LOC/Coma

Question 1

1. What is a concussion?
2. Caused by?
3. What does this result in?
4. Resolution of clinical & cognitive sx follows a _______course?
5. Associated w/ what?

Answer 1

1. Trauma induced alteration in mental status may or may not involve loss of consciousness:
2. Caused by direct blow to head, face, neck or body
3. Result in neuropathological changes—functional not structural
4. sequential
5. grossly normal neuroimaging studies

Question 2

Glasgow Coma Scale

Answer 2

See picture

Question 3

1. What is a TBI?
2. MIld TBI is measured how?
3. Moderate is measured how?
4. Severe is measured how?

Answer 3

1. Traumatic Brain Injury (TBI): Head injury due to contact and/or acceleration and/or deceleration forces
2. Mild: GCS—13-15 measured 30 min after injury
3. Moderate: GCS—9-12 4. Severe: GCS

Question 4

Pts at high risk for a TBI?

Answer 4

Patients at higher risk: less than 5YO and > 60YO

Question 5

Etiologies of TBI? 7

Answer 5

1. MVAs (20-45%)
2. Falls (30-38%–increasing in the older patient)
3. Occupational accidents (10%)
4. Recreational accidents (10%)
5. Assaults (5-17%–increasing)
6. Contact sports—U.S.: 1.6-3.8 million sports-related concussions
7. Soldiers in combat

Question 6

1. Cortical contusion (direct trauma) is what?
2. Severe is characterized pathologically how?
3. Mild?

Answer 6

1. -Coup-direct blow to brain -Contrecoup-injury to brain on opposite side of brain
2. axonal rupture
3. Mild: diffuse axonal injury:

Question 7

What kind of axonal injury occurs in mild Cortical contusion? 2

Answer 7

• Disruption of axonal neurofilament organization
• Impairs axonal transport and leads to axonal swelling

Question 8

Describe the closed head injury (coup and contracoup)

Answer 8

Secondary and Primary impact

Question 9

Secondary Brain Injury

1. Begins when?
2. Continues for how long?

Answer 9

1. Begins quickly after primary phase
2. Continues for hours to days

Question 10

Secondary Brain Injury: Cascade of molecular injury mechanisms? 5

Answer 10

1. Neurotransmitter-mediated excitotoxicity causing glutamate, free-radical injury to cell membranes
2. Electrolyte imbalances
3. Mitochondria dysfunction
4. Apoptosis
5. Secondary ischemia from vasospasm, focal microvascular occlusion and vascular injury

Question 11

Clinical Features of TBI 4

Associated symtpoms? 4

Answer 11

1. (+) or (-) LOC,
2. confusion,
3. stupor,
4. amnesia
5. Headache
6. Dizziness
7. Disorientation
8. Nausea and vomiting

Question 12

Signs w/ TBI 7

Answer 12

1. Vacant stare
2. Inability to focus
3. Gross incoordination
4. Memory difficulties
5. Delayed verbal expression
6. Slurred or incoherent speech
7. Emotionality out of proportion to events

Question 13

What symptoms Indicates more serious brain injury or rising intracranial pressure (ICP)? 6

Answer 13

1. Seizures
2. Focal neurologic signs
3. Worsening HA, confusion, lethargy
4. Protracted N/V
5. Other injuries to head and neck
6. Decreasing GCS

Question 14

Amnesia almost always involves loss of memory of traumatic event and frequently includes loss of recall for events immediately before and after trauma. What does this tell us about the severity of the injury?

Answer 14

The longer the frame of amnesia the more serious the injury**

Question 15

Guidelines for CT Scan in the ER 9

Answer 15

1. GCS less than 15
2. Open or depressed skull fracture
3. Any sign of basilar skull fracture: CSF Leak, etc
4. Two or more episodes of vomiting
5. 65 years of age or older
6. Amnesia before impact of 3 or more minutes
7. Dangerous mechanism (ejected from vehicle, fall > 3 ft)
8. Bleeding diathesis or on oral anticoagulant
9. Seizure or focal neurologic sign Intoxication

Question 16

CT scan abnormalities indicating TBI? 4

Answer 16

1. Subdural hematoma
2. Intracranial bleeding
3. Cerebral edema
4. Skull fracture

Question 17

Review of brain injuries

Answer 17

See picture

Question 18

Management of TBI: Hospitalization for those at risk? (who should we admit) 4

Answer 18

1. GCS less than 15 or deteriorating
2. Abnormal CT 3. Seizures
3. Abnormal bleeding parameters

Question 19

If the pt has a GCS of 13-15 and a normal CT sacn what can we do?

Answer 19

Outpatient: (must have RESPONSIBLE companion!)

