Lecture 1

Question 1

1. s/s

2. s/p

Answer 1

1. signs and symptoms

2. satus post (patient is being seen after an surgery)

Question 2

1. Signs
2. Symptoms
3. SOA

Answer 2

1. Signs are what the clinician finds upon examination
2. Patients report symptoms (ex. sore throat)
3. Short of air

Question 3

Traumatic Brain Injury

Answer 3

• TBI, insult to the brain that is not degenerative (progressive) or congenital nature (birth). Caused by an external force that may produce a diminished or altered state of conciousness. Can be caused by a shake, slap, fall, or bullet.

Question 4

Epidemiology of TBI

Answer 4

• 1.5-1.9 million TBIs occur annually
• # 1 cause of disability in kids and young adults
• Risk factors for TBI are determined by age, ethnicity, SES, gender, substance abuse, or recurrent TBI
• Myelin (lipoprotein) not complete until 25
• We care about infants and children with this because it inhibits their growth and learning.

Question 5

Risk factors for TBI

Answer 5

• Increased risk for persons age 15-24y
• Males > Females; 2:1
• Race is too variable
• One study found that approximately 56% of persons with TBI had a high blood OH+ level (alcohol)
• Mayo Clinic found that risk for recurrent TBI increased 2.8-3.0x for a second TBI and 7.8-9.3x for a third TBI

Question 6

Closed Head Injury

Answer 6

• CHI-Non-penetrating; Blunt Head Trauma
• Meninges remain intact
• Skull may be fractured-brain has not been exposed
• Associated with diffuse injury
• More common than OHI (children with shaking baby syndrome) damage is widespread

Question 7

Open Head Injury

Answer 7

• OHI- Penetrating wound
• Coverings of the brain are ruptured due to tearing of the dura by skull fragments and/or other penetrating force
• Associated with focal injury; More common in wartime (specific location in the brain)

Question 8

TBI Etiologies

Answer 8

• Falls are the most common cause of TBI per age overall
• MVA (motor vehicle accidents) acount for 50% of TBIs persons age 15-24
• Brain Injury (BI) impacts 1in5 households (KY)
• KY BIs are (2x) USA average
• 1/3 of ED visits are due to BI
• A child’s skull is 1/8th as strong as an adults
• KY has highest # of ATV fatalities

Question 9

Brain Injury and Sports/Recreation

Answer 9

• BI is #1 cause of sports deaths.
• 65% of sports BI occur in ages 5-18y
• Activities that cause greatest # of ED visits are bicycling, football, playground activities, basketball, horseback riding, and riding ATVs
• < 13% of sports related BI are seen in ED
• number of concussion rates are rising in females and they sustain more than males in
  sports played by both sexes
• Football players have a high occurrence of mTBI
• Concussions are mTBI

Question 10

Primary Brain Damage

Answer 10

• Damage that happens at time of impact:Skull fracture
• Contusion (Bruise)
• Hematoma (Blood Clot- collection of blood)
• Laceration (cut)
• Nerve Damage (DAI- diffuse axonal injury- widespread)
• Part(s) of the brain damaged > than the size of the overall injury

Question 11

Secondary Brain Damage

Answer 11

Damage that evolves over time following BI:

• Edema (swelling)
• Anemia
• Cardiac changes
• Increased ICP (intracranial pressure)
• Epilepsy- seizures
• Pulmonary changes
• Infection (especially with OHI)
• Hypo/Hyperthermia
• Nutritional changes
• Fever (febrile (low fever) )
• Abnormal Blood Coagulation (clotting issues)
• Other

Question 12

Closed Head Injury

Answer 12

• BI that occurs secondary to impact causing deformation of the brain resulting in characteristic pathological changes
• MVAs, assaults, suicides, falling objects, and falls
• Leading cause of death under the age of 45y

-Accounts for 25-33% of all deaths related to trauma

Question 13

Coup/Contrecoup injuries

Answer 13

brain acceleration vs. deceleration-deceleration of the brain- KNOW THIS- head and brain moves forward (hits the steering wheel and then the head slams back with the brain as it hits the chair)

