Head trauma (Garcia)

Question 1

Objectives (5)

Answer 1

1. Recognize head trauma/TBI
2. ID CS head trauma and/or TBI
3. Primary TBI vs secondary TBI
4. Patient monitoring and management
5. Prognosis/outcomes

Question 2

head trauma inc cats vs dogs vs horses

Answer 2

Dogs - HBC
Cats - crush inj
Horses - rearing and going backwards, unknown, etc

Question 3

TBI doesn’t require

Answer 3

fractures

Question 4

Patient assessment (4)

Answer 4

1. Assess life-threatening extraranial things first
2. ABCs
3. stabilize systemically
4. 60% of TBI patients have other major injuries

Question 5

Extracranial priorities (5)

Answer 5

1. Airway obstruction
2. Oxygenation - maintain Sp02 > 95%
3. Ventilation - art blood gas
4. Volume status
5. Penetrating wounds - thoracic/abdominal

Question 6

Initial neuro assessment (3)

Answer 6

1. Level of conciousness
2. Motor activity
3. Brain stem reflexes (CN V-XII?!?!)

Question 7

Modified Glascow Coma Scale (3)

Answer 7

1. Level of Consciousness (1-6)
2. Motor Activity
3. Brain Stem Reflexes

Question 8

About GCS (4)

Answer 8

1. 18 best score
2. Objective assessment of progression of neuro signs
3. Aids in prognosis
4. Do serially

Question 9

Bilateral Miosis with left pupil pinpoint (2)

Answer 9

1. early severe trauma

2. sympathetic nucleus dysfunction

Question 10

Asymmetric left-sided mydriasis

Answer 10

1. progressive trauma

- symp nucleus first, then parasympathetic nucleus dysfunction

Question 11

Normal Brain Physiology (5)

Answer 11

1. Brain gets 15-20% Cardiac Output
2. CBF: systemic BP and Cerebral metabolic rate and Pa02 & PaCO2
3. Glucose is primary energy source - no stores
4. Low tolerance for hypoxia
5. Autoregulation between MAP 50-150 mmHg

Question 12

TBI: Primary injury

Answer 12

Direct injury of intracranial structures

Question 13

Examples of direct injury of IC structures (3)

Answer 13

1. Concussion
2. Contusion
3. Laceration - vasculature or parenchyma

Question 14

Types of primary injury that can be addressed (4)

Answer 14

Not much we can do

2. Hematoma
3. Depressed skull fractures
4. Foreign bodies

Question 15

TBI: Secondary injury (3)

Answer 15

1. TBI triggers biochem changes - cell death distant to injury site
2. Minutes to days after injury
3. Severity of secondary inj most important determinant of outcome

Question 16

Brain damage ->

Answer 16

Neuronal dysfunction -> cell death

Question 17

Extracranial phenomenon (5)

Answer 17

1. BP alterations
2. Anemia
3. Hypercapnia
4. Infection
5. Electrolyte abnormalities

Question 18

Intracranial alterations (3)

Answer 18

1. Ischemia
2. Cerebral edema
3. Inc ICP

Question 19

Main cause vasodilation

Answer 19

CO2

Question 20

Secondary brain inj schematic (7)

Answer 20

1. Cerebral lactic acidosis
2. Excitotoxicity
3. Inflammation
4. ATP depletion
5. Ischemia
6. Production of ROS
7. Accumulation of Na and Ca

Question 21

Cerebral Perfusion Pressure equation

Answer 21

CPP = MAP - ICP

• normal ICP 5-12 mmHg
• normal CPP 40-120 mmHg: force driving blood into calvarium: O2 and nutrients

Question 22

Monro-Kellie Doctrine

Answer 22

Vintracran=Vbrain+Vcsf+Vblood+Vmasslesion

Question 23

Cushing’s reflex

Answer 23

Bradycardia with reflex hypertension

Question 24

If there is increased ICP DO NOT

Answer 24

hold off the jugular vein

Question 25

Emergency blood screening (6)

Answer 25

Arterial blood gas + PCV/TS 1. Glucose 2. Acid-base status 3. Ventilation (CO2) 4. Perfusion (Lactate) 5. Electrolytes 6. Renal values

Question 26

Cardiovascular and resp assess (5)

Answer 26

1. Blood pressure 2. SpO2 3. Capnography 4. Radiographs 5. T-FAST and A-FAST

Question 27

Imaging considered when (4)

Answer 27

1. Moderate to sev CS of TBI on presentation 2. Failure in imp of CS 3. Deterioration in CS 4. Rule in/out things requiring sx

Question 28

CT (4)

Answer 28

1. Fast 2. IDs acute hemorrhage 3. less spensive 4. gen anesth not req'd

Question 29

MRI

Answer 29

1. anesth req'd (patient must be stable)

Question 30

TBI TX (4)

Answer 30

1. Address EC concerns first 2. Oxygen (flow by or ET tube) - SpO2 > 95% - ventilation (CO2 35-40 mmHg) 3. Fluids (MAP 80-100 mmHg) - blood - crystalloids 4. Pain managment - BE CAREFUL, NO VX - neuro assess first

Question 31

Hypertonic saline

Answer 31

1. Need smaller vol. 2. Imp hemodynamic stat 3. Imp cardiac contractility 4. Dec endothel swelling 5. Immunomodulatory?!?! 6. 3-5 ml/kg IV over 15 followed by crystalloids - can redose I think

Question 32

Mannitol

Answer 32

1. Gold standard?!?! 2. Osmotic diuretic 3. Free radical scavenger 4. Rheological properties 5. May worsen hypovolemia -> arterial hypotension 6. Cause renal injury 7. 0.5-1.5 g/kg IV over 15 min followed by crystalloids 8. Can redose once (I think)

Question 33

Other TX (5)

Answer 33

1. NO CORTICOSTEROIDS 2. Furosemide not recommended 3. Elevate head 4. Nutrition asap 5. Therapeutic hypothermia...?!?!?!

Question 34

Seizure prophylaxis

Answer 34

Not necessary if no seizures - DO TREAT seizures

Question 35

Monitoring (7)

Answer 35

1. BP q2h 2. Continuous ECG 3. Continuous Pulse Ox 4. Neuro assess q4-6 h 5. Serial blood gas 6. Prevent aspiration 7. Prevent pressure sores

Question 36

Prognosis (3)

Answer 36

1. linear correlation between MGCS score and survival w/in 72 hours 2. Presence of hyperglycemia (I think) is poor prognostic indic 3. TIME IS BEST FRIEND