Describe approach to removal of C-spine collar in I+V head injured patient
High risk. Check fit appropriately, Cannot be cleared as sedated. C-spine plain film not indicated. 64 slice HRCT reported by radiologist <0.1% false negative. SCIWORA possible - do MRI. If expected to be sedated >48hrs then remove if scan OK but caution. If <48hrs, keep on. If longer than 48hrs and worried - Ortho/spinal for possible fixation
Risks of having on C-collare extended period
Patient factors - Pressure areas, reduced venous drainage - bad in head injury, increased risk aspiration/pneumo - on back, more sedation - slow recovery, less spontaneous breathing, pain, stiffness, DVT, CVC access reduce. Nursing factors - difficult care, high numbers needed for turns, general cares-potential for core infection as more staff
Outline your approach to a patient who appears to have had a brain stem stroke
1. Activate stroke team - shown better care and outcomes, 2. ABCD - Airway secure early, aim normoxia 94-96%, Normocarbia 35-45, Avoid hypotension and extremes of hypertension - SBP 120-160, MAP <150, Glucose 6-10 - avoid hypoglycaemia, Head up 30 degrees, Confirm diagnosis and exclude haemorrhage - HRCT , go to CTA if no haemorrhage, may need MRI to exclude pos fossa event. In discussion with stroke team and family, clot retrieval if available, if not thrombolysis (tPA) if <4.5hrs, aspirin, heparin infusion not indicated, usual cares, discussion with family. ongoing neuro assessment
What are the risk factors for post-traumatic seizures in patients with traumatic brain injury?
GCS < 10, Cortical contusion, Depressed skull fracture Subdural, epidural or intracerebral haematoma Penetrating head wound Seizure within 24 hours of injury
Name two score that can be used to screen for stroke
FAST and Rosier
What is the difference between FAST and Rosier?
FAST - rapid, prehospital. Rosier - Post triage, more in-depth, recommended by NICS, NICE, NSF and is 90% sensitive to exclude id score 0. ENcorporates FAST, but also takes into account physiology - GCS, BP, BSL
What is the main stroke assessment scale and what are its benefits?
NIHSS. Quick, comprehensive, universal, prognosticates, correlates to volume, can be used over a period of time to reassess
Name a stroke score used for MCA CVAs
ASPECT - CT score, predicts outcomes and risk of haemorrhage
What are the mains pros of GCS ?
Universilly recognised, easy, easy to teach, motor features correlate to pathophysiological outcomes, can be used to categorise head injury to mild, moderate, severe
What are the cons of GCS?
High inter observer variability, most people don't know how to use it, eye injury and intubation render it almost useless, never meant for trauma, influenced by drug and alcohol, GCS 14 is very wide,total score is not useful, language effects, does not asses higher cortical function
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