Question 14

Penetrating Head Injury

Answer 14

• Penetrating head injuries are less common than CHI (OHI)
• Occur secondary to the penetration of an object be it a: bullet, knife, bolt, shrapnel, nails, teeth, screwdriver, or the Eiffel Tower
• These injuries are often described as being: depressed, penetrating, or perforating
• Mortality rate appears lower for AP (anterior/posterior) wounds (25%) than lateral wounds (83%)

Question 15

Depressed Head Injury

Answer 15

Object does not enter the cranial vault but causes a depressed fracture and cortical contusions

Question 16

Penetrating Head Injury

Answer 16

Object enters the cranial cavity but does not pass through to the other side

Question 17

Perforating Head Injury

Answer 17

Object traverses the cranial cavity and exits through a wound characteristically larger than the entry wound

Question 18

TBI and the military

Answer 18

Recent warring activities in the Middle East, the US is now treating more TBIs than chest or abdominal wounds
As many as 1/3rd combat forces are at risk for TBI
In Iraq/Afghanistan, the ratio of wounded to fatalities is 16:1; while in Vietnam it was 2.6:1
TBI is separate from PTSD but both are co-related

Question 19

Blast Injuries

Answer 19

• Explosion resulting in over-pressurization related trauma
• Blast-induced BI associated most frequently with high-power explosives
• There are four (+) basic mechanisms of blast injury labeled as:
• Primary
• Secondary
• Tertiary
• Quaternary
• Quinary
• Psychological Trauma (PTSD)

Question 20

Blast Injury Breakdown

Answer 20

• Primary: Occurs secondary to over-pressurization impulse created by a detonated high-explosive usually impacting the auditory, GI, and/or pulmonary systems- can cause rupture of tympanic membrane or abdomen
• Secondary: Injuries that occur secondary to flying objects
• Tertiary: Injuries sustained due to the person becoming airborne
• Quaternary: References burns and crushing injuries from falling objects
• Quinary: Chemical, biological, and/or radiological exposure

Question 21

Explosives

Answer 21

• Explosives are categorized as either high-order or low-order types
• High Order (HE): TNT, dynamite, ammonium nitrate
• Low Order (LE): Result in shrapnel-like injuries
• Improvised Explosive Devices (IEDs): Contain both HE and LE

Question 22

Concussion

Answer 22

• Concussion is an injury to the brain that is loosely defined as a “jarring” of the brain
• Concussion is the most common type of TBI
• Frequently occurs secondary to violent shaking, a direct blow to the head, or whiplash

Question 23

Concussion Grading

Answer 23

1. Grade 1- no LOC
   PTA< 30 mins
2. Grade 2- LOC< 5 mins
   PTA (< 30 mins- PTA < 24 hours
3. Grade 3- LOC >5 mins
   PTA > 24 hours

Question 24

Pyramidal System

Answer 24

The pyramidal system is responsible for volitional motor control; Direct activation pathways

Question 25

Extrapyramidal System

Answer 25

The extrapyramidal system is responsible for modulating and regulating motor movements; Indirect activation pathways.

Question 26

Cerebellum

Answer 26

The cerebellum does not initiate movement, rather it works in tandem with the EPS to maintain balance/posture and coordination of motor movements; includes motor learning

Question 27

Dementia Pugilistica

Answer 27

- Punch-Drunk Syndrome or Chronic Traumatic Encephalopathy- common in boxers - Occurs secondary to repeated concussive blows to the head- could be repeated grade 1 concussions -Estimated that 10-25% of boxers ultimately develop post-boxing neurological syndrome characterized by cerebral atrophy, cellular loss in the cerebellum, and increased cortical and subcortical neurofibrillary tangles s/s may begin to appear 12-16y post initiation of boxing career -Occurs in both professionals and amateurs; NOT JUST BOXING

Question 28

Dementia Pugilistic Stages

Answer 28

1. Stage 1- affective disorder (mood or attention), mild incoordination 2. Aphasia, apraxia, agnosia (sensory), apathy (indifferent), flat affect, neuro s/s 3. Global cognitive decline and parkinsonism

