Head Trauma and Acute Intracranial Events

Question 1

What is the initial assessment of someone in an emergency?

Answer 1

Airway
Breathing
Circulation
Disability - AVPU (GCS, pupils)

2 line history

Question 2

What is important in a full evaluation of someone with head trauma or an acute intracranial event?

Answer 2

History
- Onset, pattern of change, previous episodes

Examination
- GCS, neurological, cardiovascular

Investigations

• Target to differentials
• CT scan when there is uncertainty

Question 3

What are some common symptoms of an acute intracranial event?

Answer 3

Loss of function
- Motor
- Sensation
Change in conscious level/collapse
Abnormal behaviour
Headache
'Funny turn'

Question 4

What are the differential pathologies in an acute intracranial event?

Answer 4

Lack of substrate
- Blood
- Glucose/oxygen
Abnormal activity
- Fitting
Local damage
- Injury or bleed

Question 5

How can a lack of blood occur?

Answer 5

Blockage in vessels
- Ischaemic stroke

Systemic hypotension

Raised Intra-cranial pressure

• Brain swelling
• Space occupying mass
• Blockage CSF circulation

Question 6

How can a lack of glucose come about?

Answer 6

Systemic hypoglycaemia

Impaired cerebral circulation

Question 7

How can there be a lack of oxygen?

Answer 7

Airway problem
Breathing problem
CO poisoning

Question 8

What is meant by abnormal activity (fitting) in terms of an acute intracranial event?

Answer 8

RAS control lost
Disorganised activity
Increased brain metabolic requirement
Can be local or generalised

Question 9

How can abnormal activity be caused by head injury?

Answer 9

RAS function disturbed - knocked out

Degree of disturbance depends on force

Lesser degree=amnesia

Question 10

What can be the results of raised ICP?

Answer 10

Compensation

• Blood squeezed out
• CSF squeezed out
• Brain squeezed out

Tentorial herniation
Uncal herniation

Question 11

What are some clinical signs of raised ICP?

Answer 11

Change in behaviour
Drop in level of consciousness - GCS
Neurological localising signs
Change in pupil reaction
Change in blood pressure, pulse and breathing

Question 12

How do we get a raised intra-cranial pressure?

Answer 12

Head is a closed box
Normal contents - brain, blood, CSF
Abnormal contents - haematoma, tumour

Increase in any put up ICP

Question 13

What can cause a raised ICP?

Answer 13

Brain

• Head injury
• Infection - meningitis/encephalitis

Blood

• Coughing
• Impaired venous drainage

CSF
- Subarachnoid blood

Haematoma

• Trauma - extradural, subdural, intra-cerebral
• Haemorrhagic stroke

Tumour

• Primary brain
• Secondary

Question 14

What can happen with a head injury?

Answer 14

Two pathologies:

• Diffuse axonal injury
• Bleeding (haematoma)

Bleeding

• Extra-dural
• Subdural
• Subarachnoid

Question 15

How can we tell if a head injury is serious?

Answer 15

Mechanism of injury
Signs of brain injury
- Changes in consciousness
- Focal neurology
Pattern of change

Question 16

What is the difference between a secondary and primary brain injury?

Answer 16

Primary injury - we cannot change
Secondary injury
- Hypoxia
- Hypotension
- Blood clot causing raised intracranial pressure