Itls - Head Trauma

Front 1

How are head injuries classified?

Back 1

Either open or closed depending on whether the object compromised the skull and exposed the brain.

Front 2

What is primary brain injury?

Back 2

The immediate damage to the brain tissue that is the direct result of the injury force and is fixed at the time of injury.

Front 3

How does primary injury occur inside the skull?

Back 3

Most primary brain injury occurs from external forces applying a force outside the skull or from movement of the brain inside the skull.

Front 4

How do deceleration injuries affect the brain?

Back 4

The head strikes an object such as the windshield causing sudden deceleration of the skull. The brain continues to move forward impacting first the side of the skull in the path of the motion and then rebounding to strike the opposite side.

Front 5

What is secondary brain injury?

Back 5

The result of the brains response to the primary injury with swelling causing a decrease in perfusion or from complications of other injuries such as hypoxia or hypotension.

Front 6

What is the response of the injured brain?

Back 6

To swell. Bruising or injury causes vasodilation with increased blood flow to the injured area. The extra blood takes up space and exerts pressure on surrounding brain tissue.

Front 7

What does the swelling do?

Back 7

Increases intracerebral pressure amd decreases the blood flow to the brain that causes further brain injury.

Front 8

What is it important to do with ventilation and TBI?

Back 8

Keep the level of PaCO2 in the normal range 35-40 mg by maintaining good ventilation at a rate of one breath every 6-8 seconds with high flow oxygen.

An increase in PaCO2 increases ICP by promoting vasodilation

A decrease in Pa CO2 decreases blood flow by causing vasoconstriction

Front 9

What is the blood pressure you need to maintain with a patient with a TBI?

Back 9

You need to maintain a systolic blood pressure of at least 110-120mmHg in a patient with a severe head injury.

Front 10

What is Cerebral Herniation Syndrome?

Back 10

The sudden rise in ICP as a result of a blow to the head can force portions of the brain downwards and apply great pressure to the brain stem.

Front 11

What are the classic findings that point to CHS?

Back 11

Decreasing LOC that rapidly progresses to coma, dilation of the pupil and outward-downward deviation of the eye on the side of the injury.

Also paralysis of the arm and leg on the side opposite the injury or decerebrate posturing.

Front 12

What are the vital signs indicating cerebral herniation?

Back 12

Increased blood pressure and bradycardia

Front 13

What needs to take place if these signs are developing in a head injury patient?

Back 13

Hyperventilation. This will decrease the size of blood vessels in the brain and briefly decrease ICP.

The danger or immediate herniation outweighs the risk of cerebral ischemia that can follow hyperventilation.

Front 14

What are the ventilation rates?

Back 14

Every 3 seconds (20/min) for Adults
Every 2.5 seconds (25/min) for children
Every 2 seconds (30/min) for Infants

Front 15

What are important considerations with scalp wounds?

Back 15

The scalp is highly vascular and bleeds briskly.

They can lead to significant blood loss which can lead to shock in children.

If you have an adult with shock and a scalp injury look for another cause for the shock.

Most bleeding from a scalp can easily be controlled in the field with direct pressure as long as there are no unstable fractures under the wound.

Front 16

What are the types of skull injuries?

Back 16

Linear nondisplaced

Depressed

Open

Impaled Object

Front 17

When should you suspect skull fractures?

Back 17

When there is a large contusion or darkened swelling of the scalp.

Front 18

What is the management for Skull Injuries in the field?

Back 18

There is little that can be done except to

AVOID placing direct pressure on an obvious depressed or compound skull fracture.

Treat the potential brain injury with adequate oxygenation and maintain perfusion.

Open fractures need the wound dressed but avoid excess pressure when controlling bleeding.

Penetrating objects should be secured in place and not removed.

Front 19

What is a concussion?

Back 19

There is no structural injury to the brain that can be demonstrated by current imaging techniques.

There is a brief disruption of neural function that often results in a loss of consciousness, many do not loose consciousness.

There may be a period of amnesia often to before the event. Short term memory can be affected.

Patients can report dizziness, headache, ringing in the ears and/or nausea.

Front 20

What is a cerebral contusion?

Back 20

Bruised brain tissue. pts will have a Hx of prolonged unconsciouness or altered level of consciousness.

Brain swelling can be rapid and severe.

Pt can have focal neurological signs such as weakness or speech problems and can resemble a stroke.

Patient have personality changes such as inapropriately rude behaviour or agitation

Front 21

What is a subarachnoid Hemorrhage?

Back 21

Blood can enter the subarachnoid space as a result of trauma or spontaneous hemorrhage.

This causes irritation that results in intravascular fluid leaking into the brain and causing more edema.

Severe headache coma and vomiting from the irritation is common.

The swelling can develop into cerebral herniation syndrome.

Front 22

What is diffuse axonal injury?

Back 22

The most common injury type as a result of severe blunt head trauma. There is generalized edema and in most cases the patient presents unconscious without focal deficits.

Front 23

What is Anoxic brain injury?

Back 23

An injury to the brain resulting from a lack of oxygen.

Front 24

What is intercranial hemorrhage?

Back 24

Hemorrhage than can occur between the skull and the dura, between the dura and the arachnoid or directly onto the brain tissue.

Front 25

What is an acute epidural hematoma?

Back 25

Most often caused by a tear in the meningeal artery that runs along the inside of the skull in the temporal region.

