herniating
- increased blood pressure
- bradycardia
- decreased respiratory effort |
|
|
Term
| Rates of CT findings in MILD traumatic brain injuries are very __. |
|
Definition
low
CT abnormalities in 5% of TBI and GCS of 15, with 1% needing intervention
so do NOT do a CT on mild brain injuries |
|
|
Term
| __ can detect almost 100% of intracranial abnormalities (ICA) needing interventions. |
|
Definition
|
|
Term
| Studies show __% of intracranial abnormalities (ICA) are associated with skull fractures. |
|
Definition
|
|
Term
| With skull fractures, there is usually an external sign that raises suspicion (laceration or hematoma) |
|
Definition
|
|
Term
| If you suspect a skull fracture, order a __ not a __. |
|
Definition
|
|
Term
| A linear fracture with no ICA you can __ with __ __, but NOT __. |
|
Definition
- discharge with strict precautions
- NOT infants |
|
|
Term
| Skull fractures> evaluate ABCs and determine GCS. |
|
Definition
|
|
Term
| __, __ __, or __ __ need admission and neurosurgery consult. |
|
Definition
- ICA
- open fractures
- depressed fractures |
|
|
Term
| __ skull fractures are result of direct head trauma. |
|
Definition
|
|
Term
| Signs of basilar skull fractures: |
|
Definition
- Battle sign
- Periorbital ecchymosis
- CSF leak from nose/ears
- Hemotympanum |
|
|
Term
| What should you do if you suspect basilar skull fracture? |
|
Definition
- CT scan
- consult neurosurgery
- discuss use of antibiotics |
|
|
Term
| What is the battle sign and what does it suggest? |
|
Definition
- bruising behind ear
- basilar skull fracture |
|
|
Term
| Mild traumatic brain injury is what glasgow coma scale: |
|
Definition
| GCS 13-15 = mild TBI (measured 30 minutes after injury) |
|
|
Term
| almost 90% of head traumas seen in the ER are mild. |
|
Definition
|
|
Term
| Concussion can be considered a subset of __ TBI. Loss of consciousness (LOC) is or is not required for concussion? |
|
Definition
|
|
Term
| A concussion has __ onset and shows __ lived impairment of neurological function. |
|
Definition
|
|
Term
| A concussion is due to a __ disturbance not a structural injury. |
|
Definition
|
|
Term
| Westmead Post-Traumatic Amnesia Scale |
|
Definition
What is your name?
What is the name of this place?
Why are you here?
What month are we in?
What year are we in?
What city is this?
How old are you?
What is your date of birth?
What time of day is it? |
|
|
Term
MRI more sensitive, but CT shown to pick up virtually all lesions needing intervention
1% of pts with GCS 15 needs surgical intervention from findings on CT |
|
Definition
|
|
Term
| What are the two sets of rules used to determine necessity of neuroimaging: |
|
Definition
- Canadian CT Head Rule
- New Orleans Criteria (used more)
These are almost 100% sensitive |
|
|
Term
| Anyone with drug or alcohol involved with their head injury needs a __. |
|
Definition
|
|
Term
| Canadian CT Head Rule. If ANY of the following are present> CT scan. If none> no CT, if one> Ct. |
|
Definition
- GCS <15, 2 hours after injury
- Open, depressed, or basilar fracture signs
- Vomiting > 2 times
- 65 y/o or older
- Amnesia < 30 min before impact
- Dangerous mechanism
- Seizure
- Neurological deficit
- Anticoagulation use |
|
|
Term
| New Orleans Critera for neuroimaging. If ANY of the following are present get a CT. If none> no CT. If one> CT. |
|
Definition
- GCS < 15
- Headache
- Vomiting
- 60 y/o or older
- DRUG OR ALCOHOL INVOLVED
- Persistent anterograde amnesia
- Visible tramua above clavicle |
|
|
Term
Canadian Criteria more specific resulting in lower CT rates.
