Head Injury and Traumatic Brain Injuries
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Questions and Answers

What is the primary indication for a CT scan in a patient with a head injury?

  • Loss of consciousness
  • Focal neurological deficits
  • Skull fracture
  • All of the above (correct)

    • What is the total Glasgow Coma Scale (GCS) score for a patient who is intubated, opens their eyes to pain, and briskly localizes?

  • 7
  • 6
  • 8 (correct)
  • 9

    • What is the primary limitation of a skull X-ray in the trauma setting?

  • It wastes time (correct)
  • It is not indicated in patients with a GCS ≤ 14
  • It is not sensitive for skull fractures
  • It is not specific for skull fractures

    • What is an indication for observation at home in a patient with a head injury?

    <p>Normal CT and GCS 15</p> Signup and view all the answers

    What is a sign of a skull base fracture?

    <p>Raccoon eyes</p> Signup and view all the answers

    What is the primary goal of autoregulation?

    <p>To maintain a constant intracranial pressure</p> Signup and view all the answers

    What is the primary indication for cervical spine X-ray?

    <p>Patients with a mechanism of injury that suggests cervical spine injury</p> Signup and view all the answers

    What is the term for the point at which the intracranial pressure increases rapidly?

    <p>Point of decompensation</p> Signup and view all the answers

    What percentage of traumatic brain injuries are caused by transportation?

    <p>44%</p> Signup and view all the answers

    What is the term for the disturbance of behavioral or emotional functioning resulting from traumatic brain injury?

    <p>Behavioral dysfunction</p> Signup and view all the answers

    What is the name of the doctrine that relates to the interplay between the brain, cerebrospinal fluid, and venous blood in the skull?

    <p>Monro-Kellie Doctrine</p> Signup and view all the answers

    What is the approximate annual mortality rate of children from road traffic accidents in South Africa?

    <p>3.89 per 100,000</p> Signup and view all the answers

    What is the primary mechanism of traumatic brain injury?

    <p>External physical force</p> Signup and view all the answers

    What percentage of traumatic brain injuries are caused by firearms?

    <p>8%</p> Signup and view all the answers

    What is the level of Glasgow Coma Scale associated with coma or severe head injury?

    <p>GCS &lt; 8</p> Signup and view all the answers

    What is the main goal of operative and non-operative strategies in managing head injuries?

    <p>Reducing mass effect and ICP</p> Signup and view all the answers

    What is the cutoff for hypoxia in terms of PO2?

    <p>PO2 &lt; 60 mmHg</p> Signup and view all the answers

    What is the consequence of a single episode of hypotension in motorbike crashes?

    <p>&gt; 50% increase in mortality</p> Signup and view all the answers

    What is the term for a patient who is awake but unaware of their surroundings?

    <p>Vegetative state</p> Signup and view all the answers

    What is the imaging study of choice in the acute assessment of head injury?

    <p>CT</p> Signup and view all the answers

    What is a primary indication for re-admission in a patient with a head injury?

    <p>Fever</p> Signup and view all the answers

    What is the primary goal of preventing secondary brain injury?

    <p>Maintaining adequate oxygenation and blood pressure</p> Signup and view all the answers

    What is the recommended glucose control in a patient with a head injury?

    <p>Normoglycaemic state</p> Signup and view all the answers

    What is the target cerebral perfusion pressure (CPP) in a patient with a head injury?

    <p>60 mmHg</p> Signup and view all the answers

    What is the indication for ICP monitoring in a patient with a head injury?

    <p>GCS ≤ 8</p> Signup and view all the answers

    What is the normal range of brain tissue oxygen tension (PbtO2) in a patient with a head injury?

    <p>20-35 mmHg</p> Signup and view all the answers

    What is the most important prognostic factor in a patient with a head injury?

    <p>Age</p> Signup and view all the answers

    What is the recommended head elevation in a patient with a head injury?

    <p>30 degrees</p> Signup and view all the answers

    Study Notes

    Head Injury

    • Traumatic brain injury is an insult to the brain caused by an external physical force, resulting in a diminished or altered state of consciousness and impairment of cognitive abilities or physical functioning.

