chapter 31

You are treating a patient with a brain injury. The patient is​ apneic, unresponsive,​ hypertensive, and bradycardic and has unequal pupils. Which intervention should be​ provided?

Given the​ findings, the best thing for the EMT to do is start ventilations at​ 20/minute. Consider controlled hyperventilation if signs of severe head injury and brain herniation are​ present, such as unequal​ pupils, severely depressed mental​ status, increased systolic blood​ pressure, irregular or absent breathing​ (or Cushing​ reflex, which is increased systolic blood pressure with decreased heart rate and changed breathing​ pattern), absent motor or sensory function on one side of the​ body, weakness on one side of the​ body, seizures, abnormal posturing​ (nonpurposeful movement), or a decrease of two points or more on the Glasgow Coma Scale.

What is the skull coverd by?

A layer of fascia (fibrous membrane) and then by the scalkp. The fascia adheres to the skull lossely more easily crating a scalp avulsion.

Why does the scalp bleed so heavily?

BEcause the scalp has a rich supply of blood vessels and these blood vessel are not able to constrict as easily as other blood vessels in the body.

tentorium

The cerebellar tentorium or tentorium cerebelli (Latin: "tent of the cerebellum") is an extension of the dura mater that separates the cerebellum from the inferior portion of the occipital lobes.

When does a skull deformity present no danger?

if their is no sign of a deformity if it is not accompanied by brain injury, hematoma, cerbrospinal fluid leakage or subsequent infection.

Where does subdural hematoma occur? Where is the blood collecting between? What causes it?

its a collection of blood between the dura mater and arachnoid layer of the brain. Low pressure bleeding venous bleeding from small briding veins that are torn during the impact to the head. Bleeding occurs above the brain

Dysphasia

language disorder marked by deficiency in the generation of speech, and sometimes also in its comprehension, due to brain disease or damage.

what are the 2 types of skull fractures?

linear or closed skull fracture

What is the most common type of skull fracture? How can it be diagonsed? What is a depressed skull fracture?

linear skull fracture. No obvious gross deformity and can only be diagonsed through a radiograph. A depressed skull fracture occurs when the bone ends are pushed inward toward the brain. Typically the depression can be palpated in the area of fracture

Injury that results from the shearing, tearing, and streching of nerve fibers is called?

A diffuse axonal injury (DAI) .This injury diffuses with the communication and transmission of nerve impulses throughout the brain. A concusion mis a mild form of a diffuse axonal injury.

What GCS score would you document on your PCR if the patient had no​ motor, verbal, or eye​ response?

15 is the highest score on the Glasgow​ Score, and 3 is the lowest. To have a​ 15, the patient would have​ Eye: 4,​ Verbal: 5,​ Motor: 6​ = 15. The EMT should report the Glasgow always as​ E__ V__​ M__ then the total score. This patient would receive one point each for no eye​ response, no verbal​ response, and no motor response.

Concussion Signs whats the f=difference between retrograde amnesia and anterograde amnesia?

A concussion can either cause brief confusion or complete loss of brain function and the person becomes unresponive and usually causes a headache. IF their is loss of consciousness it is usually very brief lasting only a few minutes and does not recur. A concussion is caused by the streching, tearing and shearing of brain tissue. A concussion results in an altered mental status that generally improves restlessness nausea and vomiting inability to answer questions or obey commands inablity to recall incident and sometimes the period just before it known as retrograde amnesia and after known as anterograde amnesia

Mental status how would a patient respond to pain? Flexion posturing indicates injury? Extension posturing indicates injury to?

A decreasing mental status is the most important sign in a suspected head injury. ASsessed using the AVPU method a patient will either have a purposful responce where they try to move away from the pain or a nonpuposeful responce which is when the paitn does not try to stop the pain. PAtients who respond nonpurposefully will eider to flexion posturing- which indicates an upper-level brainstem injury, or they will extend both arms down at their sides, extend their legs and sometimes arch their backs Extension posturing- or decerebrate posturing indicateing lower level brain stem injury

Your patient fell from a roof. He has a laceration to the forehead that is bleeding minimally. He is currently unresponsive with vital signs of BP​ 140/100, heart rate​ 72, and respiratory rate 12. Which finding may indicate that this patient has a brain​ injury?

