Code Black Flashcards
What is the aim of the Code Black trauma call?
To optimise the care of critically brain injured patients requiring emergent neurosurgical decompression
What are the principles of management of severely brain injured patients?
Avoidance of secondary insults - through control of intracranial pressure and emergent removal of surgical evacuable lesions
When should a Code Black be activated?
If the patient is or requires intubation and their pre intubation GCS was less than 8
Clinical suspicion of significant head injury
There are pupillary changes
CT scan reveals acute haematoma with mass effect
Who is expected to attend a Code Black?
All members of an advanced trauma team
Neurosurg Reg
Neurosurg SHO
What are the prioritise for a Code Black on arrival to resus?
Identification and treatment of immediately life threatening extra cranial injuries
CT imaging of the brain
Radiological clearance of the spine
Rapid correction of any coagulopathy or thrombocytopenia
Evacuation of appropriate mass lesions demonstrated on CT
Prevention of secondary brain insult
How can secondary brain insult prevention (hypotension, hypercarbia, hypoxia, impaired cerebral venous return and uncontrolled seizure activity) be achieved?
Ventilation to low normal capnea (paCO2 of 4.5 KPa) and maintain sats above 95%
Avoid high levels PEEP
Sufficient sedation
Anti-convulsant if has had at least 1 seizure since injury - keppra
Maintain systolic BP above 100 mmHg
No collar - head blocks and tape
Tilt bed to 30 degree head up position
Hypertonic saline
Maintain mormothermia
Where is the Code Black box kept?
Back of resus bay 8
What is contained in the Code Black box?
Surgical hair clippers and charger
Permanent marker pen
Consent form 4
2 bags of 500ml of 5% saline
What are the different ways of assessing levels of consciousness?
GCS
AVPU
What does AVPU stand for?
Alert
Verbal
Pain
Unresponsive
How do you assess if pupils are equal
and reactive?
Shine a light on both and compare
What is a SAH?
Subarachnoid haemorrhage - bleeding in the space that surrounds the brain
What is an EDH?
Extradural haemorrhage - bleeding that occurs outside the dura mater beneath the skull
Why is an extradural haemorrhage dangerous?
The expanding haematoma compresses the brain beneath it
Often the bleed is rapid and the patients will loss consciousness at the time of injury or as it worsens
What is the management for an extradural haemorrhage?
Emergency surgery to evacuate the haematoma
What is a SDH?
Subdural haemorrhage - haematoma forms beneath the dura matter as a result to injury to bridging veins
Associated with worst outcomes
What it the more common type of bleed associated with severe head injuries?
Subdural haemorrhage
How does an acute SDH present?
Occurs within the first few hours and can quickly evolve in size leading to loss of consciousness and coma
What does an acute SDH require?
Immediate referral to neurosurgery
How does a chronic SDH present?
May appear days or weeks after the initial accident
Bleeding is slow and patient will deteriorate slowly
What is an intracerebral bleed?
Bleeding that occurs deep within the brain tissue often caused by severe force
What is an intracerebral bleed associated with?
Subdural haematoma
How do you manage a intracerebral bleed?
Neurosurgical referral
Close monitoring to observe for ongoing bleeding or increasing ICP
What is the mechanism for a axonal injury?
Rapid acceleration to deceleration force e.g high speed RTa
What is an axonal injury?
Stretching and shearing that occurs causing swelling and injury to the axons
Associated with permanent disability and high morbidity and mortality
What is a normal ICP?
Approximately 10 mmHg
IPs greater than 22 mmHg are associated with what?
Poor outcomes
What is the Monroe-Kellie doctorine?
It explains the dynamics of ICP. The total volume of intracranial contents must remain the same because the cranium is rigid that is incapable of expanding. When normal intracranial volume is exceeded ICP rises.
Why can ICP remain stable immediately after injury whilst a mass, such as a haematoma, can grow?
Venous blood and CFS can be compressed out of the cranium providing some degree of pressure buffering
What can diffuse axonal injuries range from?
Mild concussions to severe hypoxic, ischemic injuries
What happens to a patients ICP once the limit of displacement is reached?
It rapidly increases
Can the primary injury/initial insult that has caused a TBI be reversed?
No
What is the management of a
TBI aimed at?
Avoiding secondary injury caused by hypoxia and hypotension through the maintenance of adequate cerebral blood flow and the prevention of hypoxia
Why is it important to make sure that patients who have TBI have adequate sedation?
It minimises pain, anxiety and agitation
Reduces cerebral metabolic rate of oxygen consumption
Facilitates mechanical ventilation
What can brain stem injuries directly effect?
Cardiovascular stability
Why must hypotension be avoided at all costs for TBI patients?
It causes a reduction in cerebral blood flow and is likely a result of cerebral ischemia
How does mannitol work?
Plasma expanding effect and improved blood rheology due to a reduction of haemocrit
Establishes an osmotic gradient between plasma and brain cells, reducing cerebral oedema by drawing water across areas of intact blood brain barrier into the
vascular compartment
How does hypertonic saline work?
It produces a reduction in cerebral edema by moving water out of cells, reducing tissue pressure and cell size, resulting in a decrease in ICP
What drug improves cerebral blood flow, independently of ICP, by decreasing endothelial cell volume, increasing diameter of capillary lumen and reducing erythrocyte size thereby improving blood rheology?
Hypertonic saline
Why is hypertonic saline preferred over mannitol for patients with TBI?
Has proven efficacy in controlling ICP in patients refractory to mannitol and is also effective as a volume expander without causing hyperkalaemia and impaired renal function