    Anatomy

    • Scalp
    • Skull
    • Brain

    Epidemiology

    • Transportation accounts for 44% of traumatic brain injuries
    • Falls account for 26% of traumatic brain injuries
    • Other causes include: • Firearms (8%) • Non-firearm assaults (9%) • Annual mortality of children from road traffic accidents is 3.89 per 100,000

    Pathophysiology

    • Primary vs secondary brain injury
    • Monro-Kellie doctrine: the concept of a fixed volume of the cranial vault, where an increase in one component (blood, CSF, or brain tissue) leads to a decrease in another

    Concepts

    • Autoregulation
    • Volume-pressure curve: • 60-55 mmHg: herniation • 50-40 mmHg: point of decompensation • 30-20 mmHg: compensation • 15-10 mmHg: volume of mass

    Classification of Head Injury

    • Glasgow Coma Scale (GCS): • Eye opening: 1-4 points • Verbal response: 1-5 points • Motor response: 1-6 points • Total GCS: 3-15 points
    • Clinical scenario: a 20-year-old male in a motor vehicle accident, intubated, with a GCS score of 8

    Approach to Head Injury

    • History: • Mechanism of injury • Loss of consciousness • Vomiting • Seizures • Intoxicants • Post-traumatic amnesia
    • Clinical examination: • Dilated non-reactive pupils • Hemiplegia/hemiparesis • Aphasia/dysphasia • Facial weakness • Cranial nerve palsy • Papilloedema
    • Signs of skull base fracture: • Raccoon eyes • Battle sign

    Investigations

    • Skull X-ray: useful only for detecting skull fractures, but may waste time in the trauma setting
    • CT scan: • Indications:
      • GCS ≤ 14
      • Focal neurological deficits
      • Deteriorating GCS
      • Penetrating head injuries
      • Post-traumatic seizures
      • Loss of consciousness and amnesia
      • Multiple trauma
      • Skull fracture
      • Patients who are intoxicated
      • Patients on anti-coagulant therapy
      • Mechanism of injury • Indications for observation at home:
      • Normal CT
      • GCS 15
      • No focal deficits
      • Easy access to ER
      • Responsible adult to observe at home
      • No complicating circumstances • Indications for re-admission:
      • Drowsiness
      • CSF leak
      • Seizures
      • New focal deficit
      • Fever

    Pathology

    • Primary injury: • Acute extradural hematoma • Acute subdural hematoma • Contusion/intracerebral hematoma • Diffuse cerebral injury • Skull fracture • Gunshot injuries • Penetrating stab injuries • Concussion in sports • Non-accidental injury
    • Secondary brain injury: • Prevention: maintain Po2 > 60 mmHg, systolic BP > 90 mmHg, glucose control, and appropriate IV fluids • Conservative management:
      • GCS 13-15
      • No focal deficits
      • Neurological observations: ICU/high care (hourly) • Surgical management:
      • ICU management:
        • General measures:
          • Head elevation 30 degrees
          • Neck neutral position
          • Urinary catheter
          • Analgesia
          • Gastro-protective agents
          • Anti-seizure prophylaxis
          • DVT prophylaxis
          • Nutrition
          • Fluids
        • Medical management:
          • Ventilation: PCo2 30-35 mmHg
          • Sedation
          • Mannitol
          • Hypertonic saline
        • General monitoring:
          • ECG
          • Saturations: 100%
          • Systolic BP: > 90 mmHg
          • Pulse
          • Temperature: maintain euthermia or mild hypothermia
          • CVP: 8-14 mmHg
          • Glucose: normoglycemic
        • ICP monitoring:
          • Indications:
            • GCS ≤ 8
            • Polytrauma
            • Prolonged ventilation
            • Hypotension
            • Posturing
          • ICP > 20 mmHg: abnormal
        • Brain tissue oxygen tension (PbtO2) monitoring:
          • Normal values: 20-35 mmHg
        • Cerebral perfusion pressure (CPP):
          • CPP = MAP – ICP
          • Targeted value: 60 mmHg
          • Values < 50 mmHg: cerebral ischemia and hypo-perfusion
          • Values > 70 mmHg: cardiorespiratory failure, ARDS

    Prognostic Factors

    • Age: younger patients have a greater potential for survival and recovery
    • Mechanism of injury: e.g., motorbike crashes
    • GCS < 8
    • ICP > 45
    • Hypotension: > 50% increase in mortality with a single episode of hypotension
    • Hypoxia: PO2 < 60 mmHg, Sats < 90%

    Glasgow Outcome Scale

    • 1: Dead
    • 2: Vegetative state
    • 3: Severe disability
    • 4: Moderate disability
    • 5: Mild disability

    Late Complications

    • Post-traumatic seizures
    • Hydrocephalus
    • Infections
    • Post-concussive syndrome: • Somatic: headaches, dizziness, anosmia, hearing difficulties, balance difficulties • Cognitive: difficulty concentrating, dementia, impaired judgment • Psychosocial: emotional problems, personality changes, loss of libido, tiredness, difficulty sleeping

    Multidisciplinary Team

    • Physiotherapists
    • Occupational therapists
    • Psychologists
    • Social workers
    • Nurses
    • Doctors

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    Description

    This quiz covers the basics of head injuries, including traumatic brain injuries, anatomy, and epidemiology. Topics include the causes, consequences, and statistics of head injuries.

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