A decreasing mental status is the most important sign in cases of suspected head injury. The mental status is initially assessed by using the AVPU mnemonic. Keep in mind that the​ patient's mental status may change. For​ example, the patient may be alert but deteriorate​ slowly, or he may respond to verbal stimuli and deteriorate to responding to painful stimuli before becoming unresponsive. The other vital signs are within normal limits.

A victim suffering a concussion and epidural hematoma concurrently may present with which of the following prior to an increase in intracranial​ pressure?

A lucid interval Concussion results in immediate​ unconsciousness, which resolves after only a few minutes. The patient becomes conscious and alert but then later exhibits a deteriorating level of consciousness as the epidural hematoma expands and increases intracranial pressure. This interim period of consciousness is called a lucid interval. The other findings of​ Cushing's reflex, decerebrate​ posturing, or​ Cheyne-Stokes breathing pattern are typically found during​ herniation, not as a precursor to it.

What does a nonpurposful response indicate? What are 2 thing that patients will do who respond nonpurposefully?

A nonpurposeful response to pain indicates a deeper state of unresponsiveness. Patients who respond nonpurposefully will usually do one of two things. They will posture by flexing their arms across their chest and extending their legs​ (flexion posturing or decorticate​ posturing), which indicates an​ upper-level brainstem​ injury, or they will extend both arms down at their​ sides, extend their​ legs, and sometimes arch their backs​ (extension posturing or decerebrate​ posturing). Decerebrate posturing represents the lowest level of nonpurposeful pain​ response, indicating a​ lower-level brainstem injury.

You are managing a patient with a suspected brain injury and a pulse ox reading of 86 percent. What is the MOST detrimental effect of this​ finding?

Although all of these effects are​ detrimental, the MOST detrimental effect is worsened neurological outcome. Increasing tachycardia can worsen cardiac output and cause a drop in cerebral blood​ flow; seizure activity may increase CO2​ levels, which worsens the​ injury; and brain herniation also worsens the overall outcome of the patient. Worsened neurological outcome encompasses all of these.

In the primary assement, what type of injuries should you be looking for? if no pulse oximeter is avaliable what should you use? IF the patient is unresponsive or has an altered mental status extablish airway using ?

Be aware of possible cervical spine injury. Manual in line stabilzation of the head should be the first step. If the pateint is unresponive or has an altered mental status establish airway using jaw thrust maneuver while holding in line stabilazation if no pulse oximeter is availbe apply a nonbreather mask at 15lpm

What type of injury to the head can result in blood accumulation between the dura mater and the​ skull?

Bleeding that occurs between the dura mater and the skull is called epidural and usually involves the​ brain's outermost arteries. Recognized and treated​ early, such bleeding may have no permanent consequences. Subdural​ bleeding, by​ contrast, occurs beneath the dura and is usually venous. Bleeding that occurs between the arachnoid membrane and the surface of the brain is called subarachnoid hemorrhage. Any bleeding within the meningeal layers can be fatal within​ minutes, especially epidural​ bleeding, which is commonly from a lacerated or ruptured artery.

Ecchymois is usually a late signo of? Occurs in what type of fracture?

Bruise-type discolaration around the eyes and behind the ears often occurs with a basilar skull fracture.

What often follows a concussion?

Bruising or swelling of brain tissue A contusion causes bleeding into the surrounding tissues and may or may not cause increased intracranial pressure, even in cases of open head injury.

What should you be looking for in the ears and nose? What is the battle sign?

Check both ears for leakage of flood or clear fluid skull fracture or intracranial bleeding can cause both Battle sign- purplish discolaration or brusing of the mastoid area behind the ear, another late sign of a basilar skull fracture check the nose for leakage of blood or clear fluid wich can inidciate skull frature or intracranial injury

2 types of subdural hematomas . Subdural hematoms are commonly associated with?

