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Neurology: Head Trauma
Head Trauma
115
Anatomy
Graduate
11/18/2011

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Cards

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
- eyes
- verbal
- motor
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
75-95%
Term
Causes of brain injury:
Definition
MVC> falls > job accidents > assaults
Term
male to female ratio for TBI:
Definition
males more common 3:1
Term
50% of TBI are in pts between ages of _ and __ years old.
Definition
15 and 34 years old
Term
There is a higher risk of injury in those younger than __ and those older than __.
Definition
- 5
- 60
Term
__ of TBI are associated with c-spine injury.
Definition
5%
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
Hypoxia and hypotension
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
90
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
CT scan
Term
Studies show __% of intracranial abnormalities (ICA) are associated with skull fractures.
Definition
40-100%
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
- CT
- not a x-ray
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
Basilar
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
- mild
- NOT required
Term
A concussion has __ onset and shows __ lived impairment of neurological function.
Definition
- rapid
- short
Term
A concussion is due to a __ disturbance not a structural injury.
Definition
functional
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
CT scan
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
Decision to admit:
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
second impact syndrome
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
Order of the meninges:
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
epidural hematoma
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
epidural hematoma
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
extension
Term
Decorticate posture is ___.
Definition
flexed
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
Epidural hematoma tmt:
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
is u
Definition
Term
Are subdural or epidural hematomas more common?
Definition
subdural
Term
Epidural hematoma is __ blood, subdural hematoma is __ blood.
Definition
- arterial
- venous
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
subdural hematoma
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
- CBC
- CMP
- PT/PTT/INR
Term
A __ __ is contraindicated with subdural hematomas.
Definition
lumbar puncture
Term
EPIDURALS AND SUBDURALS ARE SPACE OCCUPYING LESIONS, SO YOU DO NOT WANT TO DO LPS ON THESE PTS.
Definition
Term
Subdural hematoma tmt:
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
Circle of Willis
Term
most common cause of SAH:
Definition
trauma
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
CCB
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
white matter
Term
Diffuse axonal injury pts will often present in __.
Definition
coma
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
Urine Tox
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
MRI
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
- Coup
- Countercoup
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
head injury
Term
most common cause of head injury in infants/children;
Definition
falls
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
staples
Term
With scalp lacerations, __ might be associated with increased risk of infection.
Definition
shaving
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
Take home points:
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
More take home points:
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
Subdural Hematoma
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
C. Dexamethasone
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