ODESSA NATIONAL MEDICAL UNIVERSITY



ODESSA NATIONAL MEDICAL UNIVERSITY

Department of Neurology and Neurosurgery

Methodical guidelines

for independent students work

Discipline “Neurology”.

Section 2 “Special neurology”.

3. Vascular diseases of the brain and spinal cord, paroxysmal states, cephalgias, sleep disorders, neurointoxications. Traumatic affections of the nervous system.

Theme 23. «Neurologic aspects of the craniocerebral injury. The spinal injury»

Course 4 year Faculty medical

Speciality 222 «Medicine»

Approved

at a methodical conference chair

«__» ________

Protocol № __

Head of the department,

Prof. ________ Son A.S.

Odessa – 2020

Theme of independent students work: Neurologic aspects of the craniocerebral injury. The spinal injury.

1. Actuality of theme:

The trauma of spinal cord and brain is the important medical problem. Clinical course with the presence of many complications, and pathogenesis of traumatic disease of the nervous system dictates the necessity of rapid correct diagnosis and treatment. Therefore neurologists, neurosurgeons, physicians must know this pathology.

2. Particular goals:

To know:

1.Clinical classification of cranial-cerebral traumas.

2.Pathogenesis, clinical course of the cranial-cerebral trauma

3.Symptoms of lesion of the brain at CCT.

4. Symptoms of lesion of spinal cord at the closed trauma.

To be able:

1. To differentiate between epi-, subdural and intracerebral haematoma.

2. To estimate the results of skull X-ray and CT-findings.

3. To give an adequate therapy in the acute phase and late period of disease with the purpose of prevention of complications.

3. Interdiscipline integration.

|№ |Disciplines |To know |To be able |

|1 |Previous disciplines | | |

| |а) Human anatomy. | | |

| | |Structure of spinal cord and cerebrum. |On macropreparations to distinguish different parts of spinal cord and |

| |b) Normal physiology. | |cerebrum. |

| | |Structure of spinal cord and cerebrum and normal function of organism, that |To check up the functions of spinal cord and cerebrum. |

| | |provide CNS. | |

| |c) Pathological physiology. | |To diagnose the damage of spinal cord and cerebrum on the basis of appeared |

| | |The CNS structure and morphological changes in it at a cranial- and spinal |symptoms. |

| | |trauma. | |

|2 |Next disciplines. | | |

| |1.Neurosurgery |Structure of spinal cord and cerebrum; basic leading ways, symptoms of damage |To set the topic diagnosis of lesion. To diagnose epi-, subdural and |

| | |of spinal cord and cerebrum. |intracerebaral haematoma and to apply the surgical methods of treatment. |

| | | | |

| | |Structure and functions of spinal cord and cerebrum. |To suspect the lesion of spinal cord and cerebrum and in good time appoint |

| |2.Obstetrics and gynecology | |consultation of necessary specialist. |

| | |Structure of spinal cord and cerebrum. Basic functions of CNS. |To set the diagnosis and other damages of CNS and to appoint adequate |

| | | |treatment. |

| |3. Paediatrics. | | |

|3 |Interdiscipline integration. |Structure of cerebrum, symptoms of irritation of different departments of |To diagnose the epileptic attacks and area of localization of epileptic focus.|

| |1.Epilepsy |cortex. Reasons of origin of aftertraumatic epilepsy. | |

| | | | |

| | |The CNS structure and symptoms of its damage. |To make the differential diagnostics between the tumor of spinal cord and |

| |2.Tumours of spinal cord and brain. | |cerebrum. |

| | | | |

| |3.Disease of the vegetative nervous system. |Structure and functions of vegetative N.S., symptoms of its damage during a |To diagnose posttraumatic disorders of the nervous system, appoint adequate |

| | |trauma. |treatment. |

4. Tasks for ISW while class

4.1. Common terms: concussion of the brain, squeezing of brain, epidural and subdural haematoma.

4.2. Theoretical questions:

1. Clinical classification of cranial-cerebral traumas.

2. Pathogenesis, clinical course of the cranial-cerebral trauma

3. Treatment of cranial-cerebral traumas.

4.3. Practical skills:

1. Inspection of patient with the concussion of the brain

2. Inspection of patient with squeezing of brain.

3. Therapy in the acute phase and late period of trauma with the purpose of prevention of complications.

5. Table of contents of the class:

Types of Brain Injury

All brain injuries are unique. The brain can receive several different types of injuries depending on the type of force and amount of force that impacts the head. The type of injury the brain receives may affect just one functional area of the brain, various areas, or all areas of the brain.

