TCAR module 7- head injuries fully solved questions with 100% accurate solutions(Latest Update)

in senior trauma patients, which set of vital signs is most alarming

BP 137/82 HR 123

BP 158/91 HR 86

BP 107/79 HR 112

BP 104/60 HR 74

BP 107/79 HR 112

in senior trauma patients, a HR > 90 and a SBP <110 are red flags for deterioration

when an older adult dies as a result of a fall, the most common cause of death is....

brain injury

of all trauma patients with a brain injury, only 7% of them are considered severe

GCS and brain injury severity

3-8 severe

9-12 moderate

13-15 mild

a primary brain injury is any damage that directly results from the initial application of force to brain tissue. such injuries include concussions, lacerations, hematomas, DAIs, and skull fractures. a secondary brain injury is any damage that occurs due to the brains response to the primary injury. common secondary injuries include edema, vascular changes, increased ICP, and numerous inflammatory and biochemical reactions

diffuse injuries directly affect consciousness, focal injuries indirectly affect consciousness

physiologically there only two ways to lose consciousness

shut down the RAS in the brainstem, disrupting the flow of impulses to the rest of the brain (concussion, DAIs, a brainstem legion)

impair both of the cerebral hemispheres (Edema, hypoxia, brain shift, hypoglycemia, seizures, etc)

each of these loss of consciousness etiologies occurs in trauma patients. understanding the distinction helps identify whats happening in an altered patient's brain

the brain can accommodate around slow-growing masses such as tumors and AV malformations. however, the brain poorly tolerates the acute changes associated with traumatic injury (edema or hematomas). instead, patients quickly decompensate

limitations of a CT scan

cant find concussion

only indicated for moderate-severe injuries in children, much more utilized in older adults

post concussion syndrome

lingering symptoms from a concussion

HA, dizziness, poor concentration, and impaired memory

Diffuse axonal injury / shearing jury

axons being torn apart

result from sudden changes in head velocity associated with high energy mechanisms. most common MVC. can also result from direct blow to head, blast pressurization wave, referred energy from blow to other part of body

the axons are disrupted as a direct result to injury, or as subsequent neuronal degeneration. The axons simply "fall apart" in the hours after injury

stunned, stretched, edematous axons may recover- as edema resolves, myelon sheaths are repaired and new dendronic connections are formed

but if the axon is torn, there is no regeneration. there is no putting the axons back together again.

because the brain has limited regenerative and restorative abilities, recovery from a severe DAI is very slow, and usually minimal

in children, commonly associated with child abuse.

a restrained driver involved in a high-speed rollover arrives at this hospital with a GCS of 5. Her brain CT is negative. She survives but never regains consciousness. What is her most likely injury?

- second impact syndrome

- SAH

- frontal contusion

- Diffuse axonal injury

DAI

CT vs MRI

CT- perofmred faster, less expensive, best visualzied bony fractures and other focal lesions

MRI- often requires sedation, takes longer

doesn't involve radiation exposure

DAI wont be present for many hours post injury

so MRIs are never done emergently

second impact syndrome

rare, but often fatal diffuse brain injury

when a patient receives head trauma resulting in concussion, then patient sustains second impact before the brain has completely healed. within minutes of the second blow, the patient collapses due to massive cerebral edema that progresses to herniation

CTE chronic traumatic encephalopathy

a diffuse, progressive, degenerative brain disease with repetitive trauma

symptomatic concussions, or asymptomatic sub-concussive blows.

symptoms don't usually manifest until the fourth decade of life

(football, other contact sports)

initial CT scan of patient with a DAI

usually will not show DAI. 50-80% of DAI patients will have no early CT findings, although some will exhibit the multiple punctate hemorrhages characteristic of this injury

DAI treatment primarily consists of supportive care. damage can range from mild to severe, but patients with a brainstem injury have a high mortality rate

90% of those with a severe injury will die within 6 months. patients with brainstem trauma have the highest mortality rate because vital cardiac and respiratory centers are located in this region

conditions that can produce a brain injury without a direct or indirect force to the head

airway obstruction

blunt carotid vertebral injury

profound hypovolemia

strangulation

cardiac arrest

drowning

drugs and alcohol

not all brain injuries in our trauma patients are the result of a head injury. hypoperfusion, anoxia, and toxins also cause brain damage. major trauma patients are at risk for each of these conditions. dont forget to look beyond head trauma to explain an altered mental status

in adults, which facial bone is most frequently fractures?