Question 20

Outpatient Observation: Why would we have to have them come back to the ER? 7

Answer 20

1. Somnolence or confusion
2. Difficulties w/ vision, severe or worsening HA
3. Urinary or bowel incontinence
4. Weakness or numbness involving any body part
5. Unsteadiness or seizures
6. Nausea/vomiting more than 2 episodes
7. Allow the patient to rest as needed but check on the patient and if any of the above occur return to ED

Question 21

Sequelae from TBI What are the some of these? 7

Answer 21

1. Post-concussion syndrome
2. Post-traumatic headaches
3. Post-traumatic seizures/epilepsy
4. Post-traumatic vertigo
5. Other cranial nerve injuries
6. Second impact syndrome
7. Cumulative neuropsychological impairment:

Question 22

1. What are raccoon eyes a sign of?
2. What is the battle sign a sign of?
3. What does blood behind the TM tell us?

Answer 22

1. basilar skull fracture
2. Subdural hematoma
3. Hemitympani- CSF flud coming out of nose or ears

Question 23

1. What is post concussion syndrome?
2. Symptoms? 4

Answer 23

1. direct brain injury/psychogenic

2.

• Headache
• Dizziness
• Neuropsychiatric
• Cognitive impairment including noise sensitivity

Question 24

PCS diagnosis? 2

Treatment? 4

Answer 24

1. Clinically and w/ history
2. If severe sx and patient hasn’t had MRI-get one!
3. Education, education, education!!!
4. Minimize meds, but use appropriately—low dose
5. Typically resolves by 3 months 90% of the time\
6. May need more extensive neurocognitive rehab

Question 25

What is the definition of a Coma?

Answer 25

“unarousable and unresponsive” Lasts \> 1 hour

Question 26

Common etiologies of coma? 6

Answer 26

1. TBI 2. Hypoxic-ischemic encephalopathy (HIE)- heart is going brain is not 3. Drug overdose 4. Intracranial hemorrhage 5. CNS infections 6. Brain tumors

Question 27

Primary cerebral disorders: Bilateral? 8 Unilateral? 4

Answer 27

1. TBI 2. Malignancy 3. Ischemia 4. Infections 5. Hemorrhage 6. Status epilepticus 7. HIE 8. Hydrocephalus 1. Trauma (subdural hematoma, etc) 2. Large hemispheric stroke 3. Cerebral abscess 4. Tumor

Question 28

Coma Pathophysiology is caused by lesions that affect what?

Answer 28

Focal lesions to the upper brainstem can alter alertness by damaging the ARAS -Ascending reticular activating system (ARAS)

Question 29

Coma: Obtained from family, witnesses, medical personnel, questions to ask? 5

Answer 29

1. Time course of LOC 2. Focal signs or symptoms precede? 3. Did patient have previous neurologic episode? 4. Recent illness, fever, HA, falls, confusion? 5. Prescription drugs, illicit drugs or alcohol?

Question 30

Coma: PE? 4

Answer 30

1. LOC 2. Brainstem reflexes 3. Pupillary light, extra-ocular and corneal reflexes 4. Motor exam

Question 31

What should we do on the motor exam?3

Answer 31

1. Assess muscle tone 2. Spontaneous and elicited movement- note if asymmetric 3. Reflexes

Question 32

1. Describe decorticate posturing. 2. Wheres the dysfunction? 3. Prognosis?

Answer 32

1. UE adduction, (flexion at the elbows and fingers) with LE extension (plantar flexion and inversion 2. Dysfunction of cerebral cortex or thalamic damage 3. (better prognosis)

Question 33

1. Describe Decerebrate posturing? 2. Where is the dysfunction? 3. Prognosis?

Answer 33

1. UE extension, adduction and pronation with LE extension 2. Injury to caudal diencephalon, midbrain or pons 3. Poorer prognosis

Question 34

What is Cheyne-stokes and what is it seen in 2?

Answer 34

1. cyclic pattern, hypernea and apnea— 2. seen patients w/ -bilateral hemispheric or -diencephalic insults

Question 35

Hyperventilation happens in an injury to what? 2

Answer 35

1. injury to pontine or 2. midbrain tegmentum

Question 36

What is Apneustic breathing and where is the injury? 2

Answer 36

1. prolonged pause end of inspiration 2. indicates lesions to mid- and caudal pons

Question 37

What is Ataxic breathing and what is it an injury to?

Answer 37

1. irregular in rate an tidal volume 2. damage to medulla

Question 38

Goal: identify treatable causes? 5 Treatment? 5

Answer 38

1. Infection, 2. metabolic abnormalities, 3. seizures, 4. intoxications/overdoses, 5. surgical lesions 1. Give O2, 2. thiamin, 3. fluids, 4. Narcan, 5. glucose

Question 39

What do Papilledema/focal neurologic findings suggest?

Answer 39

structural etiology—urgent brain CT

Question 40

Diagnosis of coma: What labs should we order? 6

Answer 40

1. Complete blood count 2. Electrolytes, 3. glucose, 3. thyroid, 4. kidney and liver function 5. Carbon monoxide poisoning 6. Drug or alcohol overdose

Question 41

Management of Cma? 3

Answer 41

INDENTIFY TREATABLE CAUSE 1. Protect airway 2. Hydrate 3. Monitor blood glucose and electrolytes