Traumatic Brain Injury

Concussion

Even a concussion can cause substantial difficulties or impairments that can last a lifetime. Whiplash can result in the same difficulties as head injury. Such impairments can be helped by rehabilitation, however many individuals are released from treatment without referrals to brain injury rehabilitation, or guidance of any sort.

A concussion can be caused by direct blows to the head, gunshot wounds, violent shaking of the head, or force from a whiplash type injury.

Both closed and open head injuries can produce a concussion. A concussion is the most common type of traumatic brain injury.

A concussion is caused when the brain receives trauma from an impact or a sudden momentum or movement change. The blood vessels in the brain may stretch and cranial nerves may be damaged.

A person may or may not experience a brief loss of consciousness.

A person may remain conscious, but feel dazed.

A concussion may or may not show up on a diagnostic imaging test, such as a CAT Scan.

Skull fracture, brain bleeding, or swelling may or may not be present.

Therefore, concussion is sometimes defined by exclusion and is considered a complex neurobehavioral syndrome.

A concussion can cause diffuse axonal type injury resulting in temporary or permanent damage.

A blood clot in the brain can occur occasionally and be fatal.

It may take a few months to a few years for a concussion to heal.

Contusion

A contusion can be the result of a direct impact to the head.

A contusion is a bruise (bleeding) on the brain.

Large contusions may need to be surgically removed.

Coup-Contrecoup

Coup-Contrecoup Injury describes contusions that are both at the site of the impact and on the complete opposite side of the brain.

This occurs when the force impacting the head is not only great enough to cause a contusion at the site of impact, but also is able to move the brain and cause it to slam into the opposite side of the skull, which causes the additional contusion.

A Diffuse Axonal Injury can be caused by shaking or strong rotation of the head, as with Shaken Baby Syndrome, or by rotational forces, such as with a car accident.

Injury occurs because the unmoving brain lags behind the movement of the skull, causing brain structures to tear.

There is extensive tearing of nerve tissue throughout the brain. This can cause brain chemicals to be released, causing additional injury.

The tearing of the nerve tissue disrupts the brain’s regular communication and chemical processes.

This disturbance in the brain can produce temporary or permanent widespread brain damage, coma, or death.

A person with a diffuse axonal injury could present a variety of functional impairments depending on where the shearing (tears) occurred in the brain.

Penetration

Penetrating injury to the brain occurs from the impact of a bullet, knife or other sharp object that forces hair, skin, bones and fragments from the object into the brain.

Objects traveling at a low rate of speed through the skull and brain can ricochet within the skull, which widens the area of damage.

A “through-and-through” injury occurs if an object enters the skull, goes through the brain, and exits the skull. Through-and-through traumatic brain injuries include the effects of penetration injuries, plus additional shearing, stretching and rupture of brain tissue. (Brumback R. (1996). Oklahoma Notes: Neurology and Clinical Neuroscience. (2nd Ed.). New York: Springer.)

The devastating traumatic brain injuries caused by bullet wounds result in a 91% firearm-related death rate overall. (Center for Disease Control. [Online August 22, 2002: ,]).

Firearms are the single largest cause of death from traumatic brain injury.

