Concussion:
- what is this?
- caused by?
- results in what?
WHat: trauma induced alteration in mental status may or may not involve loss of conciousness.
Concussion = Mild TBI
Caused by:
-direct blow to the head, face, neck, or body
Results in neuropathological changes- function not structural.
What is the glasgow coma scale?
Eye opening:
- spontaneous = 4
- response to verbal command = 3
- response to pain = 2
- no eye opening = 1
Best verbal response:
- oriented = 5
- confused = 4
- inappropraite words = 3
- incomprehensible sounds =2
- no verbal response = 1
Best motor response:
- obeys commands = 6
- localizing response to pain =5
- withdrawl response to pain = 4
- flexion to pain =3
- extension to pain =2
- no motor response =1
What is a TBI?
-what would their GCS score be for mild moderate and severe?
-head injury d/t contac and/or acceleration/deceleration forces
Mild TBI: 13-15 measured 30minutes after injury
Moderate TBI: 9-12
Severe TBI: less than 8
What are the two most common causes accounting for TBI?
What is the leading cause of death persons aged 1-45?
- MVAs
- Falls
-TBI is leading cause of death, males affected greater than females
what are the two phase of brain injury?
Primary: cortical contusion; may be coup or contracoup injury
- Coup= direct blow to brain
- Contracoup = injury to brain on opposite side of brain from where it was struck.
Phase 2: molecular injury mechanisms
- continues for hours to days
- free radical injury, apoptosis leading to ischemia
Describe mild and severe primary injury in TBI.
Severe: axonal rupture, can get generalized cerebral edema
Mild: diffuse axonal injury; leads to axonal swelling
TBI
- clinical features
- Sx
- signs
Clinical features: +/- LOC, confusion, stupor, amnesia
important to know how long theyve had them.
Sx: HA, dizziness, disorientation, N/V
Signs: vacant stare, inability to focus, gross in-coordination, memory difficulties, delayed verbal expression, slurred or incoherent speech, emotion out of proportion to events.
Complicated TBI
-what sx indicate a more serious injury or rising intracranial pressure?
- seizures
- focal neurologic signs
- worsening HA, confusion, lethargy
- protracted N/V
- other injury to head and neck
- decreasing GsC (repeat every 5-10mins)
Pt comes in with suspected TBI/concussion what would you like to examine?
pupils, are they moving their extremities, fingers, cranial nerves, moving facial muscles, strength, reflexes, orientation.
…the longer the frame of amnesia the more serious the injury!
Guidlines for CT scan in the ER?
- GSC less than 15
- open or depressed skull fx
- any sign of basilar skull fx: CSF leak
- two or more episodes of vomiting
- 65yrs or older
- amnesia impact of 3 or more minutes
- dangerous mechanism (ejected from vehicle)
- seizure
- intoxication
What are signs of basilar skull fx?
can you detect basilar skull fx on CT?
-raccoon eyes, battle signs, blood behind eardrum.
Basilar skull fx is hard to detect on CT, you will need MRI
CT scan abnormalities found with TBI?
- subdural hematoma
- intracranial bleeding
- cerebral edema
- skull fx
Who do we hospitalize with TBI?
GSC less than 15 or deteriorating
Abnormal CT
Seizures
abnormal bleeding parameters
those who do not have someone to care for them.
Outpatient Observation of TBI:
-what are signs you need to be aware of indicating that you should return to the ER?
- somnolence or confusion
- difficulties w/ vision
- severe or worsening HA
- urinary or bowel incontinence
- weakness or numbness
- unsteadiness or seizures
- N/V greater than 2x
Sequelae from TBI
- post-concussion syndrome
- post-traumatic HA
- post traumatic seizures
- post traumatic vertigo
- other cranial nerve injuries
- second impact syndrome (person develops second concussion before the first one resolves leading to brain swelling)
Post concussion syndrome:
- sx
- dx
- tx
Sx: HA, dizziness, neuropsychiatric, cognitive impairment including noise sensitivity
Dx: clinically with Hx, if severe sx get MRI
Tx:
- education
- resolves in 3mo
Coma:
- what is this?
- common causes
What: unarousable and unresponsive
Common Causes:
- TBI
- hypoxic ischemic encephalopathy (post CPR hypoxic brain)
- drug overdose
- intracranial hemorrhage
- CNS infection
- brain tumor
- bilateral and unilateral cerebral disorders
- brain stem disorders (IICP)
- systemic (toxins, metabolic=sepsis, renal/hepatic failure)
- endocrine (panhypopituitarism)
Coma pathophysiology
focal lesion in the upper brainstem can alter alertness by damaging the ARAS (ascending reticular activating system)
ARAS: neurons project from the pons/midbrain up to the cortex.
Coma related to toxic, metabolic, & infectious etiologies is not well understood.
What is decorticate posturing? decerebrate?
Decorticate posturing: UE addiction (flexion oat the elbows and fingers) w/ LE extension. Dysfunction of cerebral cortex or thalamic damage; better outcome.
Decerebrate: UE extension, adduction and pronation with LE extension. Injury to diencephalon, midbrain, or pons. Worse outcome,
Describe each of the following breathing patterns.
- cheyne stokes
- hyperventilation
- apneustic
- ataxic
Cheyne stokes: cyclic pattern, hypernea & apnea
Hyperventilation: increased RR.
Apneustic: prolonged pausee at the end of inspiration
Ataxic: irregular in rate and tidal volume.
Dx coma
figure out underlying cause via:
- neuroimaging (CT)
- LP
- EEG
- any lab you can think of
- Physical exam
Management of Coma
- protect airway
- hydrate
- monitor blood glucose and electrolytes