Again both have been validated in several well run studies
The American College of Emergency Physicians has endorsed the New Orleans Criteria for neuroimaging. |
|
Definition
|
|
Term
|
Definition
- GCS<15
- Abnormal CT
- Seizures
- Anticoag. |
|
|
Term
| Most patients with TBI and a normal CT scan can be __ with __. |
|
Definition
| - discharged with precautions |
|
|
Term
| Sequelae of Mild TBI/Concussion: |
|
Definition
- Postconcussion Syndrome
- Second Impact Syndrome |
|
|
Term
| Postconcussion syndrome symptoms include __, __, and __ __. This is usually seen in the first days and resolves within a __ __ to __. This occurs in up to __% of Mild TBI. |
|
Definition
- headache
- dizziness
- cognitive impairment
- resolves within a few weeks to months
- 50% of mild TBI |
|
|
Term
| Second Impact Syndrome is __ __ with __ __ that occurs when a second concussion occurs when the patient is still __ from the earlier concussion. This is a rare, but generally __ complication. |
|
Definition
- cerebral edema with increased intracranial pressure
- symptomatic
- fatal |
|
|
Term
| Return to play guidelines are implemented to prevent __ __ __. |
|
Definition
|
|
Term
| Athletes who have had a concussion with __ _ __ OR symptoms lasting greater than __ minutes CANNOT return to play until asymptomatic for at least __ __. |
|
Definition
- with loss of consciousness (LOC)
- greater than 15 minutes
- one week |
|
|
Term
| Athletes who have suffered repeated concussions that are associated with __ _ __ OR symptoms greater than__ minutes CANNOT play the __ of the __. |
|
Definition
- loss of consciousness
- 15 minutes
- CANNOT PLAY THE REST OF THE SEASON |
|
|
Term
| 2 resources for Guidelines for return to play: |
|
Definition
- Cantu Guidelines
- Colorado Guidelines |
|
|
Term
| Intracranial Injuries (severe TBI): |
|
Definition
- Epidural Hematoma
- Subdural Hematoma
- Subarachnoid Hemorrhage
- Diffuse Axonal Injury
- Contusion (coup/countercoup) |
|
|
Term
|
Definition
- Skull
- Dura
- Arachnoid
- Pia matter
- Brain |
|
|
Term
| Epidural hematomas are between the __ and __. This is most common in __ and __ __, very rare in those older than __. Bleeding is caused by injury to the __ __ artery with __ __ impact. |
|
Definition
- skull and dura
- adolescents and young adults
- rare in those older than 50
- middle meningeal artery
- temporal bone impact |
|
|
Term
| Temporal bone impact damaging the middle meningeal artery will result in an __ hematoma. |
|
Definition
|
|
Term
| Pts with an epidural hematoma may give hx of brief loss of consciousness followed by a __ __ and then __ __. |
|
Definition
- lucid interval
- rapid deterioration |
|
|
Term
| A lucid interval is associated with an __ hematoma. |
|
Definition
|
|
Term
| Clinical findings of an epidural hematoma: |
|
Definition
- Ipsilateral pupil dilation
- Nausea/vomiting
- Seizures
- Focal neuro deficts
- Hyperreflexia
- Positive Babinkski
- Cushing Reflex
- Decerebrate Posturing (herniation) |
|
|
Term
| Decerebrate posture is the __ response. |
|
Definition
|
|
Term
| Decorticate posture is ___. |
|
Definition
|
|
Term
| An epidural hematoma on a CT scan will show a __ shaped __ __ that does NOT cross __ __. |
|
Definition
| - lens shaped biconcave disk that does NOT cross suture lines |
|
|
Term
|
Definition
- ABCs: will need ET tube, consider lidocaine prior to tubing to prevent increase in ICP
- Immediate neurosurgical consult- craniotomy and hematoma evacuation is mainstay of tmt within 1-2 hours
- Seizure prophylaxis- fosphenytoin
- Mannitol 1g/kg IV bolus for increased ICP
- Reverse coagulopathy if necessary - frsh frozen plasma and vitamin K
KNOW THIS |
|
|
Term
| Glucocorticoid therapy is/is not indicated with tmt of epidural hematoma? |
|
Definition
is NOT
associated with increased mortality |
|
|
Term
| mainstay of tmt with epidural hematoma: |
|
Definition
| craniotomy and hematoma evacuation |
|
|
Term
| Epidural hematoma mortality in adults is 10% and 5% in children. Indications for outcome include: |
|
Definition
- Low GCS
- Pupillary abnormalities
- Older age
- Longer time b/w neuro signs and surgery
- Post-op IC pressure |
|
|
Term
| Subdural hematomas from between the __ and __ membranes. |
|
Definition
| - between the dura and arachnoid membranes |
|
|
Term
| Subdural hematomas are associated with tearing of the __ __ from the surface of the brain to the __ __, most common from __ __ trauma. |
|
Definition
- bridging veins
- dural sinuses
- acceleration deceleration |
|
|
Term
|
Definition
|
|
Term
| Are subdural or epidural hematomas more common? |
|
Definition
|
|
Term
| Epidural hematoma is __ blood, subdural hematoma is __ blood. |
|
Definition
|
|
Term
| Subdural hematomas often result due to __ __ or __ __ resulting in loss of buoyancy of the brain. This results in traction on anchoring and supporting structure. |
|
Definition
| - decreased CSF or intracranial hypotension |
|
|
Term
| What population is at increased risk for subdural hematomas? |
|
Definition
- patient with significant atrophy
- elderly
- chronic alcohol abuse |
|
|
Term
| Subdural hematoma clinical findings: |
|
Definition
- large spectrum of manifestations
- acute -coma in 50% of patients
- 12-38% with lucid interval followed by progressive neurological decline
- space occupying lesion> HA, vomiting, CN palsies, nuchal rigidity
- possible to have onset of symptoms 1-2 weeks after injury |
|
|
Term
| epidural hematomas have lucid intervals, but subdural hematomas may also. |
|
Definition
|
|
Term
| CT shows a high density crescent that extends across suture lines but is limited to dura attachments: |
|
Definition
|
|
Term
| Epidural hematomas do NOT cross suture lines, but subdural hematomas do cross suture lines |
|
Definition
|
|
Term
| Besides a CT what else would you do for a subdural hematoma? |
|
Definition
|
|
Term
| A __ __ is contraindicated with subdural hematomas. |
|
Definition
|
|
Term
| EPIDURALS AND SUBDURALS ARE SPACE OCCUPYING LESIONS, SO YOU DO NOT WANT TO DO LPS ON THESE PTS. |
|
Definition
|
|
Term
|
Definition
ABC’s
Same as EH, immediate NS consult!!!