Levels of Brain Injury

Mild Traumatic Brain Injury (Glasgow Coma Scale score 13-15)

Mild traumatic brain injury occurs when:

Loss of consciousness is very brief, usually a few seconds or minutes

Loss of consciousness does not have to occur—the person may be dazed or confused

Testing or scans of the brain may appear normal

A mild traumatic brain injury is diagnosed only when there is a change in the mental status at the time of injury—the person is dazed, confused, or loses consciousness. The change in mental status indicates that the person’s brain functioning has been altered, this is called a concussion

Moderate Traumatic Brain Injury (Glasgow Coma Scale core 9-12)

Most brain injuries result from moderate and minor head injuries. Such injuries usually result from a non-penetrating blow to the head, and/or a violent shaking of the head. As luck would have it many individuals sustain such head injuries without any apparent consequences. However, for many others, such injuries result in lifelong disabling impairments.

A moderate traumatic brain injury occurs when:

A loss of consciousness lasts from a few minutes to a few hours

Confusion lasts from days to weeks

Physical, cognitive, and/or behavioral impairments last for months or are permanent.

Persons with moderate traumatic brain injury generally can make a good recovery with treatment or successfully learn to compensate for their deficits.

Severe Brain Injury

Severe head injuries usually result from crushing blows or penetrating wounds to the head. Such injuries crush, rip and shear delicate brain tissue. This is the most life threatening, and the most intractable type of brain injury.

Typically, heroic measures are required in treatment of such injuries. Frequently, severe head trauma results in an open head injury, one in which the skull has been crushed or seriously fractured. Treatment of open head injuries usually requires prolonged hospitalization and extensive rehabilitation. Typically, rehabilitation is incomplete and for most part there is no return to pre-injury status. Closed head injuries can also result in severe brain injury.

TBI can cause a wide range of functional short- or long-term changes affecting thinking, sensation, language, or emotions.

TBI can also cause epilepsy and increase the risk for conditions such as Alzheimer’s disease, Parkinson’s disease, and other brain disorders that become more prevalent with age.

Repeated mild TBIs occurring over an extended period of time (i.e., months, years) can result in cumulative neurological and cognitive deficits. Repeated mild TBIs occurring within a short period of time (i.e., hours, days, or weeks) can be catastrophic or fatal.

Treatment

Treatment may be needed continuously or on an intermittent basis throughout the individual's lifespan.

Intensive Care Unit (ICU)

After receiving emergency medical treatment, persons with a moderate to severe brain injury may be admitted to a hospital’s Inpatient Intensive Care Unit. The goals in the ICU include achieving medical stability, medical management, and prevention of medical crisis. Some preventive rehabilitation may be initiated in the Intensive Care Unit such as body positioning, splinting, and range of motion (a therapist moves the person’s limbs).

Persons treated in the ICU may be unconscious, in a coma, and medically unstable. Many tubes, wires, and pieces of medical equipment may be attached to the patient to provide life sustaining medical care.

Medical equipment frequently used in the ICU includes:

A Ventilator (also called a Respirator) is a machine that helps a person breathe.

A person who has sustained a brain injury may be unable to breathe on his or her own.To use a ventilator, a tube is placed through the person’s mouth to the breathing passage, (trachea, “windpipe”). This procedure is called intubation.

Intubation with the use of a ventilator allows a person to breathe and receive oxygen, which is necessary for life.

Intravenous lines (IVs) are tubes placed in a person’s veins to deliver medications and fluids to the person’s body.

Arterial lines are tubes placed in a person’s arteries to measure blood pressure.

A Foley Catheter is used to collect and monitor a person’s urine output.

A person who has sustained a brain injury may be unable to control bladder functions.

A rubber tube is inserted into the person’s bladder. This allows urine to move from the bladder, through the tube, and to a container at the end of the tube.

A Nasogastric Tube (NG Tube) is used to deliver medication and nutrients directly to a person’s stomach.

A person who has sustained a brain injury may be unable to swallow.

A tube is placed through a person’s nose or mouth and ran through the swallowing passage (the esophagus), to the stomach.

An EKG machine monitors a person’s heart.

Wires with sticky ends are placed on the body.

An Intracranial Pressure (ICP) Monitor is a device attached to a person’s head with a monitor that indicates the amount of pressure in the brain.

When the brain is injured it may swell.

When the brain swells, the brain has no place to expand. This can cause an increase in intracranial pressure (the pressure within the skull).

If the brain swells and has no place to expand, this can cause brain tissues to compress, causing further injury.