Commonly associated with a contusion. Acute- singns and symptoms beigin almost immediatley after the injury Occult or Chronic-bleeding occurs over time and the sings and symptoms don't become apparent for days to weeks after the injury SUBDURAL HEMATOMAs- are the most common type of severe head injury

What is a sign of a severe head injury?

Cushing reflex systolic b.p increases and heart rate decreases. The systolic b.p will increase from an attempt to force blood flow into the brain to maintain perfusion of brain cells that are being compressed from the injury

Dysphagia

Difficulty swallowing

What are the 3 types of brain injuries?

Direct from penetrating trauma, indirect from a blow to the skull or secondary form lack of oxygen and a buildup of co2

What is herniation?

IF the swelling or hematoma continues to develop in the brain, pressure inside the skull called intercrainal pressure rises(ICP). with a rise in ICP, the brain is eventually compressed and pused out of its normal position downward toward and through the foramen magnum, wchi is the large opening in the base of the skull or other opening in the tentorium Compression of the brain destroy vital functions including heartbeat respirations and blood pressure. Extremely serious and potentially deadly condition

Your​ 55-year-old male patient was kicked in the side of the head when wrestling with his son. He has swelling to the side of his head and is a bit confused. He seems to have forgotten how the injury occurred and his pulse is 56 and BP is​ 148/88 mmHg. What do you suspect is wrong with​ him?

If a hematoma or cerebral swelling develops within the​ cranium, the added mass will cause some other substance or structure to be pushed out.​ Initially, blood and cerebrospinal fluid are squeezed out of the brain. If the swelling or hematoma continues to​ develop, pressure inside the skull​ (called the intracranial​ pressure, or​ ICP) rises. With a rise in​ ICP, the brain is eventually compressed and pushed out of its normal​ position, downward toward and through the foramen​ magnum, which is the large opening in the base of the skull or other openings in the tentorium. This process is referred to as herniation. Early findings may include an altered mental​ status, amnesia, and confusion. Later in the​ syndrome, the patient may display findings consistent with herniation.

Open head injury involves a break in what 2 places?

In the skull and the scalp caused by a windshiled or by an implaed object

What should you pay attnention to in the physical exam? What should you look for on the head? What should you check on the yes? What is a racoon sign a sign of?

On the head paplate for deformities, depressions, alcerations, or impaled objects around the head and face. Be careful not to apply pressure to skull depressions or deformities They eye check for consencual reflex. If one of the pupils are fixed and dilated this may be a signal of increase in pressure in the rain also check eye movemtns is one positioned downwward or outward? Raccon sign a purpilish discolarion of the soft tissues around one or both eyes raccon sign may be sign of intracranial injury but it is a delayed sign appears after 4-6 hours

Subdural hematoms are more likely to occur in?

Patients over 60 years.The older the patient gets the more fragile the brain becomes. Hemophilliacs are more prone to subdural hematoma as a result of their clotting disorder. weakness or parayliss to one side of the body detoriation in level or responsiveness vomiting dilation of one pupil abnormal respirations or apnea decreasing pulse rate headache seizures confusion peronsality change chronic subdural hematoma

incorrect, Pre Test 31.2.2 What is a common finding in patients who survive traumatic head​ injuries?

Perment neurological deficets Injuries to the head pose some of the most serious situations that you will face as an EMT. The patient is often confused or​ unresponsive, making assessment of her condition difficult. Drug and alcohol use can also cloud the assessment and make head injury diagnosis difficult. Head injuries to a patient can occur days or weeks before the onset of any signs or symptoms. In​ addition, many injuries to the head are life threatening. Such injuries​ are, in​ fact, a leading cause of death among this​ nation's young people. Many patients who survive head injuries suffer permanent neurological disability. The cost of failing to recognize or properly treat such injuries can be very high.

Anterograde amnesia the patient is unable to remember circumstances? Retrograde amnesia is not being able to rembere stuff? Complete Amnesia Reversible amnesia

Rationale In anterograde​ amnesia, the patient is unable to remember circumstances after the incident. Retrograde amnesia is not being able to remember circumstances leading up to the​ incident, complete amnesia is the inability to recall​ anything, and reversible amnesia is amnesia that passes with time​ (meaning that the patient regains the memories​ eventually).

