Clincial Assessmnet V748 Head Trauma And Vertigo

Front 1

Most common cause of traumatic brain injuries for teens to 30yo

Back 1

motor vehicle accidents

Front 2

Most common cause of traumatic brain injuries for both baby to teen and elderly

Back 2

falls

Front 3

Common head trauma optometric visits

Back 3

assaults (black eye), sports injuries, auto/bike accidents, falls

Front 4

Common CC for head trauma in optometry office

Back 4

blurred vision, diplopia, HA, dizziness, reading/concentration problems, increased light sensitivity

Front 5

Trauma Hx

Back 5

1. date and time
2. where it occurred
3. mechanism (need to be exact: what hit what, where, how)
4. self Tx and results
5. changes in Sx
6. Hx of similar trauma

Front 6

Head Trauma Hx ... need all of trauma Hx plus

Back 6

1. Loss of consciousness or change in level of consciousness
2. Use of alcohol or drugs

Front 7

Head Trauma Hx caused by motor vehicle accident need these extra Hx questions

Back 7

1. more mechanism: what did you hit (steering wheel, dash, etc), what part of head
2. speed at impact, what did you hit
3. seat belt usage?, airbag deploy?
4. if motorcycle or bike, helmet?

Front 8

Levels of Consciousness

Back 8

1. Alert
2. Lethargy: drowsy, responds to loud voice, opens eyes, fixates, responds, falls back to sleep
3. Obtuned: after shaking opens eyes, fixates, responds slowly, and somewhat confused
4. Stupor: opens eyes after mildly painful stimuli, responses slow to absent
5. Coma: unarousable (so this is obviously not possible for you Dan, they would just have to take you over to harmony), eyes closed

Front 9

Review: other name and break what
1. Racoon Eyes
2. Battle's Sign

Back 9

1. Periorbital ecchymosis, orbital basilar or cribriform plate
2. Mastoid ecchymosis, temporal or basilar plate (delayed 12-24hr after injury)

Front 10

Traumatic Brain Injury common causes of
1. non penetrating
2. penetrating

Back 10

1. secondary to shearing action of brain, coup-counter coup
2. skull fracture, gunshot

Front 11

3 skull fractures

Back 11

1. Simple or linear: linear crack without underlying damage
2. Depressed: indentation involving brain tissue, may fragment into brain tissue, if beyond 5mm will need surgery
3. Basilar: more serious linear fracture with potential to rupture meningeal artery, difficult to see on x-ray best with Water's view

Front 12

Hematotypanum
1. what is it?
2. when does it most frequently occur?

Back 12

1. blood behind tympanic membrane
2. secondary to fractured temporal bone

Front 13

Cerebralspinal fluid leak
1. where does it leak from?
2. when does it most frequently occur?
3. how do you test for it?

Back 13

1. nose or ear canal
2. secondary to fractured temporal bone
3. test fluid leak with dextrose strip, if positive glucose then CSF leak, they may report salty taste too

Front 14

What is crepitation?

Back 14

popping sound

Front 15

What causes crepitation along the orbital rim?

Back 15

Blow-out fracture with air leakage into orbit

Front 16

2 things that frequently cause diplopia

Back 16

1. blow-out fracture
2. hematoma

Front 17

5 types of non penetrating head traumas from least serious to most serious

Back 17

1. concussion
2. contusion
3. hematoma (subdural, epidural)
4. whiplash
5. spinal

Front 18

Concussion definition

Back 18

Edema resulting from brain hitting inside the skull secondary to acceleration-deceleration (coup-counter coup)

Front 19

If you dive into the water and your forehead smacks a sandbar, what part of brain hits on the
1. coup
2. counter coup

Back 19

1. frontal lobe (head hits in front and brain continues until frontal lobe hits skull)
2. occipital lobe (once frontal lobe hits, there is a rebound action and the brain goes back and the occipital lobe smacks the skull)

Front 20

4 mechanisms a brain becomes injured after being concussed

Back 20

1. focal injury
2. diffuse axonal injury
3. hypoxia and ischemia
4. microvascular injury with loss of autoregulation

Front 21

Concussion S&Sx
1. how long is loss of consciousness
2. do you remember the event
3. most common vision complaint
4. these can occur 24-48hr later

Back 21

1. less than 15min
2. usually short amnesia
3. diplopia (but PERRLA and full EOM)
4. HA, nausea, vomiting, vertigo
additional info: also can have tinnitus and coordination defects and numbness, if loss of consciousness is greater than 3min need observation for first 24hr, neurological exam performed