A Pulse Oximeter is a small, clamp-like device placed on a person’s finger, toe or earlobe. The Pulse oximeter measures the amount of oxygen in the blood stream.

Acute Rehabilitation

As early as possible in the recovery process, individuals who sustain brain injuries will begin acute rehabilitation. The treatment is provided in a special unit of the trauma hospital, a rehabilitation hospital or another inpatient setting. During acute rehabilitation, a team of health professionals with experience and training in brain injury work with the patient to regain as many activities of daily living as possible. Activities of daily living including dressing, eating, toileting, walking, speaking and more.

Postacute Rehabilitation

When patients are well enough to participate in more intensive therapy, they may be transferred to a postacute rehabilitation setting, such as a residential rehabilitation facility. The goal of postacute rehabilitation is to help the patient regain the most independent level of functioning possible. Rehabilitation channels the body's natural healing abilities and the brain's relearning processes so an individual may recover as quickly and efficiently as possible. Rehabilitation also involves learning new ways to compensate for abilities that have permanently changed due to brain injury. There is much that is still unknown about the brain and about brain injury rehabilitation. Treatment methods and technologies are rapidly advancing as knowledge of the brain and its function increases.

Subacute Rehabilitation

Patients who cannot tolerate intensive therapy may be transferred to a subacute rehabilitation facility. Subacute rehabilitation programs are designed for persons with brain injury who need a less intensive level of rehabilitation services over a longer period of time. Subacute programs may also be designed for persons who have made progress in the acute rehabilitation setting and are still progressing but are not making rapid functional gains. Subacute rehabilitation may be provided in a variety of settings, often a skilled nursing facility or nursing home.

Day Treatment (Day Rehab or Day Hospital)

Day treatment provides rehabilitation in a structured group setting during the day and allows the person with a brain injury to return home at night.

Outpatient Therapy

Following acute, postacute or subacute rehabilitation, a person with a brain injury may continue to receive outpatient therapies to maintain and/or enhance their recovery. Individuals whose injuries were not severe enough to require hospitalization or who were not diagnosed as having a brain injury when the incident occurred may attend outpatient therapies to address functional impairments.

Home Health Services

Some hospitals and rehabilitation companies provide rehabilitation therapies within the home for persons with brain injury.

Community Re-entry

Community re-entry programs generally focus on developing higher level motor, social, and cognitive skills in order to prepare the person with a brain injury to return to independent living and potentially to work. Treatment may focus on safety in the community, interacting with others, initiation and goal setting and money management skills. Vocational evaluation and training may also be a component of this type of program. Persons who participate in the program typically live at home.

Independent Living Programs

Independent living programs provide housing for persons with brain injury with the goal of regaining the ability to live as independently as possible. Usually, independent living programs will have several different levels to meet the needs of people requiring more assistance and therapies as well as those who are living independently and being monitored.

Medications

Medications for persons with brain injury are carefully selected, prescribed, and monitored by the physician on an individual basis. The physician or pharmacist can explain a medication’s purpose, side effects and precautions to you. A general explanation of medication groups is described below:

Analgesics may be used for pain relief and pain management.

Anti-Anxiety Agents may lesson feelings of uncertainty, nervousness, and fear.

Anti-Coagulants may be used to prevent blood clots.

Anti-Convulsants may be used to prevent seizures.

Anti-Depressants may be used to treat symptoms of depression.

Anti-Psychotics may be used to target psychotic symptoms of combativeness, hostility, hallucinations, and sleep disorders.

Muscle Relaxants may be used to reduce muscle spasms or spasticity.

Sedative-Hypnotic Agents may be used to induce sleep or depress the central nervous system in areas of mental and physical response, awareness, sleep, and pain.

Stimulants may be used to increase levels of alertness and attention.

Alternative Medicine and Brain Injury

Alternative medicines, including alternative therapies, are an under-researched area of brain injury treatment.

Healthcare Professionals

A Physiatrist is a doctor of physical medicine rehabilitation. The physiatrist typically serves as the leader for the rehabilitation treatment team and makes referrals to the various therapies and medical specialists as needed. The physiatrist works with the rehabilitation team, the person with a brain injury, and the family to develop the best possible treatment plan.

