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29 Cards in this Set
- Front
- Back
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traumatic brain injury
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-most common cause of traumatic death for pts age<25
-TBI 10x more common than spinal injury -peak age groups: 15-24 and >65 |
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TBI: goal is early recognition of
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1. Hypoperfusion
2. Cerebral ischemia 3. High intracranial pressure (ICP) |
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increased intracranial pressure
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-results from swollen brain, tissue, blood, or CSF, the pressure within the skull increases as the volume does not change
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Cerebral perfusion pressure (CPP)
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-decreasing BP and/or increasing ICP, may result in decreased cerebral blood flow
-mechanisms include: increased bl flow to injured areas, cerebral edema, intracerebral hemorrhage, intracerebral hematomas -even with mino head injuries there may be a loss of nml cerebral auto-reg resulting in alterations of cerebral O2 delivery |
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primary survey/head injury
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-Mental status: level of consciousness, orientation to person, place and time
-preservoration: cant hole on to short term memory -ABC's -Cervical spine protection -Pupils: size, responsiveness, asymm -Motor exam: symmetry, abnl movements, strength, reflexes -Cranial nerves: gag (not for pts with obvious head injuries), corneal reflex -Brainstem function: RR and pattern, eye movements |
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Glasgow coma scale (GCS)
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-easy bed side test that gives you a good indication of the pts brain injury severity
-Eye opening -Best verbal response -best motor response -best score is 15, worst is 3 |
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GCS problems
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-serial exams are impt!!
-a pt can have a sig intracranial injury & a nml GCD -factors which may interfere w/obtaining GCS: ocular or oral trauma and severe periorbital edema, intubation, impediments to nml communication, paralytic drugs, SC injuries, extremity fxs |
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Clinical History
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-VS
-GSC -obtain an AMPLE history A llergies M edications P ast medical hx L ast meal (may need surgery) E TOH/other drugs -post traumatic evens: cardiac arrest, apnea, seizures, vomiting -current condition: compared to baseline -focal complaints |
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Signs of increasing ICP
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-altered mental status: ECS eye <4; GCS verbal < 5
-persistent or projectile vomiting -severe HA -sluggish or abnl eye movements -papilledema -abnml posturing (decorticate/decerebrate) -abnml breathing patterns: taachypnea, hyperventilation, snoring, expiration breathing w/cheeks puffed, cheyne-stokes breathing |
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secondary survey: neuro exam
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-level of consciousness
-repeat GCS -mini-mental status exam -additional bedside neuro testing: gag and corneal reflexes -brain stem function: RR and pattern, eye movements, dolls eyes (eyes track w/head) (only if C-spine is cleared), caloric testing-infuse cold and warm water in ears (COWS = cold opposite/warm same) |
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External signs of trauma
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-lacerations
-soft tissue hematomas -bleeding -deformity -impaled/retained foreign objects -hemotympanum (blood behind TM) -otorhinorrhea (bloody CSF fluid leaking from ears or nose) |
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Radiographic test for head injury
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-CT scan is gold standard
-all severe head trauma pts should have a CT scan including bone windows! |
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Epidural Hematoma
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-bleeding b/t skull and dura
-usually unilat -origin of bleeding: middle meningeal a., dural sinuses -reach max size w/in min of injury -classic hx: dec level of consciousness followed by a lucent period then neurological deterioration -injury of the YOUNG, uncommon in elderly |
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Subdural hematoma
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-rapidly clotting blood below the dura but external to the brain and arachnoid
-formed by shearing of bridge veins -bleeding occurs slower -brain injury results from: direct P, increased ICP, assoc intraparenchymal injuries -can result in herniation syndromes |
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Subdural hematoma mortality rate
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increase with...
1. lower GCS score 2. unilat pupil dilation 3. non-reactivity to light -any coagulopathy increases risk -more common in pts with cerebral atrophy: elderly, alcoholics |
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acute subdural hematoma symptoms
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1. HA
2. N/V 3. Altered mental status 4. Changes in personality 5. Muscle weakness |
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SDH-prognosis
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-survival not related to hematoma size
-controlling ICP is more impt -hypoxia and hypotension are independent predictors of poor outcome |
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TBI- Treatments (acute-in first hour)
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1. positioning: elevate head (unless hypotensive)
2. insure adequate ventilation to avoid hypoxia: supplemental O2, pts with GCS < 8 should be intubated b/c they are at high risk for vomiting 3. Maintain BP at nml or high levels |
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For pts with symptomatic elevated ICP
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-Hyperventilation: goal --> pCO2 !30-35-->dec vascular sweeling in head
-mannitol by IV (NOT for pts with hypotension) -shot acting sedatives -barbituates (therapeutic coma)--. slows down brain action and this can reduce the production of fluid -anticonvulsants |
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Surgical tx
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1. Crainiotomy: small hole drilled in the skull to remove clots
2. Decompression Craniectomy: removal of part of the skull to allow brain swelling |
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Anoxic brain injury
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-an injury that results from a lack of O2 to the brain
-most often from a lack of blood flow due to injury or bleeding -May also occur due to smoke inhalation, respiratory arrest, drowning, purposeful or accidental asphyxia. |
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Diffuse axonal injury (DAI)
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-Damage to the pathways (axons) that connect the different areas of the brain
-occurs when severe shearing forces are applied to the brain tissue -brain messages slowed or lost -tx: aimed at managing swelling b/c torn axons cannot be repaired |
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Who to scan????
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-all GCS <13
-lower threshold if pt at high risk -consider head CT for any pt w/loss of consciousness -all pts with hx of head injuries w/altered mental status |
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who to scan: high risk
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look at slide
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skull fxs
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-CLOSED: if there is no communication b/t the fx and the atmosphere
-OPEN: no communication -Linear or fissure fx; depressed fx; basilar skull fx |
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Linear fx
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-involves skull vault and can extend down to the base of the skull
-indicates that there has been sig injuries to the head -mgmt may include admission and close observation |
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Depressed skull fx
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-w/more severe trauma, the skull fragment is circumferentially broken and may be pushed below the level of the skull
-bone may be fragmented -may cause a tear in the dura and brain lacerations |
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Significant skull fxs
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1. Fractures over the middle meningeal artery or a major dural sinus
2. Depressed fractures below the level of the inner table of the skull 3. Basilar skull fractures 4. Fractures associated with intracranial air. 5. Fractures through an air-filled sinus 6. Fractures under a scalp laceration: Occult, open fractures |
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Basilar skull fxs
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-Linear fx at the base of the skull, usually through the temporal bone
-difficult to detect by plain film or CT -physical signs: hemotympanum, otorrhea, rhinorrhea, periorbital ecchymosis (racoons eyes), retroauricular ecchymosis (battle's sign), CN deficits, hearing loss |