Seizure prophylaxis
Mannitol if suspected increased ICP
Coagulopathy should be reversed (Vitamin K SC or FFP)
Steroids have shown NO benefit.
Worse prognosis than Epidural Hematoma |
|
|
Term
| does subural hematoma or epidural hematomas have a worse prognosis? |
|
Definition
| subdural hematomas- worse prognosis than epidural |
|
|
Term
Traumatic subarachnoid hemorrhage:
Diagnostic challenge..it is important to differentiate a spontaneous SAH from a traumatic SAH – “which came first the chicken or the egg?”
Trauma is the most common cause of SAH
Bleeding site often located at the Circle of Willis |
|
Definition
|
|
Term
| Subarachnoid hemorrhages are often bleeds of the __ of __. |
|
Definition
|
|
Term
| most common cause of SAH: |
|
Definition
|
|
Term
| Traumatic Subarachnoid Hemorrhage findings: |
|
Definition
- Headache
- Nausea/vomiting
- Pupil changes
- Neuro deficits
- Acute mental decline is correlated with large amount of bleeding |
|
|
Term
| Bleeding spreads diffusely in subarachnoid space with SAH> can lead to cerebral vasospasms> permanent brain damage |
|
Definition
|
|
Term
| Traumatic Subarachnoid Hemorrhage tmt: |
|
Definition
- Airway management
- Neurosurgical Consultation
- Mannitol and Seizure Prophylaxis
- Outcome directly related to amount of bleeding
- Control bp, systolic should be greater than 90 but less than 140
- Heart rate should be 50-90
- asymptomatic pts can be admitted for monitoring |
|
|
Term
| Most common complication of traumatic subarachnoid hemorrhage: |
|
Definition
| cerebral vasospasms - treat with calcium channel blocker |
|
|
Term
| ___ will decrease likelihood of death of a traumatic subarachnoid hemorrhage. |
|
Definition
|
|
Term
| Diffuse Axonal Injuries result from tremendous __ forces in high speed __, these are __ injuries. |
|
Definition
- shearing forces in high speed MVC
- deceleration injuries |
|
|
Term
| Diffuse Axonal Injury is generalized damage to the __ matter of the brain. |
|
Definition
|
|
Term
| Diffuse axonal injury pts will often present in __. |
|
Definition
|
|
Term
| Diffuse axonal injury Ct findings: |
|
Definition
- most of the time norma
- blurring of margins b/w gray and white matter, punctate hemorrhages
Also do CBC, CMP, Coag studies
Urine tox for pts in coma |
|
|
Term
| With diffuse axonal injury pts in a coma do a __ __ |
|
Definition
|
|
Term
| Diffuse Axonal injury management: |
|
Definition
- airway management
- immediate ns consult
- needs ICP monitoring
- mannitol
- seizure prophylaxis
- prognosis hard to determine
- stable patients can get MRI to help guide prognosis |
|
|
Term
| stable diffuse axonal injury pts you can get an __. |
|
Definition
|
|
Term
| Cerebral contusions are regions of neuronal and vascular injury followed direct acc/dec. injuries. __ injuries are at the site of direct trauma. ___ injuries are at the site opposite of trauma. |
|
Definition
|
|
Term
| Cerebral contusion imaging: |
|
Definition
| CT is still test of choice, however MRI technically still more sensitive in detecting smaller injuries |
|
|
Term
cerebral contusions :
Disposition:
Neurosurgery Consult and admission
Will need follow up CT
Surgical resection if increased edema or ICP |
|
Definition
|
|
Term
| Mosst common cause of death/disability in childhood: |
|
Definition
|
|
Term
| most common cause of head injury in infants/children; |
|
Definition
|
|
Term
| usually don’t scan kids with frontal head hit b/c frontal bone very strong in kids |
|
Definition
|
|
Term
| Mild Head Injury in Infants and Children: |
|
Definition
Children with minor HI and normal neuro exam.. 3-7% will have IC injury on CT and 1% needing intervention
LOC in appx. 5% of children with MHI
Many children who vomit following head trauma do not have ICA
Scalp Hematoma
Increased size and location suggest higher risk of skull fractures
