Neuro Emergencies: Traumatic Brain Injury

Question 1

How are TBI’s classified?

Answer 1

Mild
Moderate
Severe
According to GCS

Question 2

Mild head injury GCS is?
Moderate head injury GCS is?
Severe head injury GCS is?

Answer 2

13-14
9-12
</= 8

Question 3

What can cause the initial exam to be altered?

Answer 3

ETOH
Drugs

Question 4

FOUR Score
Eye Response
4=
3=
2=
1=
0=

Answer 4

Eyelids open or opened, tracking or blinking to command
Eyelids open but not to tracking
Eyelids closed but opens to loud voice
Eyelids closed but opens to painful stimuli
Eyelids remain closed with painful stimuli

Question 5

FOUR Score
Motor Response
4=
3=
2=
1=
0=

Answer 5

Thumbs up, fist, or peace sign
localizing to pain
flexion to response to pain
extension to response to pain
no response to pain or generalized myoclonus status

Question 6

FOUR Score
Brainstem Reflexes
4=
3=
2=
1=
0=

Answer 6

Pupil and corneal reflexes present
one pupil wide and fixed
pupil or corneal reflexes absent
pupil and corneal reflexes absent
absent pupil, corneal or cough reflexes

Question 7

FOUR Score
Respiration
4=
3=
2=
1=
0=

Answer 7

Regular breathing pattern
Cheyne-Stokes breathing pattern
Irregular breathing
Triggers ventilator or breaths above ventilator rate
Apnea or breathes at ventilator rate

Question 8

FOUR Score
What is it?
Allows examiner to test what?
Can recognize what?
Can detect different stages of what?
Lower scores indicate higher what?

Answer 8

A 16 pt scale that provides greater neurological detail
brainstem reflexes
locked-in syndrome
brain herniation
coma severity

Question 9

What are Primary Mechanisms of Injury?
Open

Answer 9

Penetrating
Skull fxs

Question 10

What are Primary Mechanisms of Injury?
Closed

Answer 10

Concussive
Diffuse Axonal Injury (DAI)
Hematomas
Coup-countercoup

Question 11

What are Secondary Mechanisms of Injury?

Answer 11

Ischemia
Edema
Loss of cerebral vascular autoregulation
Loss of blood brain-barrier
Mass Lesions

Question 12

Pre-Hospital Care
A meta-analysis of clinical trials demonstrated that what two insults were each associated with poor outcomes?
Both were also associated w/ increase in what?

Answer 12

Hypoxia (PaO2 < 60)
Hypotension (SBP < 90)
Mortality

Question 13

Emergency Department Care
Initial Evaluation includes?
Imaging?

Answer 13

ATLS (ABCDE)
Head CT

Question 14

Emergency Department Care
Hearniation or deterioration may require what?

Answer 14

+/- Hyperventilation
+/- Mannitol
+/- Hypertonic Saline
+/- Ventricular drain

Question 15

Emergency Department Care
Surgical lesion requires?

Answer 15

OR

Question 16

Emergency Department Care
What level of care is required?

Answer 16

ICU management

Question 17

Emergency Department Care
Lab/diagnostic test?

Answer 17

CBC
CMP
blood glucose
Coags
BAL
Urine tox
type and screen
d-dimer
Fast Exam
Pertinent imaging

Question 18

Emergency Department Care
Should perform rapid reversal of what?

Answer 18

coagulopathy

Question 19

Emergency Department Care
What additional imaging should be considered?

Answer 19

CTA Head and Neck

Question 20

TBI Management
Hyperventilation
How is it used?
Target?

Answer 20

Acutely until other targeted interventions implemented
PCO2 of 35-40

Question 21

TBI Management
Osmotic Therapy
Consideration with mannitol?
Consideration with 23.4%?
Consideration with 3% and 5%?

Answer 21

Diuretic effect of mannitol can interfere with systemic resuscitation
23.4% saline requires central access
Can use 3% and 5% saline via peripheral as a bolus

Question 22

TBI Management
Neurosurgery consult
What’s the likely intervention?
This intervention allows for what?
Advantage of material used?

Answer 22

EVD placement
Continuous CSF diversion in pts with GCS of < 6
Antimicrobial-impregnated catheters

Question 23

TBI Management
Sedation/Pain Control
Disadvantages? (2)
Should use what?

