-
Skull fractures can be either
vault or basilar
-
A vault skull fx is either
- linear or stellate
- Depressed or nondepressed
-
A basilar skull fx is either
- with/without CSF leak
- with/without nerve VII palsy
-
Intracranial lesions are either
-
focal intracranial lesions include
- epidural
- subdural
- intracerebral
-
diffuse intracranial lesions may be
- mild concussion
- classic concussion
- diffuse axonal injury
-
unilateral dialated pupil with sluggish or fixed light reflex
nerve III compression secondary to tentorial herniation
-
bilaterally dialated with suggish or fixed light reflex
- inadequate brain perfusion
- bilateral nerve III palsy
-
unilaterally dilated with cross reactive light reflex (marcus gun)
optic nerve injury
-
bilaterally miotic with difficult to assess light reflex
- drugs
- metabolic encephalopathy
- pontine lesion
-
unilaterally miotic with preserved light reflex
injured sympathetic pathway
-
brain injury from trauma results from
- primary brain injury
- secondary brain injury
-
primary brain injury
- Occurs at time of truama
- - cortical contusions
- - lacerations
- - bone fragmentation
- - diffuse axonal injury
- - brain stem contusion
-
secondary injury
- develops subsequent to initial injury
- - injury from intracranal hematomas
- - edema
- - hypoxema
- - ischemia (usually due to inc. ICP)
- - vasospasm
-
hypotension is attributed to head injury when
- terminal stages - due to dysfunction of medulla, CV collapse
- infancy - blood loss
- profuse scalp bleeding
-
delayed deterioration occurs in
15% who do not initially exhibit signs of significant brain injury
-
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
-
vascular events that may have a delayed presentation of deterioration
- dural sinus thronbosis
- carotic artery dissection
- SAH - ruptured aneurysm
- cerebral embolism
-
metabolic issues that may present with delayed deterioration
- hyponatremia
- hypoxia
- hepatic encephalopathy
- hypoglycemia
- adenal insufficiency
- drug and alcohol withdrawal
-
In hypoxia or hypoventilation
diagnostics
treatment
- ABG, respirtory rate
- Intubate pts with hypercarbia, hypoxemia, or if pt fails to localize
-
In hypotension or hypertension
diagnostics
treatment
- BP, Hemoglobin/Hct
- transfusion pts with significant loss of blood volume
-
In anemia
diagnostic
streatment
- Hbg/Hct
- transfuse pts with significant anemia
-
In seizures
diagnostics
treatment
- electrolytes, AED levels
- correct hyponatremia or hypoglycemia
- administer AEDs when appropriate
-
In infection or hyperthermia
diagnostics
treatment
- WBC, temperature
- LP if not contraindicated and meningitis is possible.
-
In spinal stability
diagnostics
treatment
- spine x-rays
- spine immobilization
-
Findings with low risk of intracranial injury
- asymptomatic
- HA
- dizziness
- scalp hematoma, laceration, contusion, or abrasion
- no moderate nor high risk criteria
-
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
-
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
-
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
-
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
-
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
-
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
|
|