Front 22

Concussion FU in OD office ... what do you perform

Back 22

VA, pupils, EOM, VF, SLEx, DFE
refer for CT recommended

Front 23

How long can concussion Sx last

Back 23

up to 3 months (secondary to axonal injury)
retrograde amnesia, HA, light sensitivity, nausea, vomiting, etc

Front 24

Sports related concussion 3 grades of concussion

Back 24

grade 1: confusion, no LOC, Sx last less than 15min
grade 2: confusion, no LOC, Sx last greater than 15min
grade 3: any LOC
effects of these thought to be additive

Front 25

What is second impact syndrome

Back 25

Rapid brain swelling in an already concussed brain, lead to permanent brain damage or death

Front 26

Contusion
1. definition
2. LOC length

Back 26

1. laceration or bruise across surface of brain that alters the structure of tissue (does not cause hematoma)
2. 15min to 1hr

Front 27

Sx based on contused area, Contusion of...
1. frontal lobe
2. temporal lobe
3. occipital lobe
4. basal frontotemporal lobe
5. brain stem

Back 27

1. aphasia, gaze palsy
2. receptive aphasia, restlessness
3. hemianopsia*
4. restless, combative
5. abnormal extension/flexion, decreased consiousness

Front 28

Contusion
Order a facial series, why is Water's view important

Back 28

to R/O basilar fracture

Front 29

Contusion
Order CT scan, why is this important

Back 29

to R/O hematoma

Front 30

Contusion
1. Tx
2. Sx (long term 6mo)

Back 30

1. hospitalize 24-72hr, minimal drug
2. HA, vertigo

Front 31

Hematoma
dilated pupils, gaze preference
1. if eyes look away from the affected side it is likely
2. if eyes look toward the affected side it is likely

Back 31

1. early irritative lesion
2. structural lesion (stroke)

Front 32

Hematoma Sx
1. irregular respiration, what is it called when you get deep breaths and sigh followed by apnea

Back 32

Cheyne-Stokes respiration

Front 33

1. Cushing's comatose triad
2. this indicates damage to what part of the brain

Back 33

1. HTN, bradycardia, irregular respiration
2. brain stem

Front 34

Hematoma
1. Tx if stable
2. Tx if not stable

Back 34

1. IV dexamethasone, CT, surgery
2. emergency surgery
note: rehab 1-2yr

Front 35

Hematoma, two types of bleeds
1. where is the bleed?
2. vein or artery bleed?
3. which one is more common
4. on CT is the blood focally or diffusely distributed

Back 35

1. Subdural and Epidural
2. Subdural- venous bleed often with skull fracture ... Epidrual- arterial bleed with skull fracture
3. Subdural is more common than Epidural
4. Subdural has diffuse bleeding ... Epidural has focal bleeding (see images in slideshow)

Front 36

Subdural vs. Epidural Sx differences

Back 36

Subdural: apparent immediately (altered level of consciousness due to cerebral edema), seizures and increased intracranial pressure may be present
Epidural: first loss of consciousness, then followed by period of lucidity, later period of deterioration

Front 37

Increased Intracranial Pressure (IIP)
1. Onset
2. Location
3. Duration
4. Associated Sx
5. Hx
6. Physical findings

Back 37

1. gradual
2. unilateral or bilateral, diffuse or local
3. hours to months
4. personality changes, hyperirribility
5. drug or alcohol abuse, trauma, worse in morning
6. abnormal neuro exam, papilledema

Front 38

IIP
1. type of pain, what makes it better? what makes it worse?
2. special studies ordered

Back 38

1. steady or pounding, gradual over weeks to months, valsalva makes it worse (exhalation while airway is closed ... close mouth and nose and try to exhale), lying down relieves
2. X-ray (displaced calcified pineal gland) CT (tumor or hematoma), MRI

Front 39

IIP
Why do a CT before a spinal tap

Back 39

avoid risk of herniation

Front 40

Posttraumatic seizures
Which are you more worried about: seizures within 24hr of trauma or seizures one week post trauma

Back 40

Seizures one week post trauma (will have higher risk for continuation of seizures)
note: seizures within 24hr have better prognosis, they do increase chance of bleeds and IIP

Front 41

Spinal Cord Injury
most common mechanism of injury (name others?)

Back 41

Most common: diving into a sandbar ... oh wait sorry it's actually hyperextension (whiplash)
others: hyperflexion, axial load/vertical compression, penetrating

Front 42

Whiplash, most common Sx (others?)

