CCP 219 - Trauma

Question 1

How is C-spine cleared?

Answer 1

CT or preferably MRI.

C-spine XR is not acceptable.

Question 2

What does rectal exam assess?

Answer 2

1) Rectal tone determining lower extremity neurological impairment.
2) Puncture of rectal wall in pelvic fracture.

Question 3

What does the neurological exam entail in an awake patient?

Answer 3

1) GCS (focus on M).
2) Cranial nerve assessment.
3) Peripheral neuro (ie. reflexes and tone).

Question 4

HOB elevation to 30 degrees from supine reduces ICP by ___ mmHg instantly.

Answer 4

10-12 mmHg.

Question 5

When is seizure prophylaxis indicated in TBI?

Answer 5

1) Hx of Sz.
2) Witnessed Sz after current TBI.
3) Depressed skull fracture.
4) Penetrating skull fracture.
5) Temoral lobe injury (ie. MCA rupture).

Question 6

Outline the approach to status epilepticus:

Answer 6

1st: Benzodiazepines.
2nd: Phenytoin, Keppra, VPA.
3rd: Propofol infusion, midazolam infusion, ketamine.
4th: Magnesium, hypothermia, surgery, ECT, ketogenic diet, volatile gases.

Question 7

What is the dosage of phenytoin?

Answer 7

20mg/kg (as a MAX 50mg/min because it can produce hypotension).

Question 8

When is phenytoin contraindicated?

Answer 8

In TCA overdose (because of sodium channel blockade).

Question 9

What is the risk of propofol infusions for the management of seizure?

Answer 9

Runs the risk of propofol infusion syndrome.

Question 10

Risk factors for propofol infusion syndrome include:

Answer 10

1) > 80mg/kg/hr
2) Young age
3) Prolonged infusion (ie. > 12 hr)

Question 11

Why is magnesium used in the management of eclampsia?

Answer 11

Because other antiepileptics are toxic to the fetus.

Question 12

What does the DIMSS mnemonic for status epilepticus causes stand for?

Answer 12

D - Drugs
I - Infection 
M - Metabolic 
S - Structual
S - Seizure disorder

Question 13

What is the timed approach for the management to status epilepticus?

Answer 13

0-15min = Benzos
15-30min = Phenytoin, VPA, Keppra.
30-45 = Propofol/midaz infusion, ketamine.
45-60 = Magnesium, hypothermia, surgery, ECT, ketogenic, volatile gas.

Question 14

What is “central cord syndrome”?

Answer 14

The shaking/stretching back-and-forth of the spinal cord, producing discrepancy between upper and lower neurons.

Question 15

What might indicate that propofol infusion syndrome is developing?

Answer 15

Increasing lactate without other cause of shock.

Question 16

Approximately ___% of DAI CTs are normal.

Answer 16

50%.

Question 17

Ischemic CVA without thrombolysis should have SBP managed < ___.

Answer 17

< 220.

Question 18

Ischemic CVA with thrombolysis should have SBP managed < __.

Answer 18

< 180.

Question 19

What is the ependyma?

Answer 19

The thin neuroepithelial lining of the ventricular system of the brain.

Question 20

Outline the approach to impending herniation:

Answer 20

1) Hyperventilation guiding ETCO2 between 25-30.
2) HTS 3% 5mL/kg or Mannitol 1g/kg.
3) Increase MAP (ie. to 80-100).
4) Increase sedation.
5) Hyperoxygenate.

Question 21

A patient with an upwards trending ICP (currently at 20mmHg) is being treated with osmotherapy to prevent herniation; what can be done with the dose in the absence of herniation?

Answer 21

Cut the dose of HTS/mannitol in half.

The second half can be given later as a “top-up” dose.

Question 22

How long does osmotherapy take to exert effect?

Answer 22

20-30 minutes.

Question 23

Should osmotherapy be given liberally, or conservatively?

Answer 23

Liberally.

Question 24

What is an effective bridge to reduce ICP until osmotherapy begins to take effect?

Answer 24

Hyperventilation.

Question 25

Intubation is necessary in neuromuscular disease when:

Answer 25

1) Hypercapnia exists (or normocapnia with hyperventilation).
2) Accessory muscle use.
3) C6 impairment.
4) VC < 20mL/kg.

Question 26

What are the three highest yield data points for shock state differentiation?

Answer 26

1) Skin (Distributive vs ALL)
2) JVP (Hypovolemic/distributive vs cardiogenic/obstructive)
3) U/S (Cardiogenic vs obstructive)

Question 27

What is “triple H” therapy?

Answer 27

Treatment of cerebral vasospasm associated with SAH:

Hypervolemia
Hypertension
Hemodilution