In one study, no child with FRONTAL hematoma had ICA |
|
|
Term
| Experts define Minor Head Injury in those younger than 2 as hx/signs of __ __ to scalp, skull, or brain in a child/infant who is __ and __ to _ or __ __. |
|
Definition
- blunt trauma
- alert and awakens to voice or light touch |
|
|
Term
| Need to consider CT in most children under 2 with trauma. You can consider observation if: |
|
Definition
Observation if:
- fall from greater than 3 feet
- no loss of consciousness/seizure
- asymptomatic for at least 2 hours after event
- no scalp hematoma or only a frontal scalp hematoma
2 cohort studies found that no infant with above criteria had a ICA requiring treatment or experienced clinical deterioration |
|
|
Term
Kids
NORMAL CT SCAN> NO SLEEP PRECAUTIONS
NO CT SCAN> SLEEP PRECAUTIONS TO WAKE UP EVERY 2-3 HOURS. |
|
Definition
|
|
Term
| Indications for CT in those older than 2: |
|
Definition
- focal neuro findings
- skull fractures
- seizure
- change in mental status
- prolonged LOC |
|
|
Term
| Indications for observation in kids older than 2: |
|
Definition
- normal mental status
- normal neuro exam
- no evidence of skull fx
- no seizure/sig. HA
- less than 2 episodes of vomiting
- no loss of consciousness |
|
|
Term
| Dispostion of children with mild TBI: |
|
Definition
Most children who have isolated minor head injury with normal CT can be safely d/c home…deterioration after normal head CT is extremely rare, including those less than 2 yo
Make sure that you give caregivers head injury precautions at discharge and that you document doing such. Follow up should be arranged within 24 hours, even if just phone call follow up. |
|
|
Term
| With scalp lacerations if the __ is involved you must repair with __ __, if not it can lead to __ __ that often gets infected. |
|
Definition
- galea is involved
- absorbable sutures
- subgaleal hematoma |
|
|
Term
| If galea is not involved with scalp lacerations you can use __. |
|
Definition
|
|
Term
| With scalp lacerations, __ might be associated with increased risk of infection. |
|
Definition
|
|
Term
| IF GALEA IS OPEN CLOSE IT UP WITH ABSORBABLE SUTURE. KNOW THIS BOARD B/C IF LEAVE IT OPEN HEMATOMA CAN FORM UNDER IT. |
|
Definition
|
|
Term
|
Definition
GCS : 13-15 mild TBI
Decerebrate Posture – Extensor Response
Decorticate Posture – Flexor Response
Consider cervical injury in all head injury patients.
Basilar Skull Fracture – Raccoon Eyes and Battle Sign
Neuroimaging – Canadian and New Orleans criteria |
|
|
Term
|
Definition
Epidural Hematoma – younger age, arterial source (MMA), Lucid Interval
Subdural Hematoma – Older age, EtOH, venous source, bridging veins, can be associated even with minor trauma
Head injury in children are approached differently, esp. younger than 2 years old
Consider CT in any intoxicated patient with complaints of fall |
|
|
Term
A 6 y/o male is struck by car while riding his bicycle. He is reported to be unconscious for 2 minutes following the accident. He is conscious and alert upon arrival to the ED, but within 45 minutes he begins to vomit and shortly thereafter he becomes completely unresponsive . What kind of ICA might you find on CT?
A. Acute Subdural Hematoma
B. Acute Epidural Hematoma
C. Traumatic subarachnoid hemorrhage |
|
Definition
| B. Acute epidural hematoma is answer |
|
|
Term
| Rupture of superficial bridging vessels (veins) with rapid movement of the head, as in acceleration-deceleration injuries is associated with what type of head injury? |
|
Definition
|
|
Term
All of the following can be included in the initial management of a patient with an acute epidural hematoma, that is currently being anticoagulated with warfarin, except.
A. Fresh Frozen Plasma
B. Fosphenytoin / phenytoin
C. Dexamethasone 10mg IV
D. Mannitol 1g/kg IV bolus |
|
Definition
|
|