-mandible

-maxilla

-nasal bones

-zygomas

the nasal bones

they are the weakest bones in the face

le fort I fx

le fort II fx

le fort III fx- also known as cranio facial dislocation. the entire face is no longer attached to the skull. separtes the facial bones from the cranium

in patients with severe facial injuries, early trach is commonly performed (think Billy) for airway and secretion management

cribriform plate (part of the ethmoid bone)

commonly clinical finding?

CSF leaking out the nose

potential for intracranial infection

if CSF is leaking out, all of the microbes in the nose can infect the brain

the thin ethnoid bone if the only thing separating the nose from the sterile brain

be careful when placing NG tubes in patients with facial fractures! can wind up in brain

nothing should be inserted in the nose with patient with midface trauma

in adults, most skull fractures are...

linear and non displaced

but can also be depressed and displaced

when the mandible breaks, fractures usually occur bilaterally, at the mandibular body or angle

le fort I is a horizontal fracture through the body of the maxilla. pulling the upper teeth moves the hard palate

le fort II also known as pyramidal fractures, involve the central maxilla, nasal, and ethmoid bones. tugging the upper teeth will wiggle the nose

le fort III usually start at the nasal bridge, extend posteriorly through the ethmoid bone, and then laterally through the orbits and zygomas. also known as a craniofacial disjunction

the skull base

which delayed clinical finding is characteristic of an anterior fossa (part of the base of the skull) fracture?

raccoon eyes, periorbital ecchymosis

what delayed clinical finding is a characteristic of a middle fossa fracture?

battles sign

can also have CSF otorrhea

if a patient has this, what other injury must be present? tympanic membrane rupture! how else would the CSF leak out?

what clinical finding is characteristic of a poserior fossa fracture?

uncommon

raccoon eyes, battle signs, and herniation and death

a head CT shows a left, middle fossa, basilar skull fracture. which of the following is an expected clinical finding?

intermittent blood-tinged drainage from the ipsilateral ear canal

even small amounts of blood in the posterior fossa can cause....

herniation and death

the brain can not accutely accomodate extra volume in the posterior fossa. bleeding into this region puts pressure on the cerebellum and brainstem, interfering with essential brain functions (breathing, HR, BP) causing herniation and potentially death.

dura mater

thick, outermost layer of the meninges surrounding and protecting the brain and spinal cord

comparable to periosteum that lines the bone

there is no natural epidural space!

the space only exists when dura is forcefully peeled away from the skull

epidural hematoma

occurs between bone and dural layer

epidural hematoma

whats the most common site? at the temporal bone at the site of the middle meningeal artery

perfect storm- relatively thin bone, vulnerable location, and a major artery is present

classic presentation: immediately unconscious,

lucid interval,

progressive decline in LOC

what are the only two ways to loose consciousness?

shut down the RAS in the brainstem

knockout both cerebral hemispheres

when ICP is elevated, which gets displaced first?

brain

blood

CSF

CSF first

then blood

then the brain will herniate

a midline shift can also be referred to as...

subfalcine hernation

its when the brain shifts across the midline

pupil monitoring when a patient is at risk for herniation

pupillometer can reliably identify and quantify even small changes in the pupil size and reactivity, something the human eye would be unable to do

cranial nerves are peripheral, they dont cross. so pupil changes will be ipsilateral (same side) as the injury

will the patient have left sided or right sided weakness?

weakness will be on the opposite side of the injury

motor signs are contralateral

layers of bone / brain mater from external to internal

skull bone

dura mater

arachnoid mater

pia mater

brain tissue

the falx cerebri and terntorium are folds of dura mater that separate the right cerebral hemisphere from the left, and the upper brain from the lower brain

the source of most EDH is...

arterial bleeding

as pressure in the cranial vault increases, the brain moves downward causing pupillary dilation by compressing cranial nerve ____

II - optic

III- oculomotor

IV- trochlear

VI- abducens

III - oculomotor

the patient with a right epidural hematoma will have....

right pupil dilation and left sided weakness

bedside interventions for the patient with a large, expanding epidural hematoma include....

urgently notifying medical team

preparing patient for emergent surgery

protecting the patients airway

elevate HOB to 30-45 degrees to reduce intracranial pressure

subdural hematomas

unlike an epidural hematoma, there is a subdural space that can semi accommodate for bleeding

usually from a venous bleed

blood accumulates under the dural layer- most commonly caused by tearing of the bridging veins that connect the brain to the dural sinuses

can be acute, subacute, or chronic

what stops subdural blood from migrating to the other side?

