Chapter 16 Closed Head Injury

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mbrieger
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112062
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Chapter 16 Closed Head Injury
Updated:
2012-06-18 12:21:45
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Chapter 16 Closed Head Injury
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Chapter 16 Closed Head Injury
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  1. Skull fractures can be either
    vault or basilar
  2. A vault skull fx is either
    • linear or stellate
    • Depressed or nondepressed
  3. A basilar skull fx is either
    • with/without CSF leak
    • with/without nerve VII palsy
  4. Intracranial lesions are either
    • focal
    • diffuse
  5. focal intracranial lesions include
    • epidural
    • subdural
    • intracerebral
  6. diffuse intracranial lesions may be
    • mild concussion
    • classic concussion
    • diffuse axonal injury
  7. unilateral dialated pupil with sluggish or fixed light reflex
    nerve III compression secondary to tentorial herniation
  8. bilaterally dialated with suggish or fixed light reflex
    • inadequate brain perfusion
    • bilateral nerve III palsy
  9. unilaterally dilated with cross reactive light reflex (marcus gun)
    optic nerve injury
  10. bilaterally miotic with difficult to assess light reflex
    • drugs
    • metabolic encephalopathy
    • pontine lesion
  11. unilaterally miotic with preserved light reflex
    injured sympathetic pathway
  12. brain injury from trauma results from
    • primary brain injury
    • secondary brain injury
  13. primary brain injury
    • Occurs at time of truama
    • - cortical contusions
    • - lacerations
    • - bone fragmentation
    • - diffuse axonal injury
    • - brain stem contusion
  14. secondary injury
    • develops subsequent to initial injury
    • - injury from intracranal hematomas
    • - edema
    • - hypoxema
    • - ischemia (usually due to inc. ICP)
    • - vasospasm
  15. hypotension is attributed to head injury when
    • terminal stages - due to dysfunction of medulla, CV collapse
    • infancy - blood loss
    • profuse scalp bleeding
  16. delayed deterioration occurs in
    15% who do not initially exhibit signs of significant brain injury
  17. Etiologies of the 15% of pts that deteriorate in delayed fashion
    • 75% intracranial hematoma
    • posttraumatic diffuse cerebral edema
    • HCP
    • tension pneumocephalus
    • seizures
    • metabolic abn
    • vascular events
    • meningitis
    • hypotension
  18. vascular events that may have a delayed presentation of deterioration
    • dural sinus thronbosis
    • carotic artery dissection
    • SAH - ruptured aneurysm
    • cerebral embolism
  19. metabolic issues that may present with delayed deterioration
    • hyponatremia
    • hypoxia
    • hepatic encephalopathy
    • hypoglycemia
    • adenal insufficiency
    • drug and alcohol withdrawal
  20. In hypoxia or hypoventilation
    diagnostics
    treatment
    • ABG, respirtory rate
    • Intubate pts with hypercarbia, hypoxemia, or if pt fails to localize
  21. In hypotension or hypertension
    diagnostics
    treatment
    • BP, Hemoglobin/Hct
    • transfusion pts with significant loss of blood volume
  22. In anemia
    diagnostic
    streatment
    • Hbg/Hct
    • transfuse pts with significant anemia
  23. In seizures
    diagnostics
    treatment
    • electrolytes, AED levels
    • correct hyponatremia or hypoglycemia
    • administer AEDs when appropriate
  24. In infection or hyperthermia
    diagnostics
    treatment
    • WBC, temperature
    • LP if not contraindicated and meningitis is possible.
  25. In spinal stability
    diagnostics
    treatment
    • spine x-rays
    • spine immobilization
  26. Findings with low risk of intracranial injury
    • asymptomatic
    • HA
    • dizziness
    • scalp hematoma, laceration, contusion, or abrasion
    • no moderate nor high risk criteria
  27. Findings with moderate risk of intracranial injury
    • hx of change or LOC on or after injury
    • Progressive HA
    • EtOH or drugs
    • posttraumatic seizure
    • unreliable hx
    • age <2
    • vomiting
    • posttraumatic amnesia
    • signs of basilar skull fx
    • multiple trauma
    • serious facial injury
    • possible skull penetration or depressed fx
    • suspected child abuse
    • significant subgaleal swelling
  28. criteria for home observation of head injury
    • normal cranial CT
    • initial GCS>=14
    • no high risk criteria
    • no moderate risk criteria
    • pt now neuro intact
    • responsible sober adult available to observe pt
    • pt has access to return to ED
    • no complicating circumstances - violence
  29. findings wtih high risk of intracranial injury
    • depressed level o consciousness no due to EtoH, drugs, metabolic abnormalities, postictal state
    • focal neurological findings
    • dcreased LOC
    • penetrating skull injury or depressed fx
  30. skull x-rays are helpful when
    • moderate risk of ICI/CT better
    • if CT cannot be obtained may identify
    • - pineal shift
    • - pneumocephalus
    • - air fluid levels of air sinuses
    • - skull fx
    • penitrating injuries - may help see object
  31. Follow up CT recommendations for severe head injuries patient that are stable
    • some recommend at within hours to 24hrs
    • 3-5 days
    • 10-14 days
    • perform if pt deteriorates
    • - neurogolically
    • loss of 2 or more GCS points
    • hemiparesis
    • new pupilary asymetry
    • - persistent vomiting
    • - worsening H/A
    • - seizures
    • - unexplained rise in ICP
  32. Follow up CT recommendations for mild to moderate head injuries patient that are stable
    • repeat prior to discharge
    • stable + mild injury + neg CT --> no f/u CT

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