HEAD INJURIES

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Normal intracranial pressure

1-15mmHg

2 neuropsychologic factors that are associated with a decreased prognosis following a head injury

1. Being over the age of 30 2. Less education

2 categories of focal brain injuries

1. Contusion 2. Hematoma

8 principal symptoms of temporal lobe damage

1. Disturbance auditory sensation and perception 2. Disturbance of selective attention of auditory and visual input 3. Disorders of visual perception 4. Impaired organization and categorization of verbal material 5. Disturbance of language comprehension 6. Impaired long-term memory 7. Altered personality and affective behavior 8. Altered sexual behavior

3 main factors contributing to the overall severity of a head injury

1. Edema 2. Increased intracranial pressure 3. Poor circulation of blood to the brain

2 main goals of the acute phase of treatment for a head injury

1. Monitor ICP 2. Treat if an increase in ventilation, swelling, hematoma

4 classifications used in describing a TBI

1. Penetrating vs. Nonpenetrating (mechanism) 2. Severity (mild/mod/severe) 3. Pathophysiology (primary [impact], secondary [swelling etc.]) 4. Patho-anatomical (diffuse, focal, mixed)

In terms of a head injury, a CT scan will be used to assess what 3 residual affects of the injury

1. Swelling 2. hematoma 3. Infarction

A persistent vegetative state is most often due to what 2 types of head injuries

1. anoxia (severe deficiency of oxygen 2. DAI

3 descriptions for forces in context to head injuries

1. coup (primary impact) 2. contracoup (secondary impact) 3. shearing (rotational)

Name a few of the cytologic changes that occur secondary to brain injury

1. demyelination 2. Pro-apoptotic cascade 3. Apoptosis 4. cerebral edema 5. Inflammatory cytokines 6. Vasogenic edema 7. etc. etc. etc.

2 categories of diffuse brain injuries

1. diffuse axonal injury 2. hypoxic-ischemic injury

4 major sequelae associated with a brain contusion

1. disinhibition 2. apathy 3. amnesia 4. aphasia

2 common causes that lead to CNS infection as a secondary neurologic complication

1. evacuation of fluid from the CNS space, such as with a hemorrhage 2. introduction of blood borne pathogens crossing the blood brain barrier

3 factors following a head injury that lead to a poor prognosis

1. loss of pupillary function 2. Long duration of post traumatic amnesia 3. Diffuse axonal injury

When examining a person whose suffered an injury what 2 general S/S are you looking for that might indicate an epidural hematoma

1. pupillary changes 2. bleeding of the skull

Name the order of meningeal layers starting from the skin to the brain

1. skin 2. periosteum 3. skull 4. dura mater 5. arachnoid 6. pia mater

4 mechanisms of force to cause injury to the axon in a DAI

1. twist 2. compressed 3. sheared 4. stretched

Cerebral perfusion of < __ mmHg will lead to cell death in brain tissue

10mmHg

A mild head injury is scored between what range on the GCS

13-15

Most concussions score at what range on the GCS

14-15

Normally you would notice a subdural hemorrhage in what general time frame

24-72 hours

Normal volume of blood needed per 100g of brain tissue

25cc

__-__% of athletes will experience concussion

5-10%

Females playing soccer have a __% chance of acquiring a concussion

50% chance

___% - ___% of DAI injuries can have normal CT

50-80%

Normal cerebral perfusion should be __ mmHg

60 mmHg

Males playing football have a __% chance of acquiring a concussion

75% chance

A severe head injury is scored between what range on the GCS

8-3

A moderate head injury is scored between what range on the GCS

9-12

what is the mortality rate % for a person with bilateral loss of pupillary function

95% mortality rate

A subdural hematoma is most often due to hemorrhaging of what vessel type

venous

An intraparenchymal hematoma would be forming where

within the brain tissue

T/F - A DAI is often missed on a CT & MRI scan

True

A person who is awake though responses to stimuli are reduced and movements are without purpose is said to be at what level on the Glasgow outcome scale

Vegetative state

What are the 4 levels (not including the 5th death) of the Glasgow Outcome Scale

Vegetative state Severe disability Moderate disability Good recovery

A typical time frame for a person to be in a coma, as stated by the PPT

a few days to about several weeks

Residual sequelae associated with hypoxic-ischemic injury

amnesia, dementia, persistent vegetative state (PVS), persistent cognitive deficits including memory deficits and bradyphrenia (slowness of thoughts)

An epidural hematoma is most often due to hemorrhaging of what vessel type

arterial

An epidural hemorrhage can be generally described as what shape on a CT scan?

biconvex

Contusions tend to be more often cortical or sub-cortical

cortical

Term used to describe as a certain level of consciousness defined as: disorientation, fear & agitation

delirium

Focal contusion in the skull typically affect what lobes of the brain

frontal and temporal

2 most common sites of hypoxic-ischemic injury

hippocampus, neocortex

The initial sequelae associated with diffuse axonal injury (DAI)

initial coma and amnesia

What cranial nerve is the least likely to be damaged with a head injury

CN IV - trochlear nerve

In this level of consciousness a patient experiences no sleep/wake cycles

Coma

The lowest level of consciousness

Coma

This level of consciousness is characterized by being unaraousable and unresponsive

Coma

This state of consciousness is typically the result of widespread, diffuse damage to the brain

Coma

In order from most to least severe, list the levels of consciousness following a head injury

Coma -> Vegetative state -> Stupor -> Obtundity -> Delirium -> Clouding of consciousness

Why might elderly individuals show S/S of a subdural hemorrhage days to weeks after injury

Generally smaller brain mass, takes more blood to apply pressure needed to present with S/S

What scale is used to determine severity of head injury

Glasgow Coma Scale

A person who has recovered from a brain injury and is living a normal social life, able to return to work, though may have some residual motor deficits is said to be where on the Glasgow Outcome Scale

Good Recovery

What are the major S/S of subdrual hemorrhage

Headache, altered mental status, incontinence

4 major sequelae associated with posterior cerebral artery occlusion

Hemianopsia, blindness, alexia (inability to understand print), visual agnosia (impaired recognition of objects)

A pt. chart reads "when they arrived to the ER their GCS was 8." From this information, what do we know about the patients condition

They were most likely in a comatose state

As secondary neurologic complications to head injury, brain edema causing hypoxia will lead to _______, which then leads to _______?