Injury is often caused by a fracture. Bleeding is therefore often aterial and can raise ICP rapidly causing death.

Front 26

What are the signs and symptoms of an AEH?

Back 26

Hx of head trauma followed by a period of consciousness.

After minutes to hours the pt develops signs of increased ICP (vomiting, headache, altered LOC)

Lapse into unconsciousness, develop body paralysis on the side opposite the brain injury and often fixed dilated pupil on the side of the injury.

Front 27

What is an acute subdural hematoma?

Back 27

The result of bleeding between the dura and arachnoid.

The bleeding is venous and ICP increases more slowly. Diagnosis can be hours or days after an injury.

Front 28

What are the signs and symptoms of ASH?

Back 28

Headache, fluctuations in the level of consciousness. Focal neurological signs. Weakness of one extremity or slurred speech.

Prognosis is very poor due to the underlying brain injury.

Front 29

Who should you suspect ASH in?

Back 29

An alcoholic with any degree of altered mental status following a fall. Elderly patients and those on anticoagulants are also at high risk.

Front 30

What is intracerebral hemorrhage?

Back 30

Bleeding within the brain tissue.

Can result from blunt or penetrating injuries of the head.

These injuries occur in a pattern similar to that of a stroke.

Front 31

What is the initial assessment in the head trauma patient focused on?

Back 31

Determine if the patient is brain injured and if so if the patients condition is deteriorating.

Front 32

What should patients with head or facial trauma and altered LOC be assumed to have?

Back 32

Cervical Spine injury. Restriction of cervical spine movement should accompany airway and breathing management.

Front 33

What is the neurological exam in the initial assessment?

Back 33

LOC and any obvious paralysis

Front 34

What is important with regards to the airway?

Back 34

Control of the airway is very important. A supine, restrained and unconscious patient is very prone to airway obstruction from the tongue blood or vomit. Vomiting is very common within the first hour following a head injury.

Front 35

In the Rapid Trauma Survey what is looked for in the head?

Back 35

Look for lacerations and feel for unstable areas. If there are none then pressure dressings or direct pressure will control bleeding.

Look for battles sign or raccoon eyes which are a contraindication for an NPA. Check for the presence of CSF or bleeding from ears or nose.

Front 36

What is important to note about the pupils?

Back 36

The third cranial nerve takes a long coarse through the skull and is easily compressed by brain swelling.

Front 37

What if both pupils are fixed and dilated?

Back 37

The patient probably has a brain stem injury and the prognosis is grim.

Front 38

What if pupils are dilated but still reactive?

Back 38

The injury is still reversible so every effort should be made to transport the patient rapidly

Front 39

What is a unilaterally dilated pupil that is still reactive a sign of?

Back 39

May be the earliest sign of increasing ICP.

Front 40

What does the development of a unilaterally dilated non-reactive (blown) pupil a sign of in a comatose patient?

Back 40

This is an extreme emergency pointing to CHS and requires rapid transport and hyperventilation

Front 41

What is it important to note?

Back 41

Fixed and dilated pupils only signify increased ICP in patients with a decreased LOC. If the patient has normal LOC then the dilated pupil is not from TBI but eye trauma or drugs.

Front 42

What can be noted in the extremities?

Back 42

Note sensation and motor function in the extremities. Can the patient feel you touch her hands and feet?

If the patient is conscious can she wiggle fingers and toes. If unconscious does she withdraw from pain.

Front 43

What are decorticate or decerebrate posturing a sign of?

Back 43

Signs of deep cerebral or upper brain stem injury. Decerebrate is worse and usually signifies cerebral herniation.

Front 44

What are some things to note about respiration rates with TBI?

Back 44

Increasing ICP causes the resp rate to increase, decrease or become irregular. Unusual respiratory patterns may reflect the level of brain or brain stem injury.

Respiration is affected by many other factors such as fear, hysteria, chest injuries and spinal cord injuries so is not as useful as other signs for monitoring head injury.

Front 45

What can be noted about the pulse?

Back 45

Increasing ICP causes the pulse rate to decrease.

Front 46

What about the blood pressure?

Back 46

Increasing ICP causes increased blood pressure. This hypertension is also usually associated with a widening of the pulse pressure.

Front 47

What can also cause hypertension?

Back 47

Fear and pain

Front 48

What does the injured brain not tolerate?

Back 48

Hypotension, a single episode can increase mortality by 150% and even more in children.

Front 49

What should blood pressure be maintained at with patients with severe TBI?

Back 49

Fluids should be given to maintain systolic blood pressure at 110-120 mmHg

Front 50

What about patient history?

Back 50

It is important to get a good Hx before and during the exam. The circumstances of the head injury may be extremely important.

Front 51

Why is it important to inquire about the patients behaviour from the time of injury to arrival?

Back 51

Patient may show signs of worsening mental state in line with a TBI. Could point to a worsening bleed.

Front 52

What is the management of a head trauma patient?

Back 52

1) Secure the airway and provide good oxygenation. Monitor the Sp02 and aim to keep above 95%

Maintain good ventilation 6-8 and use ETCO2 to keep at 35-40mgHg

Be prepared to log roll and suction the patient.

2) Full C-spine stabilization

3) Record baseline vital signs, LOC, Pupils, GCS if patient develops hypotension suspect hemorrhage or spinal injury

4) Insert two large bore IV's and ensure that the patient with a TBI is not hypotensive.