NRNP Finals 6560 Certified Guide 2023
coup-contrecoup injury
Dual impacting of the brain into the skull; coup injury occurs at the point of impact; contrecoup injury
occurs on the opposite side of impact, as the brain rebounds.
Scalp laceration: what, effect, management
Primary head injury
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Dual impacting of the brain into the skull; coup injury occurs at the point of impact; contrecoup injury
occurs on the opposite side of impact, as the brain rebounds.
Scalp laceration: what, effect, management
Primary head injury
profuse bleeding - signs of hypovolemia
Apply direct pressure
Suture/ staple laceration
Lidocaine 1% with epi to control bleeding, not close to nose/ ears
00:0801:41
Skull fracture: types, effect, management
Primary head injury
Simple: no displacement of bone. Observe and protect spine
Depressed: bone fragment depressing thickness of scull
Surgery for debridement. Give tetanus and seizure precautions
Basilar: fracture at floor of skull
Raccoon eye - periorbital bruising
battle's sign: mastoid bruising
otorrhea/ rhinorrhea - halo sign: do not obstruct flow
Give Ab's
Oral intubation and oral gastric instead of nasal
Brain injury: types, effect, management
Primary head injury
Concussion: reversible change in brain functioning
loss of consciousness, amnesia
Do not give opioids, admit for unconsciousness greater than 2min
Contusion: bruising to surface of brain with edema
Frontal and temporal region
Brainstem contusion: posturing, variable temp, variable vital signs
Epidural hematoma: commonly temporal/ parietal region with skull fracture, causing bleeding into
epidural space
Loss of consciousness
Rapid deterioration: obtunded, contralateral hemiparesis, ipsilateral pupil dilation
CT scan (non contrast)
Treatment based on Brain trauma foundation. Surgical if greater than 30cm
Subdural hematoma
most common type of intracranial bleed
Acute (hours): drowsy, agitated, confused, headache, pupil dilation,
CT scan (noncontrast)
surgery for 10mm thickness or 5mm midline shift or for worsening GCS
Chronic (days): headache, memory loss, incontinence
CT scan (noncontrast)
Surgery: burr holes/ crani
AVPU: awake, response to verbal stimuli, painful stimuli, unresponsive
GCS: 8 or below is comatose
Posturing:
decorticate = arms, legs in
decerebrate = arms, legs out
Electrolyte imbalances in brain injury
Hyponatremia: SIADH and cerebral salt wasting
Hypernatremia: DI (give mannitol)
Management of traumatic brain injury
- Consult neurosurgery
- Limit secondary injury
- Prevent hypotension (syst 90) and hypoxemia (PaO2 60). May give blood to improve tissue perfusion.
- Treat cerebral edema: elevate bed, sedate, paralyse, mannitol, hyperventilation (PaCO2 25-30), during
,first 24hrs.
- sedation and analgesia: opioids to reduce ICP (Fentanyl) with propofol. Could give Nimbex or Vec. to
help oxygenate/ ventilate
- steroids: avoid
- Give mannitol or hypertonic saline for herniation: bolus then gtt. monitor serum osmolality, sodium,
and bp.
- Seizure precautions: give phenytoin or keppra
- DVT prophylaxis: stockings, LMWH
- head injury means spine injury until proven otherwise
- hypothermia: can control ICP (89 - 91F)
- decompressive crani: ICP refractory to tx
- brain O2 monitoring (jugular vein O2 sats)
ICP monitoring
For: GCS 3-8 with abnormal CT and comatose pt's with normal CT and older than 40, posturing,
hypotension.
Normal value: 5-10 mmHg
Recommend initiating treatment if ICP > 20 mmHG.
Can calculate CPP (CPP = MAP - ICP). Should be 60
Brain death criteria
Must have all:
No spontaneous movement
Absence brain stem reflexes (fixed/ dilated pupils, no corneal reflexes, absent doll's eyes, absent gag,
absent vestibular response)
Absence breathing drive/ apnea
can't be declared brain dead when: hypothermia, drug intoxication, severe electrolyte/ acid-base
imbalance
EEG, CTA of brain, Cerebral angiography, transcranial doppler
Spinal cord trauma: cause and who
- MVA, falls, acts of violence, sports, wounds
- Rapid acceleration/ deceleration causes hyperextension (fall, rear-end collision)(central cord
syndrome), hyperflexion (bilateral facet dislocation), vertical column loading (compression and then
shattering from falls/ dive lands on butt, at C1 from diving), whiplash
- Distraction injury: from hanging
- penetrating trauma: from wound
- pathologic fractures (osteoporosis/ cancer)
, mainly cervical spine. High mortality.
More common in men
more common in young than old
Fractures and vertebrae
Cervical: C1-C7. Flexible and small diameter so many fractures
Thoracic (T1-T12): connected to ribs. Not common in fractures
Lumbar: L1-L5: Very mobile, requires great force to fracture
Sacral
Spinal cord trauma assessment
- History: mechanism of injury, pt's complaints, pre-hospital tx
- Physical assessment: treat airway, breathing, circulation (ABC) first. Pulm complication common in
quadriplegia. Assess respiratory status: injury above C3 is resp arrest. C5 - C6 spares diaphragm so
breathing exists.
- grade strengthening (0= no muscle contraction, 5 = full strength)
- complete lesion: pt lacks all function below level of spinal cord damage. Poor prognosis.
- incomplete lesion: parts of spinal cord intact
- sensory function: start at no feeling then go to feeling
- evaluate back (log-roll)
Motor assessment in spinal cord trauma
If unable to do, # above:
Deltoids (C4): shrug shoulder
Biceps (C5): flex arm and push arms away
Wrist (C6): try to straighten wrist while pt tries to flex
Triceps (C7): extend arm and try to bend while pt prevents that
Intrinsic (C8): fan fingers and push together
Hip flexion (L2 - L4): bend knee and apply pressure
Knee extension (L2-L4): extend knee with hip/ knee flexed
key signs of spinal cord injury - various levels
C2-C3: resp paralysis, flaccid paralysis, deep tendon reflexes loss
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