Chapter 56B. Craniocerebral Trauma Flashcards
Question 56B-1: A patient with severe head injury is low unresponsive. Eye examination shows bilateral midposition pupils. Light in the left eye produces constriction of both pupils. Light in the right results in no response from either side. Which is the most likely lesion? A. Right optic nerve B. Left optic nerve C. Right oculomotor nerve D. Left oculomotor nerve E. Brainstem
Answer 56B-l: A. The patient has an afferent pupillary defect on the right This is due to a lesion of the optic nerve. (p1132)
Question 56B-2: A patient with head injury has ventilatory failure and intubation is to be performed. Which is the most appropriate procedure? A. Sedation and pharmacological paralysis B. Sedation without paralysis C. Paralysis without sedation D. Neither
Answer 56B-2: A. Sedation and paralysis are performed immediately prior to intubation in most patients, including patients with head injwy. Paralysis and sedation temporarily cloud the neurologic examination, however, these agents are typically short acting. (p1133)
Question 56B-3: The patient mentioned above is successfully intubated and placed on mechanical ventilation. What is the role of hyperventilation? A. Hyperventilation is perfomedroutinely to reduce intracranial pressure B. Hyperventilation is perfomedonly if there is deterioration C. Hyperventilation is never performed
Answer 56B-3: B. Hyperventilation is used for acute deteriomtion as a life-saving maneuver, but should be avoided if possible. Hyperventilation can produce vasoconstriction with resultant reduction in cerebral blood flow. (p1134)
Question 56B-4: A patient is brought to the ED with severe head injury by the paramedics. There are no responses and no roving gaze. You want to check doll’s maneuvers, but the paramedics have placed the patient in cervical stabilization. There is no external evidence of cervical spine injury. Which is the best approach? A. Remove the stabilization and (Ql oculocephalic maneuvers B. Loosen the stabilization and move the neck only a few degrees to examine, then restore the stabilization until radiographic clearance is obtained C. Clear the cervical spine radiographically prior to removing the stabilization to examine the patient
Answer 56B-4: C. Examination of oculocephalic reflexes is less important than ensuring integrity of the cervical spine. Even ·though there may be no external signs of cervical spine injury, the examination should be performed only after there has been radiographic clearance of the spine. (p1134)
Question 56B-5: A patient seen in the emergency department for closed head injury has the following findings on examination: Alert and conversant Opens eyes spontaneously Follows commands Which is the correct Glasgow Coma scale? A. 0 B. 1 C. 2 D. 14 E. 15
Answer 56B-5: E. The patient receives full marks for the Glasgow coma scale. Below is a summary of the scoring system for this examinatioo as tabulated in NICP 4/e. (p1135)
Question 56B-6: A 78-year-old man presents to the ED with severe closed head injury. He is unresponsive and has no pupillary responses or oculocephalic reflexes. GCS is 3. CT shows large left frontal and central intraparenchymal hematoma. How would you advise the family regarding possible surgery? A. Prognosis is good with or without surgery B. Prognosis is poor without surgery but can be good with immediate surgery C. Prognosis for good recovery is very poor with or without surgery
Answer 56B-6: C. An elderly patient with severe closed head injury with this degree of neurologic dysfunction has a poor prognosis with or without surgery. In fact, the prognosis could have been predicted even before the CT. This information may allow us to identify patients who will not benefit from aggressive surgical or medical management. (p1135)
Question 56B-7: The figure shows a CTslice from a patient with closed head injury. How would you assess the clinical presentation? A. The appearance of the scan indicates a low probability of increased mass effect of the lesion B. The small size of the hematoma places the patient at relatively low risk unless there is marked increase in size of the lesion C. Enlargement of the small hematoma can be associated with uncal herniation
Answer 56B-7: C. The scan shows early uncal herniation already. Even minor enlargement of mass effect can result in further decompensation with an otherwise moderate-sized lesion. Contusions conunonly enlarge, both because of increased bleeding and because of edema around the lesion. (p1136)
Question 56B-8: What is the role of lCP monitoring in management of patients with TBI? A. Measurement of lCP allows for calculation of cerebral perfusion pressure B. Increased ICP can indicate imminent neurologic deterioration so that intervention can be performed C. Measurement of lCP is not necessary in patients with normal CT and good functional status D.All are true
Answer 56B-8: D. Measurement of ICP is performed in most patients with severe TBI, especially when CT shows abnormalities which could indicate the need for decompression or other surgical procedure. Patients with mild TBI do not need ICP monitoring. An increase in ICP and a reduction in CPP indicates that the patient is at risk for significant neurologic deterioratioo, and reconsideration of surgical intervention is needed. (p1137)
The figure shows a hemorrhage resulting from a closed head injury. Which type of hemorrhage is shown? A. Subdural B. Epidural C. Subarachnoid D. lntraparenchymal
Answer 568-9: D. The patient has intraparenchymal hemorrhage secondary to contusions. (p 1137)
Question 56B-10: Which is the most likely neurologic complication of cingulate gyrus herniation? A. Anterior cerebral artery infarction B. Basilar artery infarction C. Uncal herniation D. Transtentorial herniation
Answer 568-10: A. Cingulate gyrus herniation produces neurologic deficit by infarction in the distribution of the anterior cerebral artery. (P1132)