Physical Therapists evaluate and treat a person’s ability to move the body. The physical therapist focuses on improving physical function by addressing muscle strength, flexibility, endurance, balance, and coordination. Functional goals include increasing independent ability with walking, getting in and out of bed, on and off a toilet, or in and out of a bathtub. Physical therapists provide training with assistive devices such as canes or walkers for ambulation. Physical therapists can also use physical modalities, treatments of heat, cold, and water to assist with pain relief and muscle movement.

Occupational Therapists use purposeful activities as a means of preventing, reducing, or overcoming physical and emotional challenges to ensure the highest level of independent functioning in meaningful daily living. Areas addressed by occupational therapists include: feeding; swallowing; grooming; bathing; dressing; toileting; mobilizing the body on and off the toilet, bed, chair, bathtub; thinking skills; vision; sensation; driving; homemaking; money management; fine motor (movement of small body muscles, such as in the hands); wheelchair positioning and mobility; home evaluation; durable medical equipment assessment and training (such as, use of a raised toilet seat to assist with getting on and off the toilet easier). The occupational therapist also fabricates splints and casts to reduce deformities and optimize muscle functioning.

Speech/Language Pathologists evaluates a person’s ability to express oneself (speech, written, or otherwise expressed) and comprehend what is seen or heard. A speech/language pathologist trains a person to use assistive technology as an alternative form of communication if the person is unable to verbalize. The speech/language pathologist focuses on the muscles in the face, mouth, and throat. They also address swallowing issues.

Rehabilitation Nurses monitor all body systems. A rehabilitation nurse attempts to maintain the person’s medical status, anticipate potential complications, and work on goals to restore a person's functioning. A rehabilitation nurse is responsible for the assessment, implementation, and evaluation of each individual patient's nursing care and educational needs based on specific problems as well as coordinating with physicians and other team members to move the patient from a dependent to an independent role.

Case Managers/Social Workers are responsible for assuring appropriate and cost-effective treatment and the facilitation of discharge planning. Maintains regular contact with the patient's insurance carrier, family, and referring physician to assure that treatment goals are understood and achieved.

Recreational Therapists provide activities to improve and enhance self-esteem, social skills, motor skills, coordination, endurance, cognitive skills, and leisure skills. Recreational therapists plan community outings to allow the person to directly apply learned skills in the community. Additional programs provided by recreational therapists may include pet therapy, leisure education, wheelchair sports, gardening, special social functions or holiday functions for persons and their family.

Neuropsychologists focus on thinking skills, behavior, and emotional processing. Neuropsychologists provide services to reduce the impact of setbacks and to help the person return to a full productive life. The neuropsychologist’s evaluations provide valuable information to assist with school, community, or employment re-entry.

Aquatic Therapists are occupational therapists, physical therapists, or recreational therapists with specialized training to provide therapy in a heated water pool. Aquatic therapists assist a person to increase strength, coordination, ambulation skills, endurance, muscle movement, and reduce pain. The ultimate goal is to increase the person’s functional ability with activities of daily living.

Spinal cord injury (SCI) is an insult to the spinal cord resulting in a change, either temporary or permanent, in the cord’s normal motor, sensory, or autonomic function. Patients with spinal cord injury usually have permanent and often devastating neurologic deficits and disability.

Signs and symptoms

The extent of injury is defined by the American Spinal Injury Association (ASIA) Impairment Scale (modified from the Frankel classification), using the following categories:

A = Complete: No sensory or motor function is preserved in sacral segments S4-S5

B = Incomplete: Sensory, but not motor, function is preserved below the neurologic level and extends through sacral segments S4-S5

C = Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have a muscle grade of less than 3

D = Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have a muscle grade that is greater than or equal to 3

E = Normal: Sensory and motor functions are normal

Definitions of complete and incomplete spinal cord injury, as based on the above ASIA definition, with sacral-sparing, are as follows:

Complete: Absence of sensory and motor functions in the lowest sacral segments

Incomplete: Preservation of sensory or motor function below the level of injury, including the lowest sacral segments