Back 42

HA
others: low back pain, memory/concentration difficulties
note: recovery slower

Front 43

How long does wearing a cervicle collar help whiplash

Back 43

only for the first 2 wks

Front 44

Head Trauma Triage following Sx go for immediate care (ASAP) or urgent care (within 48hr)
1. loss of consciousness
2. diplopia
3. vertigo
4. confusion
5. problems with memory
6. somnolence

Back 44

1. immediate
2. immediate
3. urgent
4. immediate
5. urgent
6. immediate

Front 45

Vertigo definition

Back 45

subjective or objective illusion of motion ... everything else is NOT vertigo

Front 46

Difference between central and peripheral vertigo

Back 46

Central: brainstem vestibular nuclei problem
Perpipheral: semicircular canal and otolith problems (90% of cases) note: 8th CN goes from semicircular to vestibular nuclei

Front 47

Central vs. Peripheral Vertigo
1. latency
2. fatigability
3. tolerability
4. intensity
5. reproducibility

Back 47

1. central: none; periph: 2-40s
2. central: no; periph: yes
3. central: no; periph: yes
4. central: mild; periph: severe
5. central: good; periph: poor

Front 48

Central vs. Peripheral Vertigo
1. latency
2. fatigability
3. tolerability
4. intensity
5. reproducibilityCentral vs. Peripheral Vertigo
1. HA
2. ataxia (lack of control of muscles)
3. hearing loss/tinnitus
4. focal signs
5. positive head thrust test

Back 48

1. central: yes; periph: no
2. central: mod-severe; periph: none to mild
3. central: no; periph: occasional
4. central: yes; periph: no
5. central: no; periph: yes

Front 49

Central vs. Peripheral Vertigo
main DDx, how performed

Back 49

Head Thrust Test
move head 10 degrees to side as pt fixates straight ahead, then move head quickly back to center, repeat other side
Periph: eyes will move with the head and then back

Front 50

Dix-Hallpike maneuver

Back 50

head 45 degrees to R then drop below edge of table and extended 30 degrees, if vertigo not seen in 30 sec, repeat to left

Front 51

Causes of Vertigo

Back 51

1. Benign Positional Vertigo
2. Acute Peripheral Vestibulopathy (including Vestibular Neuronitis, acute labyrinthitis)
3. Meniere's Dz
4. others rare: migraine, CVD, etc

Front 52

DDx Benign Positional Vertigo and Acute Labyrinthitis

Back 52

Benign Positional Vertigo will have normal hearing whereas Acute Labyrinthitis will have an associated hearing loss

Front 53

Benign Postional Vertigo
1. is there a lesion in the ear?
2. caloric testing result
3. hallpike maneuver result

Back 53

1. no lesion
2. positive: (COWS cold opposite, warm same)
3. positive 2-40sec latency

Front 54

Benign Positional Vertigo Tx, how does that treatment help

Back 54

no meds, do the Epley (Liberatory) maneuver (similar to hallpike), it helps by removing the debris from the posterior semicircular canal

Front 55

Vestibular Neronitis
1. onset quick or gradual
2. length of vertigo
3. any associated hearing problems

Back 55

1. quick onset (s/p viral possibly)
2. single attack of severe vertigo peaking at 24 hr, last days
3. no tinnitus or deafness
additional info: minimal findings, pt remains immobile

Front 56

Acute Labyrinthitis
1. onest quick or gradual
2. length of vertigo
3. any associated hearing problems

Back 56

1. quick onset (s/p viral possibly)
2. single attack of severe vertigo peaking at 24-48 hr, last days
3. has associated hearing loss
additional info: very similar to vestibular neronitis except for associated hearing loss (DDx)

Front 57

Meniere's Dz
1. abrupt or gradual onset
2. difference between other vertigo problems
3. how long does vertigo last
4. associated hearing problems?

Back 57

1. abrupt onset
2. differences is vertigo is recurrent
3. minutes to hours
4. associated with tinnitus and deafness
DDx: recurrent attacks

Front 58

Meniere's Dz Tx
(clue how would you relieve the pressure in the semicircular canals)

Back 58

Sodium restricted diet and diuretic (reduces inner ear fluid overpressure)
can use valium
if nothing works can do labyrinthectomy

Front 59

Migraine Vertigo cause

Back 59

vasospasm of basilar artery which can interfere with blood supply to vestibular nuclei

Front 60

Perilymph fistula
1. what is this problem
2. what can cause it

Back 60

1. abnormal communication between inner ear and middle ear
2. trauma or barotrauma (divers)

Front 61

Dizziness (non vertigo) 2 main causes

Back 61

1. presyncope (lightheaded)
hyperventilation, orthostatic, vasovagal, cardiac arrhythmia, hypoglycemia
2. elderly
medications