Answer 23

Can impair neuro exam
May decrease CPP
Short acting opiates

Question 24

TBI Management
Steroids

Answer 24

Not recommended
High-dose Methylprednisolone assoc. w/ increased mortality and is contraindicated

Question 25

TBI Management Prophylactic hypothermia

Answer 25

no benefit

Question 26

TBI Management Anticonvulsants

Answer 26

Shown to decrease incidence of Post Traumatic Seizures (PTS) w/n 7 days of injury

Question 27

TBI Management Nutritional Support Start feeding by when? This helps how? Where is feeding recommended to occur?

Answer 27

At least day 5 to decrease mortality Post pyloric feeding is recommended to reduce incidence of VAP

Question 28

TBI Management Early Tracheostomy Helps with? Doesn't help with?

Answer 28

Reduces mechanical ventilation days No evidence that it reduces mortality or the rate of nosocomial pneumonia

Question 29

TBI Management ICP Monitoring Indicated for which patients? ICP > what should be treated?

Answer 29

Patients w/ GCS 3-8 and an abnormal CT scan and/or TBI patients w/ a normal CT scan and tow or more of the following: 1. age > 40 2. unilateral or bilateral posturing 3. SBP < 90 mmHg 22 mmHg

Question 30

TBI Management CPP should be maintained where?

Answer 30

between 60-70 mmHg

Question 31

TBI Management Advanced Cerebral Monitoring Jugular bulb monitoring of what may be considered? Jugular venous saturation of < ? may be a threshold to avoid to reduce mortality and improve outcomes. Decreases in SjVO2 may be due to what?

Answer 31

arteriovenous oxygen content difference (AVDO2) <50% increased O2 consumption (fever or seizure) or decreased O2 delivery (ICP elevation, hypotension, hypoxia, or anemia)

Question 32

TBI Management Blood Pressure Maintaining what SBP is recommended for patients 50-69? Maintaining what SBP is recommended for patients 15-49 or < 70y/o?

Answer 32

SBP >/=100 mmHg SBP >/= 110 mmHg

Question 33

TBI Management Barbiturates Administration to induce burst suppression as prophylaxis is or is not recommended? Administration to control elevated ICPs refractory to maximal medical therapy and surgical treatment, is or is not recommended? Can cause what?

Answer 33

Is not recommended Is recommended Hemodynamic Instability

Question 34

TBI Management Therapeutic Hypothermia Methods of inducing hypothermia include? (5) What complication should be avoided? how to prevent it?

Answer 34

Water or air cooled blankets above and below patient NG lavage w/ iced saline Esophageal cooling device Bolus of iced saline Intravascular devices Shivering; sedation and paralysis

Question 35

Therapeutic Hypothermia Target cooling temp is? Cooling duration should last how long? Rate of rewarming is?

Answer 35

32-35*C About 48 hrs 1*C/hr

Question 36

Therapeutic Hypothermia Potential complications include?

Answer 36

Coagulation d/o's Cardiac arrhythmias Electrolyte shifts Myocardial depression Infections - primarily pneumonia

Question 37

Therapeutic Hypothermia Induced hypothermia has been shown to be effective in improving what? Problems with the trial? Decreased risk of what? Should be limited to patients with?

Answer 37

improving neurological outcome after ventricular fibrillation cardiac arrest Small sample sizes, low quality trials death or poor neurological outcomes refractory elevated ICPs

Question 38

Decompressive Hemicraniectomy A bifrontal decompressive hemicraniectomy is not recommended to improve outcomes as measured by the Glasgow Outcome Scale-Extended (GOS-E) score at 6mo post-injury in patients w/ what?

Answer 38

diffuse injury and ICP elevation >20 mmHg for more than 15 min w/n a 1-hr period that are refractory to first-tier therapies?

Question 39

Decompressive Hemicraniectomy Bifrontal decompressive hemicraniectomy has been shown to do what?

Answer 39

Decrease ICP and minimize ICU days

Question 40

Decompressive Hemicraniectomy If you're going to do it, make it big! What size large frontotemporoparietal DC is recommended over a small frontotemporoparietal DC for reduced what? and improved what? in who?

Answer 40

not less than 12 x 15cm or 15cm diameter reduced mortality improved neurologic outcomes in patients with severe TBI