Respiratory dysfunction

Signs of respiratory dysfunction include the following:

Loss of ventilatory muscle function from denervation and/or associated chest wall injury

Lung injury, such as pneumothorax, hemothorax, or pulmonary contusion

Decreased central ventilatory drive that is associated with head injury or exogenous effects of alcohol and drugs

A direct relationship exists between the level of cord injury and the degree of respiratory dysfunction, as follows:

With high lesions (ie, C1 or C2), vital capacity is only 5-10% of normal, and cough is absent

With lesions at C3 through C6, vital capacity is 20% of normal, and cough is weak and ineffective

With high thoracic cord injuries (ie, T2 through T4), vital capacity is 30-50% of normal, and cough is weak

With lower cord injuries, respiratory function improves

With injuries at T11, respiratory dysfunction is minimal; vital capacity is essentially normal, and cough is strong

Diagnosis

Laboratory studies

The following laboratory studies can be helpful in the evaluation of spinal cord injury:

Arterial blood gas (ABG) measurements - May be useful to evaluate adequacy of oxygenation and ventilation

Lactate levels - To monitor perfusion status; can be helpful in the presence of shock

Hemoglobin and/or hematocrit levels - May be measured initially and monitored serially to detect or monitor sources of blood loss

Urinalysis - Can be performed to detect any associated genitourinary injury

Imaging studies

Imaging techniques in spinal cord injury include the following:

Plain radiography - Radiographs are only as good as the first and last vertebrae seen, therefore, radiographs must adequately depict all vertebrae

Computed tomography (CT) scanning - Reserved for delineating bony abnormalities or fracture; can be used when plain radiography is inadequate or fails to visualize segments of the axial skeleton

Magnetic resonance imaging (MRI) - Used for suspected spinal cord lesions, ligamentous injuries, and other soft-tissue injuries or pathology

Treatment

Emergency department care

Airway management - The cervical spine must be maintained in neutral alignment at all times; clearing of oral secretions and/or debris is essential to maintaining airway patency and preventing aspiration

Hypotension - Hypotension may be hemorrhagic and/or neurogenic in acute spinal cord injury; a diligent search for occult sources of hemorrhage must be made

Neurogenic shock - Judicious fluid replacement with isotonic crystalloid solution to a maximum of 2 L is the initial treatment of choice; maintain adequate oxygenation and perfusion of the injured spinal cord; supplemental oxygenation and/or mechanical ventilation may be required.

Head injuries - Amnesia, external signs of head injury or basilar skull fracture, focal neurologic deficits, associated alcohol intoxication or drug abuse, or a history of loss of consciousness mandates a thorough evaluation for intracranial injury, starting with noncontrast head CT scanning

Ileus - Placement of a nasogastric (NG) tube is essential; antiemetics should be used aggressively

Pressure sores - To prevent pressure sores, turn the patient every 1-2 hours, pad all extensor surfaces, undress the patient to remove belts and back pocket keys or wallets, and remove the spine board as soon as possible

Pulmonary management

Treatment of pulmonary complications and/or injury in patients with spinal cord injury includes supplementary oxygen for all patients and chest tube thoracostomy for those with pneumothorax and/or hemothorax.

Surgical decompression

Emergent decompression of the spinal cord is suggested in the setting of acute spinal cord injury with progressive neurologic deterioration, facet dislocation, or bilateral locked facets. The procedure is also suggested in the setting of spinal nerve impingement with progressive radiculopathy, in patients with extradural lesions such as epidural hematomas or abscesses, and in the setting of the cauda equina syndrome.

Chronic stage—late sequelae. Persistence of neurological deficits; assorted complications including venous thrombosis, pulmonary embolism, respiratory insufficiency, bowel obstruction, urinary tract infections, sexual dysfunction, cardiovascular disturbances, spasticity, chronic pain, bed sores, heterotopic ossification, and syringomyelia.