the falx cerebri

whats the intervention for a large, expanding SDH?

emergent craniotomy!

epidural vs subdural hematoma- which is a associated with a better longterm outcome?

epidural hematomas

if they are evacuated promptly?

why? epidural bleeds never touches brain tissue. the survival rate is high and patients can have a complete recovery if the clot is quickly removed and bleeding is controlled

in a patient with a SDH, blood is in direct contact with brain tissue. remember, blood outside of circulation is very irritating to surrounding tissues

SDH cause both mechanical pressure, and chemical damage. the blood to brain contact destroys brain tissue

populations at risk for SDH

alcoholics

elderly

babies

are subdurals and epidurals superficial or deep?

they are both superficial

what is the concern with an IPH?

they can occur deep within a vital area of the brain

how would a neurosurgeon evacuate it without disturbing healthy brain tissue?

management is usually supportive, prognosis is usually poor

subarachnoid hematoma

usually the result of small venous tears

bleed within the subarachnoid space- this space is usually filled with CSF

treatment is usually supportive and symptomatic

most major SAH are usually caused by spontaneous arterial bleeding from a ruptured aneurysm or AVM rupture

in a patient with a subdural hematoma blood accumulation always...

occurs on the brain's surface

by definition, a subdural hematoma occurs under the dural layer, on the surface of the brain

the most common source of subdural blood is bleeding from..

the brain-to-dura bridging veins

brain contusions can occur in gray or white matter anywhere in the brain, including the brainstem. During the post-resuscitation period, anticipate a brain-contused patient will have slow, progressive, neurological deterioration as the lesions evolve. bruises are not necessarily minor injuries. about 20% of cerebral contusions severe enough to be noted on an initial CT scan will require surgical evacuation in the hours or days after trauma due to hemorrhagic conversion or tissue necrosis

a traumatic IPH involves an area of bleeding within the brain parenchymal or in the ventricles. these injuries can occur anywhere in the brain but are frequently located deep within vital regions, making sx intervention challenging and risky. thus, supportive care is often the mainstay of management

what changes first, LOC or pupils?

LOC!

you have an alert and oriented patient, then you check his pupils?

does this make sense?

what size shift usually requires sx intervention?

5mm or greater

what is the warfarin reversal agent?

4 factor prothombin complex/ K centra

or

vitamin K and FFP

k centra is usually preferred, patients require multiple units of FFP. can our elderly patients accomodate for almost an additional L in the circulatory system? no

early signs of neurological deterioration

confusion

nausea

agitation

drowsiness

impaired balance

when LOC decreases rapidly, which metabolic disturbance is the most likely cause

hypoglycemia

how do you calculate cerebral perfusion pressure (cpp)?

MAP - ICP

a single episode of hypotension and the TBI patient is twice as likely to die

a combination of hypotension and hypoxia, is associated with up to 75% mortality in TBI patients

TBI interventions

analgesics

sedatives

antipyretics

stool softeners

anticonvulsants

high dose barbiturates

neuromuscular blockate

TBI interventions- temperature specific

no real evidence suggests that hypothermia is beneficial

however, hyperthermia is clearly detrimental to the injured brain and should be aggressively avoided

nursing internvention for a patient that has had a craniectomy

protect the fontanelle!

in the absense of ICP monitoring, the brain injury guidelines recommend keeping SBP > 110 for most adults, but only ?100 for....

50-69 year olds

nose and navel alignment promotes venous drainage (it straightens the jugular veins) as does positioning patients with HOB up 30-45 degrees.

goal of care for the patient with a moderate or severe TBI include keeping pco2 between 35-40 and SPO2 above 90%

longterm outlook ( 5 years) for a patient with moderate -severe TBI

22% died

30% alive, but in worse condition

22 % unchanged

26 % improved

80% of elderly patients with a severe TBI will die in the hospital or require long term care

which of the following is a legally binding document concerning end-of-life preferences?

a. a signed organ donor card

b. wishes expressed to family members

c. an advance directive

d. a power of attorney form

an advanced directive

a cushing ulcer is a for of gastritis that occurs in patients with increased intracranial pressure and requires appropriate prohylaxis to prevent serious GI bleeding

Nurses are the most consistent and present healthcare professionals at most patient's bedside. Trauma nurses are available 24/7 to assess patients, interpret data, manage and troubleshoot equipment, give medications, perform nursing interventions, mobilize necessary resources, and support the patient and family. Nothing can substitute for the knowledge, vigilence, and expertise of a highly-skilled nurse at an injured patient's side.