As secondary neurologic complications to head injury, brain edema causing hypoxia will lead to vasospasm, which then leads to increased intracranial pressure?

A Glasgow Coma Scale (GCS) score of 3/15 indicates what?

Totally unresponsive

An subdural hemorrhage can be generally described as what shape?

Concave

MRI as an adjunct scan to a CT, would be used to check for what residual affect of a head injury

Deep hemorrhages

This type of head injury is considered a hallmark of non-penetrating TBI

Diffuse axonal injury

Deficient ability to have foresight/ planning and flexibility of behavior are both associated with a frontal lobe lesion at what site on the frontal lobe

Dorsolateral

Executive function deficits are associated with a frontal lobe lesion at what site on the frontal lobe

Dorsolateral

Perseveration is associated with a frontal lobe lesion at what site on the frontal lobe

Dorsolateral

Poor problem-solving skills with resistance to interference is a behavior associated with a frontal lobe lesion at what site on the frontal lobe

Dorsolateral

Stimulus-bound behavior (behavior initated by external stimulus despite its appropriatness) is associated with a frontal lobe lesion at what site on the frontal lobe

Dorsolateral

Name the 3 behavior response categories for the Glasgow Coma Scale?

Eye opening response Best verbal response Best motor response

3 major sequelae associated with intracerebral hemorrhage

Initial coma residual aphasia hemi-neglect

What events are the most often cause of DAI

MVA

What is Mannitol used for?

Mannitol is used clinically in osmotherapy to reduce acutely raised intracranial pressure until more definitive treatment can be applied, e.g., after head trauma

Apathy/abulia is associated with a frontal lobe lesion at what site on the frontal lobe

Medial-frontal

Impersistence is a behavior associated with a frontal lobe lesion at what site on the frontal lobe

Medial-frontal

Lack of spontaneity and initiation are behaviors associated with a frontal lobe lesion at what site on the frontal lobe

Medial-frontal

Lower extremity paresis is associated with a frontal lobe lesion at what site on the frontal lobe

Medial-frontal

Mutism or transcortical motor aphasia are behaviors associated with a frontal lobe lesion at what site on the frontal lobe

Medial-frontal

The diminished or absent of will to act is associated with a frontal lobe lesion at what site on the frontal lobe

Medial-frontal

What GCS score range has the most unpredictable prediction for recovery

Moderate 9-12

A person who is presenting some evidence of a focal brain injury and is independent though disabled is considered to be at what level on the Glasgow Outcome Scale

Moderate disability

Term used to describe as a certain level of consciousness defined as: slow response to stimuli

Obtundity

Anosmia (decreased sense of smell) is associated with a frontal lobe lesion at what site on the frontal lobe

Orbital frontal

Disinhibition is associated with a frontal lobe lesion at what site on the frontal lobe

Orbital-frontal

Distractibility is associated with a frontal lobe lesion at what site on the frontal lobe

Orbital-frontal

Impaired judgment and insight are associated with a frontal lobe lesion at what site on the frontal lobe

Orbital-frontal

Inappropriate affect is associated with a frontal lobe lesion at what site on the frontal lobe

Orbital-frontal

Intermittent explosive disorder is associated with a frontal lobe lesion at what site on the frontal lobe

Orbital-frontal

Irritable, labile, euphoria are associated with a frontal lobe lesion at what site on the frontal lobe

Orbital-frontal

What areas of the brain are most often affected by DAI

Parasagital white matter, gray-white junctions, corpus callosum, brainstem, thalamus

Actions of a patient in this level of consciousness would be none purposeful movements and groans

Persistent vegetative state

There is no evidence of cortical function even though the patient is wakeful during this level of consciousness

Persistent vegetative state

2 common sequelae associated with Duret hemorrhage (small lineal areas of bleeding in the midbrain and upper pons of the brainstem)

Progressive stupor, coma

3 types on amnesia common as post head injury complications

Retrograde amnesia (forget their past) Post-traumatic amnesia (unable to remember immediately following injury) Anterograde amnesia (Inability to form new memories)

Equation for measuring cerebral perfusion

SBP - ICP = cerebral perfusion (normal = 60mmHg)

A person who is conscious with spastic paralysis of most limbs, dysphasia and/or imparied mental activity and dependent is at what level on the Glasgow outcome scale

Severe disability

The GCS score that is most predictive is the one taken at what point of a persons trip to the hospital

The GCS score taken in the ER

Two major S/S of hydrocephalus

mental status change and urinary incontinence

What changes to MRI imaging allow DAI to be detected?

more powerful magnets 1.5T vs. 3T vs. 7T

Seizure occurs as a secondary neurologic complication most often with a(n) open/closed head injury

open, skull fracture

What layer of the meninges is closest to the brain?

pia mater

With severe injury, a traumatic subarachnoid hemorrhage increases risk for _______ _________

post-traumatic hydrocephalus


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