6. Recommended literature:

. basic:

. Roger Simon, David Greenberg, Michael Aminoff - Clinical Neurology (7th Edition) Published: 2009. – P. 63, 164-165;

. Merritt's Neurology / Lewis P. Rowland, Timothy A. Pedley - Merritt's Neurology (12th edition) – 2009. – P. 480-493.

. H. Royden Jones et al. (eds.) - Netter’s Neurology (2nd ed.) – 2012. – P. 552-571.

.

additional:

1. Laboratory Diagnosis in Neurology Wildemann / Oschmann / Reiber. – 2010 (1st Edition). - 296 pp;

2. Anatomic Basis of Neurologic Diagnosis Alberstone / Steinmetz / Najm / Benzel. – 2009.- 600 pp.

7. Materials for self-control of quality of preparation:

Computed tomography scanning of a patient’s head within 2 hours of a newly acquired epidural hematoma should reveal which of the following?

a. A normal brain

b. A lens-shaped density over the frontal lobe

c. Increased CSF density with a fluid-fluid level

d. Multifocal attenuation of cortical tissue

e. Bilateral sickle-shaped densities over the hemispheres

The elderly person who suffers relatively mild head trauma but who subsequently develops a progressive dementia over the course of several weeks is most likely to have sustained which of the following?

a. An acute subdural hematoma

b. An acute epidural hematoma

c. A chronic subdural hematoma

d. An intracerebral hematoma

e. An intracerebellar hematoma

A 57-year-old woman is involved in a motor vehicle accident in which she strikes the windshield and is briefly unconscious. She makes a full recovery, except that 3 months later she notices that she cannot taste the food she is eating. This is most likely due to which of the following?

a. Medullary infarction

b. Temporal lobe contusion

c. Sphenoid sinus hemorrhage

d. Phenytoin use to prevent seizures

e. Avulsion of olfactory rootlets

An 18-year-old boy is brought into the emergency room after a diving accident. He is awake and alert, has intact cranial nerves, and is able to move his shoulders, but he cannot move his arms or legs. He is flaccid and has a sensory level at C5. Appropriate management includes which of the following?

a. Naloxone hydrochloride

b. Intravenous methylprednisolone

c. Oral dexamethasone

d. Phenytoin 100 mg tid

e. Hyperbaric oxygen therapy

A 42-year-old woman is involved in a head-on collision with a lamppost at 50 mph. Her head hits the windshield. She is highly likely to have an intracranial hemorrhage in which one of the following structures?

a. Occipital lobe

b. Thalamus

c. Putamen

d. Parietal lobe

e. Temporal lobe

A 72-year-old man slipped and fell in the bathroom 1 week ago. He hit the right side of his head, but did not think it was necessary to seek medical attention. He finally goes to his doctor because his son thinks his balance is off. Computed tomography (CT) of the brain may fail to reveal a small subdural hematoma in this patient for which of the following reasons?

a. The lesion is subacute

b. The hematoma extends into the brain from the subdural space

c. The resolution of the CT machine is greater than 2 mm

d. The subdural hematoma is less than 4 h old

e. The patient has extensive cerebral atrophy

A 16-year-old boy is struck on the side of the head by a bottle thrown by a friend involved in a prank. He appears dazed for about 30 seconds, but is apparently lucid for several minutes before he abruptly becomes stuporous. His limbs on the side opposite the site of the blow are more flaccid than those on the same side as the injury. On arrival in the emergency room 25 minutes after the accident, he is unresponsive to painful stimuli. His pulse is 40/min, with an ECG revealing no arrhythmias. His blood pressure in both arms is 170/110 mmHg. Although papilledema is not evident in his fundi, he has venous distention and absent pulsations of the retinal vasculature. Which of the following is the best explanation for this young man’s evolving clinical signs?

a. A seizure disorder

b. A cardiac conduction defect

c. Increased intracranial pressure

d. Sick sinus syndrome

e. Communicating hydrocephalus

8. Materials for self-control of capturing the knowledge, abilities, skills foreseen by this work:

a) Tests of rector control

b) Test of the task "КРОК-2".

9. Individual tasks for students: Exam the patient, differentiate between different types of cranial trauma. Give a specific treatment to the patient.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download