Novel Concepts And Heads Injury

Question 1

Early TBI effects

Answer 1

Multi system
Sequalae of axonal stretch
Apnoea
Dysventilation
Systemic inflammatory response
CV effects

Question 2

CV dysfunction in the context of TBI

Answer 2

HR >100 + SBP <100

Question 3

What aspects of injury correlate with plasma Catecholamines after head injury in humans

Answer 3

ISS
GCS
functional outcome
Mortality

Question 4

How does catecholamine surge cause neurogenic stunning of the myocardium and contraction band necrosis on autopsy

Answer 4

Catecholamine release form sympathetic neurones -> opens b1 channels -> calcium influx -> myofibril contraction -> ATP depletion -> mitochondrial damage -> myocyte death

Question 5

Causes of CV dysfunction in TBI

Answer 5

Apnoea -> hypoxia, hypercarbia, acidosis
Systemic CA surge -> incr SVR, afterload, myocardial demand
Local CA effects -> myocyte hyper contraction and death
Systemic inflammatory mediated response

Question 6

POCUS in CV unstable pt

Answer 6

+Ive bleeding - bleeding
-ive bleeding + low pre scan probabaility + good cardiac contractility -> low SVR
-I’ve bleeding + low pre scan probability + poor cardiac contractility -> cardiogenic shock

Question 7

Low SVR mx

Answer 7

Judicious Volume resus
Vasopressors - phenylephrine

Question 8

Cardiogenic shock mx

Answer 8

Targeted volume resus
Inotropes - adrenaline

Question 9

Head injury bundle of care

Answer 9

A - recognise apnoea and dysventilation
B - appropriate oxygenation and ventilation
C - avoid hypo or hypertension
D - optimise ICP / venous drainage
E - normalise physiology
F - inFlammation — limit coagulopathy/inflammatory changes (TXA, PCC if anticoagulated)
G - go to the right place

Question 10

Code black

Answer 10

Clinical suspicion sig head injury
GCS <8
Uni/bilat pupil dilation or Cushings

Question 11

Code red AND code black

Answer 11

Cardiac dysfunction with suspicion of severe TBI but remains diagnostic uncertainty about bleeding

Question 12

Reasons to sedate head injured pt

Answer 12

Manage agitated high GCS pt
Optimise prep and preoxygenation prior to RSI
Ongoing sedation of intubated pt

Question 13

Ways to optimise ICP

Answer 13

Analgesia
Sedation
Loosen tube ties
Avoid fitting collar tightly
Head up
Nypertonic saline 5% - 6ml/kg max 350ml)

Question 14

Treatment of persistent seizure activity

Answer 14

Levetiracetam

Question 15

When should 2g TXA be given

Answer 15

All 3
- head injury
- GCS <12 or requiring intubation for effects of their HI
- <3hrs from injury

Question 16

CRASH2 finding

Answer 16

Reduction in all cause mortality and death due to bleeding if TXA given <3hrs

Question 17

Potential benefits of beta blockers in TBI

Answer 17

Counter increased sympathetic activity and supraphysiologic levels of plasma catecholamines
Decr inflammatory mediators - TNF
Membrane stabilisation
Antioxidant effects

Question 18

In hospital neuromonitoring

Answer 18

Tympanic membrane displacement
Optic nerve sheath diameter
Invasive ICP
Trans cranial Doppler