Question 29

Second Impact Syndrome

Answer 29

- Occurs when a second TBI occurs prior to the initial one healing - causes edema and diffuse damage - LOC does not have to be present

Question 30

Long term implications of Second Impact Syndrome

Answer 30

- Increased muscle tone (spasticity) - Rapidly changing emotions - Muscle spasms - Hallucinations - Difficulty thinking and learning

Question 31

TBI infancy and childhood

Answer 31

-Mean incidence under 15 is 180 per 100K (thousand) - Fracture of skull is seen in 20-40% of cases - Abusive head trauma (25% of children <2y) -Names for abusive head trauma: Non-Accidental Trauma, Shaken Baby Syndrome, Child Maltreatment, Child Abuse (all used) -SDH is the most common intracranial injury following abuse

Question 32

Children with TBI: Symptoms

Answer 32

- Children with TBI may lack the communication skills to report headaches, sensory problems, confusion, and/or similar symptoms: - Refusing to eat - Appear listless and cranky - Altered sleep patterns - Changes in school performance - Loss of interest in preferred activities

Question 33

Abusive head trauma

Answer 33

- Improper name-nonaccidental trauma and shaking baby syndrome SBS is the leading cause of child abuse deaths in the USA -KY is #1 -Babies (newborn to 4m) are at greatest risk of shaking -Inconsolable crying is the #1 trigger for shaking a baby -1 in 4 babies that are shaken will die -It is rare that a single instance of noted injury present in the ED is the first occurrence; there is usually a chronic history of abuse

Question 34

Possible Abusive Head Trauma

Answer 34

- Glassy-Eyed; Fixed Pupils; Fixed Stare - Somnolence (Sleepiness); Inactivity - Choking - Rigidity - Seizures - Resp. problems - Inability to lift head/ turn head to the side - Decreased appetite - Lethargy and irritability - Vomiting - Retinal Hemorrhage - Bluish Color

Question 35

Diffuse Axonal Injury

Answer 35

- DAI references the neuropathological changes that occur at the axonal level following trauma - Damage results from twisting, tearing, and/or shearing of the axon - Occurs as a person is shaken, and the brain is sloshed around, axons shift or tear, diffuse and happens in greater clumps.

Question 36

Cerebral Edema

Answer 36

- Brain swelling - Frequently follows trauma; appears to be more of a secondary injury than a primary injury - Focal edema is more common in adults whereas diffuse edema is more common in pediatrics - Cerebral edema results in increased cranial pressure or ICP

Question 37

Intracranial Pressure

Answer 37

-ICP should be <20mmHg (millimeters of Mercury) when exceeded, neurosurgical intervention is necessary -There are at least three mechanisms by which intracranial pressure can be monitored: 1. EVD- extraventricular drain (or intraventricular catheter); thin, flexible tube threaded into one of the two lateral ventricles 2. Screw/bolt- placed into the space between arachnoid membrane and cortex (subarachnoid bolt/screw) 3. Epidural Sensor- placed in the epidural space below skull EVD and Screw Bolt are more common

Question 38

Fontanelle

Answer 38

- Baby's soft spot. Allows for a greater amount of movement for cerebral edema. - Bulging fontanelle- increased CSF in the brain (hydrocephalus) and causes craniocinaosis- abnormal head shape

Question 39

Monroe-Kellie Hypothesis

Answer 39

- The MKH states that the cranial compartment is incompressible; meaning, the volume is fixed and should not change - The skull, CSF, and brain tissue create a volume equilibrium such that any increase in volume of one of the cranial constituents must be compensated by a decrease in the volume of another Tumor is a violation of this hypothesis, also a hematoma

Question 40

Brain shift and herniation

Answer 40

If a hematoma continues to enlarge or focal edema of adjacent brain tissue increases, the brain may be shifted away from the growing mass, and structures that normally lie in the midline may be displaced

Question 41

Cushing's Triad

Answer 41

-Significant sign of intracranial HTN -Precursor to herniation Comprised of three components: 1. Hypertension- high blood pressure (33% chance of herniation) 2. Bradycardia- slow heart beat 3. Resp. irregularity