CCMCP Head Injury

Question 1

CCMCP Head Injury - Initial actions?

Answer 1

Ensure SpO2 > 92%
Consider SMR
Elevate head of bed 15-30 degrees
Consider airway management

Question 2

CCMCP Head Injury - If hypotensive? adult/ped

Answer 2

Adult - 500 ml bolus to maintain MAP of 85 mmHg

Ped - 10 ml/kg to maintain normal BP for age

Question 3

CCMCP Head Injury - If refractory hypotension?

Answer 3

Consult TP - Norepinephrine 0.1-1 mcg/kg/min to achieve MAP of 85

Question 4

CCMCP Head Injury - What are general brain protective measures? (5)

Answer 4

Avoid: hypoxemia
hypotension
hypercapnia
hyperthermia
hypo or hyperglycemia

Question 5

CCMCP Head Injury - What are the signs of herniation syndrome?

Answer 5

GCS <8 & 1 of the following:
Abnormal pupils
Abnormal motor exam

Question 6

CCMCP Head Injury - If signs of herniation are present?

Answer 6

Consult TP to consider:
3% hypertonic saline 3 ml/kg
Mannitol 1 g/kg

Question 7

CCMCP Head Injury - Seizing?

Answer 7

Treat per seizure protocol

Question 8

CCMCP Head Injury - Anticoagulated?

Answer 8

Consult TP to consider reversal of coagulopathy:

Octaplex, Vit K, FFP, ect.

Question 9

CCMCP Head Injury - Uncal herniation syndrome symptoms? (2)

Answer 9

Unilateral fixed / dilated pupil

Contralateral (usually) motor findings (flaccidity or posturing)

Question 10

CCMCP Head Injury - Transtentorial herniation syndrome symptoms? (2)

Answer 10

Bilateral abnormal pupils (small non-reactive, or mid-position and non-reactive)
Bilateral motor findings (flaccidity or posturing)

Question 11

CCMCP Head Injury - Tonsillar (coning) herniation syndrome? (2)

Answer 11

Bilateral mid non-reactive pupils

Bilateral flaccidity

Question 12

CCMCP Head Injury - Indications for advanced airway management? (3)

Answer 12

Airway protection (GCS less than 8)
Agitated / dangerous patient
Anticipation of worsening clinical condition

Question 13

CCMCP Head Injury - 3% hypertonic saline indications?

Answer 13

Head injury with signs of herniation

Question 14

CCMCP Head Injury - 3% hypertonic saline dose?

Answer 14

Consult TP – 3 mL/kg IV/IO at a max rate of 20 mL/min

Question 15

CCMCP Head Injury - 3% hypertonic saline contraindiations?

Answer 15

Serum osmolarity >320 mmol/L

Serum sodium >155 mmol/L

Question 16

CCMCP Head Injury - 3% hypertonic saline precautions?

Answer 16

Can cause hypernatremia and hyperosmolarity

Question 17

CCMCP Head Injury - Mannitol indications?

Answer 17

Head injury with signs of herniation

Question 18

CCMCP Head Injury - Mannitol dose?

Answer 18

Consult TP – 1 g/kg IV/IO over 15 minutes

Question 19

CCMCP Head Injury - Mannitol contraindications?

Answer 19

Serum osmolarity >320 mmol/L

Hypotension

Question 20

CCMCP Head Injury - Mannitol precautions?

Answer 20

Always inspect product for particulate matter
Infusions should always be given with an in-line filter
Avoid extravasation
Assess for signs and symptoms of congestive heart failure in patients at risk of circulatory overload

Question 21

CCMCP Head Injury - Norepinephrine indications?

Answer 21

Symptomatic bradycardia
Shock with hypotension refractory to fluid resuscitation
Cardiogenic shock with refractory hypotension

Question 22

CCMCP Head Injury - Norepinephrine dose?

Answer 22

0.1 mcg/kg/min to max of 1 mcg/kg/min to achieve MAP 85 mmHg

Question 23

CCMCP Head Injury - Norepinephrine contraindications? (4)

Answer 23

Mesenteric or peripheral vascular thrombosis
Pregnancy
Profound hypoxia
Hypovolemia

Question 24

CCMCP Head Injury - Norepinephrine precautions?

Answer 24

Use with caution if patient taking MAOI or TCAs

Administering into a large vein reduces the risk of extravasation