TBI Management

Question 1

What two vital sign findings more than double the risk of death from a brain injury?

Answer 1

SBP <90mmHg

SpO2<90%

Question 2

When tracking a brain injury over time, what are some early signs of rising ICP?

Answer 2

worsening headache
focal neurologic deficit
declining neurologic exam

Question 3

What GCS is considered mild?

Answer 3

13-15

Question 4

What GCS is considered moderate?

Answer 4

9-12

Question 5

What GCS is considered severe?

Answer 5

3-8

Question 6

What are some red-flags with TBIs?

Answer 6

Witnessed LOC
Two or more blast exposures in 72 hours
Unusual behavior or combative
Unequal pupils
Seizures
Repeated vomiting 
Double vision or loss of vision
Worsening headache
Weakness on one side of body
Cannot recognize people or place
Abnormal speech

Question 7

How can ultrasound be used to assess TBI?

Answer 7

Measuring Optic Nerve Sheath Diameter (ONSD)

Question 8

What ONSD measurement can indicated elevated ICP?

Answer 8

> 5.2mm

Question 9

In the PFC setting, what is considered “best” when it comes to monitoring?

Answer 9

Portable monitor of vitals
Foley to measure UOP
EtCO2 with capnometer
Pupillary response with GCS every hour

Question 10

If you have the capability, how often is ONSD measured in the TBI patient?

Answer 10

every 30 minutes
change in neuro exam
to check for response of interventions

Question 11

What is the goal EtCO2 in the TBI patient?

Answer 11

35-40mmHg

Question 12

What is the target SBP in TBI patients?

Answer 12

> 110mmHg

Question 13

What should you be concerned about in the hypotensive TBI patient?

Answer 13

bleeding or tension pneumothorax

hypotension is usually not caused by TBI except as a late finding due to herniation

Question 14

What is the goal UOP in poly-trauma?

Answer 14

30-50mL

Question 15

What IV fluids have demonstrated a trend toward worsening outcomes of TBI patients?

Answer 15

Colloids (albumin)

Question 16

What fluids can make brain swelling worse?

Answer 16

hypotonic fluids including lactated ringers

Question 17

In a PFC setting, what is considered “best” in airway, oxygenation, and ventilation management?

Answer 17

Circ or ETT with continuous sedation are airway maintenance
SpO2>95% and EtCO2 35-40mmHg
Arterial blood gas within 30 minutes of intubation
PEEP of 5cmH20

Question 18

What can PEEP be turned up to in the TBI patient to improve SpO2?

Answer 18

15cmH20

Question 19

What GCS score requires an advanced airway?

Answer 19

<8

Question 20

What can be done to help with gastric distention in the ventilated patient?

Answer 20

Nasogastric tube placement

Question 21

What are some general measures to reduce ICP?

Answer 21

Elevate head of bed 30-60 degrees
Maintain neck in midline
maintain SpO2 >90%
Maintain EtCO2 35-40mmHG
Maintain temp between 96-99.5
Prevent or rapidly manage seizure activity 
hyperventilate 
analgesia/sedation 
Hypertonic saline (HTS)
Mannitol if no signs of bleeding

Question 22

How long can you hyperventilate a patient for?

Answer 22

20 minutes, maintain EtCO2 of 30mmHg

Question 23

How often can a TBI patient be hyperventilated?

Answer 23

duration and frequency not known, seek guidance by teleconsultation

Question 24

How is HTS administered to the TBI patient with signs of ICP?

Answer 24

3% NaCl 250 mL bolus over 20 minutes, repeat every 3 hours as needed

Question 25

How is Mannitol administered in the TBI patient with signs of increased ICP?

Answer 25

If no signs of bleeding, SBP>90mmHg: 1g/kg - IV/IO over 20 minutes Repeat 0.5/kg ever 3 hours

Question 26

What is the approximate duration of hypertonic saline (HTS)?

Answer 26

3 hours

Question 27

What are some concerns with administering Mannitol in the TBI patient?

Answer 27

it's a diuretic that might lower blood pressure | repeated use can damage the blood-brain barrier and worsen ICP

Question 28

What antibiotics should be administered for the patient with a CNS penetrating injury?

Answer 28

Ceftriaxone 2gm IV/IO every 24 hours or Cefazolin 2g IV/IO every 8 hours x 5 days Add metronidazole 500mg IV/IO x 5 days in woulds that are grossly contaminated with organic debris

Question 29

Whats considered the minimum treatment for the TBI patient having a seizure?

Answer 29

Midazolam 5mg IV/IO/IM q 5 minutes until seizure stops

Question 30

What are some alternate benzodizepines that can be given for TBI patients have seizures?

Answer 30

diazepam 5mg q5min | lorazepam 4mg q5min

Question 31

In addition to a benzodiazpine, what other medications can be considered in the TBI patient?

Answer 31

antiepilepsy drugs: Levetiracetam Phenytoin Phenobarbital

Question 32

What is the target sodium level in patients with severe TBI?

Answer 32

145-160 mmol/L

Question 33

What should you do before administering more than two bags of hypertonic saline to a patient with severe TBI?

Answer 33

obtain telemedicine consultation

Question 34

What are some conditions in the patient with severe TBI that can lower or raise serum sodium levels?

Answer 34

cerebral salt wasting syndrome of inappropriate autidiuretic hormone secretion diabetes insipidus

Question 35

How often should you check blood glucose in the TBI patient?

Answer 35

every 6 hours

Question 36

How would you treat the TBI patient with a blood glucose <100mg/dL?

Answer 36

20g oral glucose 5 teaspoons of sugar or 4 of honey 25g (50mL) D50 solution IV/IO recheck blood glucose in 1 hour

Question 37

During air-transport, what altitudes risk additional complication in the TBI patient?

Answer 37

>8,000 ft

Question 38

What finding on ophthalmscopic exam might suggest increased ICP?

Answer 38

loss of spontaneous venous pulsations (SVPs)