Your head injury patient had a GCS score of 14 on the scene. When you conduct a reassessment en​ route, you note that the​ patient's GCS score is now 10. What should you​ do?

Recognize a decreasing​ head-injured patient and transport the patient to a level 1 trauma facility for care The EMT knows that this​ patient's condition is deteriorating and that the care the patient needs is found only at a facility with neurosurgical capabilities.​ Hence, it is important to transport rapidly to a trauma center. Providing PPV at​ 6/minute is too​ slow, placing an advanced airway is outside the​ EMT's scope of​ practice, and transporting to a level 4 trauma center is not beneficial to the patient.

What does the glasgow coma scale measure?

The scale is a measure of the patients eye opening, verbal response, and motor response to different stimuli. Eye opening- spontaneous 4 to verbal command 3 to pain 2 no responese 1 Verbal response oriented and converses 5 disoriented and converses 4 inapporiate words 3 incomprehensible sounds 2 no repsone 1 The higher the glasgow scale the more mild the case is

Why are head injuries dangerous?

The skull encases structures of the central nervous system. The central nervous system, made up of the brain and the spinal cord, cooridinates the functions of other body systems.

Which of the following is the one step in the prehospital care of a head injury victim with suspected increasing intracranial pressure that the performance of all other treatment is evaluated​ against?

Transport to appropiate ED Recognize that a progressing traumatic brain injury requires care that is available only at a trauma center with neurosurgical​ capabilities, which your patient cannot receive until you arrive there.

In the secondary assement you should perfomr?

a physical exam. A patient with a head injury will not always complain of pain or other symptoms of trauma. following the physical exam you take vitals and then take the history. A patient whose mental status worsens at any stage of the assessment or treatment process needs immediate transport, preferably to the highet-level trauma center and contionous monitoring during transport

Epidural hematoma occurs in what type of accidents?

accounts for only 2% of head injuries. Occurs from a low-velocity impact to the head or from decceleartion injury. Almost always associated with a skull frature, espeially in the temporal region because of the location of the meningeal arteries posturing-withdrawl or felxion decreasing mental status apnea

AVPU

alert verbal pain unresponive

A 45 year old male fell while exiting the shower. Upon your​ arrival, he continually asks you​ "What happened?" even after you explained the incident. He is experiencing

anterograde amnesia

What region of the skull is considered to be the weakest​ portion?

basilar skull The basilar​ skull, or floor of the​ skull, is made up of many separate pieces of bone and is the weakest part of the skull. Some of its bones are thin and perforated extensively by the spinal​ cord, nerves, and blood vessels. Most people believe that the temporal region is​ thinnest, but the thinnest region is actually the basilar region. The occipital region is much thicker than the basilar​ skull, and the parietal regions are also thicker and stronger than the basilar region.

Why would b.p decrease in a brain injury?

because their is very little room for bleeding in the brain. IF the b.p is decreasing the pulse pressure is narrow the heart rate is elevated and the respiratory rate is increased signs of hemorrhage suspect shock but look for evidence of bleeding

The MOST primitive and BEST protected part of the brain is​ the:

brainstem The​ brain's funnel-shaped inferior​ part, the​ brainstem, is the most primitive and best protected part of the brain. Tethered to the skull by numerous nerves and​ vessels, it controls most automatic functions of the​ body, including​ cardiac, respiratory, vasomotor​ (blood pressure), and other functions that are vital to life. The brainstem is made up of the​ pons, the​ midbrain, and the​ medulla, or medulla​ oblongata, which physically connects the brain to the spinal cord. All of the messages between the brain and the spinal cord pass through the medulla.

Ceberal LAceration can occur in what type of injuries? If patient's b.p is dropping what should you expect?

can occur in either a open or closed head injury with an isolated head trauma a patients b.p may go up and therie pusle rate go down which is a late finding. if a patient has a subdural or epidural but his b.p is dropping you should suspect internal bleeding

What are some specific types of brain injuries?

concussion- temporary loss of the brains ability to function Contusion- bruising or swelling of the brain Hematoma- pooling of blood within the brain Laceration- tearing of the brain tissue

What should you do if their are signs of hernation if it is allowed depends on protocal?

controlled hyperventilation can be considered but depends on your protocoal.

