Leading cause of death in persons less than __ years

Up to__% of these are due to head injury

What is the most commonly affected group?

Others?

Leading cause of death in persons less than 45 years

Up to 50% of these are due to head injury

Most commonly affected groups are young males, other groups at increased risk are the elderly, very young and  EtOH abusers

How many layers of skin are in the scalp?

What are they?

5 layers

subcu. Tissue

galea

areolar tissue

pericranium

Define the following:

– next to skull

– thin fibrous

Meninges:  Dura– next to skull

Arachnoid– thin fibrous

What are the two potential spaces?

where are they located?

1- Between Dura and Skull– area where epidural hematomas form, usually as a result of meningeal artery bleeding

2- Subarachnoid Space– between Arachnoid and Pia, where Cerebral Spinal Fluid (CSF) circulates

1) Cerebral Hemispheres-- separated by dura known as falx cerebri into L and R

and further divided into lobes named for skull plates they are beneath– frontal, parietal, temporal, occipital

2)  The cerebellum

3)  The brainstem

All persons who present with neurological symptoms should be presumed to 

_________.

•All persons suspect of C5 or higher injury should be immediately intubated secondary to concern that the phrenic nerve may be affected; think about intubating immmediately!

What should be part of neuro exam?

(7)

•Glasgow Coma Scale, initial and serial

•Motor function evaluation

•Deep tendon reflexes

•Cranial nerve evaluation

•Sensory changes centrally, peripherally

•If unresponsive (indicates brainstem injury) watch ventilatory effort and pattern, pupillary responses, body positioning

• cold calorics and doll’s eyes testing may be performed after c-spine clearance

What are signs of INP?

(5)

•A fixed, dilated pupil is suggestive of ipsilateral hematoma with uncal herniation

•BL fixed and dilated pupils suggests hypoxemia and uncal herniation

•Altered motor fxn suggest CNS injury

•Decorticate positioning indicates injury above midbrain

•Decerebrate positioning indicates higher brain injury with poorer outcome

Pt presents with Symptoms of HA, Visual chg, N/V, dizzy. What are you thinking?

How long is recovery time?

concussion

up to 12 weeks

What is head injury after care instructions to be given?

when do they follow up?

what's diet?

when do they return to ER?

•If patient follows criteria for discharge after emergency room care

•Follow-up with PCP in 24 hours

•Limiting diet to liquid or lite faire for 24 hrs

•Return to ED if experiencing HA, N/V, worsening dizziness, weak/numb/tingling of extremities, chg hearing/vision, seizure activity

What ist he most frequent result of blunt trauma and what lobes are involved?

Associated with what type of hemorrhage?

Contussion

•Occurs at impact site or contracoup area (opp side)

•May not be bleed immediately on CT

•Hospitalize to monitor MS and ICP

•Etiology of ‘shaken baby syndrome’

•Occurs between dura and skull

•Often follows skull fracture with injury to middle menigeal artery

•Initial HI, ‘period of lucidity’, rapid change mental status– LOC possible

•Death caused by herniation secondary to rise of ICP

What is it?

How do you treat?

EPIDURAL HEMATOMA

•Occurs between dura and skull

•Often follows skull fracture with injury to middle menigeal artery

•Initial HI, ‘period of lucidity’, rapid change mental status– LOC possible

•Death caused by herniation secondary to rise of ICP

•Surgical emergency for evacuation, may need burr hole placement by ED MD-put bird hole into head to relieve pressure

•Occurs between dura and arachnoid, most likely during acceleration-deceleration injury, tearing of bridging veins below dura

What is most frequent population affected? 

What type of acute onset vs chronic?

What are sxs? 

Subdural Hematoma

•Occurs between dura and arachnoid, most likely during acceleration-deceleration injury, tearing of bridging veins below dura

•More frequent in elderly, alcoholics, very young

•Acute onset presents 3-14 days after HI

•Chronic recognized after 14 days

•Vague symptoms:  chg MS,HA,  unresponsive

•Early surgical intervention improves mortality– can be up to 60%

Pt presents with HA, photophobia, menigeal signs

What is it? What is it due to?

What is mortality?

Subarachnoid  Bleed

•Occurs in subarachnoid space

•Disruption of subarachnoid vessels and blood into CSF

•S/P Mild to moderate TBI up to 2 months after insult

•Symptoms included HA, photophobia, menigeal signs

•Mortality higher if SAH present on initial CT scan following HI

Pt presents with  raccoon eyes, battle sign

–Symptoms include dizzy, change hearing, seventh nerve palsy, hemotympanum, nothing

What could it be?

Skull fracture: spec basilar

•Basilar skull fracture

–usually ____ through ______ bone and may involve______ perhaps _______

•Blunt trauma: stable or depressed fracture

•Basilar skull fracture

–usually longitudinally through temporal bone and may involve external auditory canal, perhaps tympanic membrane

•Risk of increased intracranial pressure is highest with _____

•Risk of increased intracranial pressure is highest with closed head injury

•Usage of medications:  barbituates, mannitol, other diuretics

•Hyperventilation techniques, guided by neurosurgery

•Constant ICP monitored by usage of a ‘Philadelphia Bolt’ placed thru a burr hole in the skull area, NICU area

•Burr hole placement by ED attending

What causes spinal shock? What results?

What is poorest prognosis?

Spinal Shock

•Due  to devastating injury to T6 or above resulting loss of reflexes

•Loss of sensation and flaccid paralysis below area of lesion

•Loss of rectal and bladder tone

•Hypotension and bradycardia are present

•Recovery dependent on injury

Spinal Injury Cord Syndromes

1) Anterior cord syndrome:  damage to corticospinal, spinothalamic pathways caused by ant. cord compression (flexion of c-spine, thrombosis of ant. cord).

–Symptoms include loss of motor fxn and pain/temp. sensation distal to lesion

–Prognosis is poor, surgical decompression and stabilization are treatment of choice

2)Central Cord Syndrome:  caused by hyperextension injury causing disruption of blood flow to spinal cord

-Increased in elderly population with underlying spinal degenerative problems

-Quadreparesis with loss of pain and temp sensation greater in UE

-Prognosis is good, usually residual loss of fine motor fx of UE

3)  Brown-Sequard Syndrome:  More frequently caused by penetrating injury causing hemisection of the spinal cord

•Ipsilateral loss of motor function, proprioception, sensation

•Contralateral loss of pain and temp sensation

•Good prognosis for recovery

Only one half of spinal cord affected

4) •Cauda Equina Syndrome:  occurring at the tail end of the spinal cord

•Presentation of injury is variable motor or sensory loss in lower extremities, sciatica, bladder or bowel dysfunction, ‘saddle anesthesia’

•Stabilization of spinal column primary concern

•Referral to neurosurgical services ASAP

•Radiographic studies to evaluate extent of injury

•Intervention to prevent, minimize secondary injury, steroid administration is controversial

•Surgical intervention would be dictated by spinal column stability and patient hemostasis

•Continual observation of vital signs, serial neurological observations are essential

•Minor Injury:  injury to the vertebral column not considered unstable

•Major Injury:  unstable injury, increased risk of spinal cord injury

–Compression (wedge) fracture

–Burst fracture

–Flexion-distraction (seat belt) fracture-

–Fracture-dislocation injury