Download Brain - Leeds LINKS

By Christopher I’Anson
SJA Advanced Student Doctor
Training Officer Leeds LINKS (2012-13)
Topics
 Head and neck injuries
 C-spine
 Concussion
 Compression
 Cerebrovascular accidents
 TIAs
 Strokes
 Meningitis
 Seizures
 Examination
 H-test
 Pupillary light reflexes
 Peripheral grip strength
Anatomy
 The brain is enclosed in several layers
 Meninges (brain covering)


Contain blood vessels
Cushion brain
 Skull (hard rigid box unlike meninges)
 Skin
 Cerebrospinal fluid

Fluid surrounding the brain
 Supports and cushions
Anatomy
 There are 7 cervical vertebra
 Each has a nerve exiting near it
 Each protects the spinal cord
 Aids movement and support of head
 Spinal Nerves C3,4,5 are important
 Supply the diaphragm


Cause breathing
“C3,4,5 keep the diaphragm alive!”
C-spine injuries
 The head is extremely heavy!
 The neck support this weight

It can be easily damaged as it is exposed and has a heavy
“bowling ball on top of it” (see DEMO)
C-spine injuries
 Clinical features:
 Mid-line tenderness
 Pain in neck
 Numbness or tingling in extremities
 Peripheral weakness or paralysis
 Deformity in the neck
 Significant MOI
 GCS<15
C-spine injuries
 Assessment:
 Maintain immobilisation until you are happy
 Feel down the back of the neck for lumps or bumps
 Ask patient to wiggle toes and/ or squeeze fingers
C-spine injures
 Management:
 Manual In-line immobilisation
 Collar and board (if ETA)
 3 point immobilisation
 999
NICE guidelines
 Indications for Spinal Immobilisation:
 GCS <15
 Neck pain or tenderness
 “Focal neurological deficits” (weakness and sensory
changes in English)
 Numbness and tingling in extremities
 Clinical suspicion (MOI, head injuries etc)
Head injuries
 Does not include minor face lacerations*
 Every year about 1.4 million people attend A&E with
one
 50% are children
 1,500 have severe brain damage
 5,000 die each year due to these
* Remain suspicious
Head injuries
 Common causes:
 RTC
 Falls
 Assaults
 Sports/leisure
 Workplace
 Others
Factors associated with
serious injuries:
•High-speed impact
•Death of another in the same accident
•Entrapment
•Intrusion of vehicles
•Ejection of the patient from the vehicle
•Pedestrian or motorcyclist vs. Motor
vehicle
•Fall from >5m
Head injuries
 Either:
 Primary (direct local or diffuse injury)

e.g Contra-coup
 Secondary
Head injuries: Concussion
 This is where the brain shacks inside the skull
 Not usually associated with long term damage
 This causes:
 Nausea +/- vomiting
 Headache
 Dizziness
 Disorientation
Head injuries: Concussion
 Management:
 ABCDE!
 Observations




Especially AVPU or GCS
Give head injury advice card
Advice to go to hospital
NO MEDICATIONS!
Head injuries: Compression
 This is where the brain is compressed inside the skull
 NB: the skull can not expand causing effects on the brain
 Can be fluid or blood
 CF:
 Drowsiness or unconsciousness (inc history of LOC)
 Amnesia (retrograde and/or anterograde)
 Seizures
 N+V
 Posturing (decortate or decerebrate)
 Sensory disturbance (e.g. Vision) and weakness
 Headache
 Personality change
 May have deformity of Skull due to cause
 Blood or fluid (CSF) from the nose or ears (BSF)*
 Battle sign or racoon eyes
*?basal skull fracture
Head injuries: Compression
 It is difficult to diagnose this as you do not have a CT
scanner 
 Use your clinical suspicions or if in doubt treat as worst
case!
 Management:
 ABCDE!
 Immobilisation in unconscious or previous LOC or BSF
 999
 Protect airway
 No pain killers
Cerebrovascular accident (CVA)
 This is a posh more PC way of taking about:
 Strokes (where symptoms last for >24 hours)
 Transient ischaemic attacks (TIA) or “mini-strokes”

Symptoms last <24 hours
 Clinically in the acute phase there is no difference
CVA: TIA and Strokes
 Clinical Features:
 FAST!




Facial weakness
Arm weakness (can not hold them up)
Speech (is slurred)
Time to call 999
CVA
 Other features
 Unconsciousness or collapse (rare)
 Sensory disturbance (e.g. Vision)
 Generalised weakness


Legs  unable to walk
Arms  unable to hold self up
Meningitis
 Inflammation of the lining of the brain
 Clinical Features:
 Nausea and Vomiting
 Fever
 Muscle ache or pain
 Aggression or drowsy
 Coma
 Seizures
 ?Rash
Meningitis
 Management:
 999
 No medications!
 Manage symptoms as best as possible
Seizures
 These are the same as fits
 There are many types and causes (inc Epilepsy and
febrile convulsions)
 Management:
 Remove dangerous/ harmful objects
 DO NOT restrain the patient
 TIME the fit
 If first fit or >5mins call 999
 Recovery position after the fit has subsided
 Cover the patient with a blanket in case the wet
themselves (DIGNITY)
Examinations
 After ABCDE
 Not for people that need immobilisation!
 Pupil response
 H-test
 Grip strength