Brain and Head Injury

Question 1

What are the three divisions that make up the Glasgow Coma Scale?

Answer 1

Eyes opening - 4
Verbal responce - 5
Motor response - 6

Question 2

IN SBAR the GCS score should be given as a number out of 15.

Answer 2

False it should be broken down into its individual divisions.

Question 3

List indications for a CT within 1 hour.

Answer 3

Any one of the following
GCS <13 upon arrival
GCS <15 2 hours post injury
Suspected open or depressed skull fracture
Any sign of basal skull fracture
Post traumatic seizure
Focal neurological defect
>1 vomiting episode
Suspicion of NAI - for evidence

Question 4

When should a CT be given immediately upon arrival?

Answer 4

Over 65
Loss of consciousness
Anticoagulation

Question 5

What are some clinical signs of a base of skull fracture?

Answer 5

Bruising behind the ear - Battles sign
Double black eye
CSF or blood running from the ear

Question 6

On CT how does an Extradural haematoma appear?

Answer 6

Doesn’t cross the suture lines

Lens shaped

Question 7

What can be a classic presentation of a extradural haematoma?

Answer 7

Lucid interval following intiall GCS reduction where symptoms improve.
Follow by a rapid deterioration.

Question 8

An Extradural haematoma often presents like this.

Answer 8

Reduced GCS
Possible hemiparesis
Unilaterally fixed and dilated pupil

Question 9

On CT how does a subdural haemotoma present?

Answer 9

No contained to suture lines

Cresent shaped

Question 10

An acute subdural bleed on CT will appear…

Answer 10

Bright white

Question 11

A chronic subdural bleed on CT will appear…..

Answer 11

Darker

Question 12

How do diffuse axonal injuries appear on imaging?

Answer 12

Generalised and diffuse swelling

Question 13

What are some imagining negative prognostic factors for a subdural bleed.

Answer 13

Basal cisterns are compressed or entirely obliterated.

Question 14

What is the Monro Kellie Principle?

Answer 14

That the skull is a box which contain three substances. Blood Brain and CSF.
If one of these increases the others will decrease in order to compensate.
When there can be no more compensation there is a sudden and rapid increase in ICP.

Question 15

List the steps taken in a patient with a raised ICP.

Answer 15

Maximise venous drainage
Sedation
CO2 control
Osmotic diuretic
CSF tap

Question 16

How can venous drainage be maximised?

Answer 16

Top of the bed is tilted to 30 degrees

Remove front of cervical collar

Question 17

What are some common sedately drugs use in a patient with a raised ICP?

Answer 17

Propoful

Benzodiazepines

Question 18

Why do CO2 levels need to be carefully monitored in a patient with a raised ICP?

Answer 18

If CO2 levels are raised it triggers an increase in blood to the brain.
This plus the raised ICP compresses the brain causing it to herniate.

Question 19

What are some examples of osmotic diuretics used in a patient with a raised ICP?

Answer 19

Mannitol

Hypetonic saline

Question 20

What is the last resort in a patient with a raised ICP?

Answer 20

Decompressive Craniotomy

Question 21

Why is a decompressive craniotomy considered a last resort?

Answer 21

Whilst in reduces mortality it has a very high risk of causing a severe disability.

Question 22

In order to determine a brainstem death what must be done?

Answer 22

No pupil reaction
No corneal reaction (Blinking)
No motor response
No vestibule ocular reflex
No gag or cough reflex
No respiration (apnea test)

Question 23

What is and what nerves are tested in the Pupil reaction test?

Answer 23

CN II and III

Light shinned into the eye

Question 24

What is and what nerves are tested in the Corneal reaction test?

Answer 24

Cornea is irritated which should evoke a blink

CN V and VII

Question 25

What is and what nerves are tested in the no motor response test?

Answer 25

Application of supraorbital pressure to elicit a grimace.

CN VII V

Question 26

Why are limbs and the trunk not tested in the motor response test?

Answer 26

Movement can be elicited through a spinal nerve reflex which can continue regardless of brainstem death.

Question 27

What is the Vestibular Ocular Reflex test and what nerves are tested for?

Answer 27

Cold water placed in the ear. Should elicit a Nystagmus

CN III VIII VI

Question 28

What nerves are involved in a gag or cough reflex test?

Answer 28

CN IX X

Question 29

What is the Respiration Apnoea test?

Answer 29

Monitor the blood oxygen and CO2 levels in a patient when removed from ventilation and exposed to hyperbolic oxygen.

Question 30

In order for a brainstem death to be pronounced what must happen?

Answer 30

2 different doctor must be present and it must be completed twice.

Question 31

In the brainstem death tests when is the respiration apnoea test done?

Answer 31

Last and only if all of the other tests are negative due to considerable risks of inserting catheter.