Signs and symptoms of a contusion

decreasing mental status or unresponiveness paralysis unequal pupils vomiting alteration of vital signs profound personality changes Contussion can lead to swelling of brain tissue which can reslult in perment disability or death. You can improve the patients recovery by providing by giving aggresive airway management, ensuring adequate ventialtion and oxygenation to prevent hypoxia and reversing and preventing hypotension

Signs and symptoms specific to brain herniation

dilated or sluggish pupil on one side abnormal posturing decortiate aka flexion and decerbration aka extension nonpurposful movement

diplopia

double vision sign of a head injury

If the pulse is weak? or fast?

fast or increasing suspect hemorrhage elsewhere in the body or early onset of hypoxia If slow suspect pressure inside the skull or severe hypoxia

Whats a useful tool for assesing the patients level or responivness?

glasgow coma scale

Brain injury may be worsened by? What is the emergency care of a traumatic brain injury?

hypoxia hypercarbia high level of co2 hypoglycemia blood glucose level <60 Hypotension systolicblood pressure <90mmHG A patent airway adequate ventilation adequate oxygneation spO2 of 94% or greater a systolic b.p greater then 90mmhg A normal body core tempearture and a normal blood glucsoe level

What should you be alert for during scene size up?

possible head injury. Unresponiveness or altered mental status. never assume drug or alcohol intoxication first.

Which of the following terms is defined as a significant injury from​ shearing, tearing, and stretching of nerve​ fibers? what causes a DAI? What is a mild DAI? A severe DAI involves what part of the brain? What are 4 specific types of brain injuries?

severe diffuse axonal injury X Injury to the brain that results from​ shearing, tearing, and stretching of nerve fibers is called a diffuse axonal injury​ (DAI). This type of injury interferes with the communication and transmission of nerve impulses throughout the brain. Severe acceleration and deceleration cause the​ shearing, tearing, and stretching injury. DAI is categorized as​ mild, moderate, or severe. A concussion is a mild diffuse axonal injury. A severe diffuse axonal injury involves the brainstem. Specific types of brain injuries include​ concussion, a temporary loss of the​ brain's ability to​ function; contusion, bruising or swelling of the​ brain; hematoma, pooling of blood within the​ brain; and​ laceration, tearing of the brain tissue.

IF the blood pressure is rising what should you suspect? If their is hypotension what could this mean?

suspect intercranial pressure. IF low suspect blood loss that has led to shock. If their hypotension low b.p, this is a bad sign because this could be brainstem failure brains not able to maintain adeqquate b.p

What is the thinnest portion of the skull?

temporal region

How do you distinquish clear fluid from the ears or nose, from tears or nasal secretions vs. cerbeospinal fluid?

test for glucose cerbospinal filuid contains blucose. tears and nasal secretions do not

anterograde amnesia

the patient is unable to rembmer circumstances afterr.

What is a fixed or dilated pupil a sign of in a brain injury?

the result of compression of the third cranial nerve in the lower brain area

In a brain injury the affected pupil is usually on?

the same side of the brain injury

How can the skull be injuried

the same way any other soft tissue Contused bruise lacerated abraded or avulsed

Coup/contercoup injury on the head

there can be damage at the point of a blow to the head and or damage on the side opposite the blow as the brain is proplled against the opposite side of the skull.

Acceleration/ decelearation injury- occurs in what type of accident?

typically in a car crash the head comes to a sudden stop but the brain contineus to move back and forth inside the skull resluting in burising possibly very severe to the brain.

Retrograde amnesia

unable to remember events leading up to incident

How does a basilar skull fracture usually star as?

usually starts as a linear temporal fracture that extends downward and contineus in to the based of the skull. basial skull fractures often cause leakage of cerebrospinal fluid from the ears nose or mouth.