EDH

Question 1

Patient came in an RTA with GSC15 Vomiting twice& with amnesia then after admission to the ortho ward GCS started dropping now it’s 8

Q1: Who would you call for help?

Answer 1

A surgeon / neurosurgeon / ITU team / Anesthesia team
I will start Resuscitating the pt and order CT brain

Question 2

Q2: What investigation will you order ?

Answer 2

CT Brain

Question 3

Q3: CT scan done, what does it show?

Answer 3

Hyperdense biconvexity,
compression of ventricles and
midline shifting – > EDH

Question 4

Q4: Would you have done a CT earlier?

Answer 4

YES

Question 5

Q5. What signs would warrant an early CT?

Answer 5

Vomiting and amnesia

Question 6

Q6: Why do some head trauma patients have blown pupils?

Answer 6

Hematoma will increase ICP which will lead to herniation of medial temporal lobe causing compression of the oculomotor nerve at the ant attachment of T. cerebelli.

Question 7

Q7: What do you know about Monroe Kellie doctrine?

Answer 7

The skull is fixed box containing 3 components
o Brain (80%), blood (10%), CSF (10%)
* ICP/volume relationship is governed by these 3 components
* Increase in volume in one component may result in compensatory decrease in the volume of another component in order to prevent rise in ICP (compensation)
* However, once the ICP has reached around 25 mmHg, small increases in brain volume can lead to marked elevations in ICP; this is due to failure of intracranial compliance (decompensation) leading to brain herniation

Question 8

Q9: In the ventilated patient, what can you do to lower ICP?

Answer 8

Raise pt head / hyper ventilation / induce barbiturate coma
Q10. What is normal ICP?
7-15 mmhg

Question 9

Q8: How can you measure ICP?

Answer 9

Many like; transcranial doppler, tympa. Memb displacement / lumbar csf pressure / intravent. Cath / epidural prob

Question 9

Q. Indications for Intubation?

Answer 9

GCS < 8 / sever facial injury or mandible # / Planning to transefer to another center (prophylactic intubation) / pt is agitated and need sedation. / RR > 35.

Question 10

Q12: What are the benefits and risks of monitoring ICP?

Answer 10

Benefits; to maintain the CPP
Risk; herniation and infection and hge, brainstem death.

Question 10

Q. Features of Increased ICP?

Answer 10

Papilledema, Headache, Vomiting, Seizures, Alterd mental status, Cushing triad (HTN, low HR, low RR), Lat gaze if abducent involved.

Question 10

Q11: Strategies to reduce / maintain ICP?

Answer 10

Non-surgical; Elevation of pt head / mannitol / hypervent if ventilated / induce barbiturate coma / Anti-diuretics
Surgical; Craniotomy / drainage catheter

Question 11

Q13: How can you explain the lucid interval?

Answer 11

Temp period of improvement of pt condition followed by rapid deterioration of his condition and GCS.
this happens due blood accumulation in Extradural space after the injury which later will lead to incr. ICP and cerebral edema leading to the deterioration.

Question 12

Q14: if patient have traumatic chest injury how will that affect the cpp ?

Answer 12

Hypoxia from pneumothorax of chest trauma that will decrease the CPP
Hypovolemia from major vessel injury
may accompanied by traumatic head injury and increasing of ICP – > compressing brainstem – > Rapid shallow breathing (Cushing reflex) also will lead to hypercapnia decrease CPP
NB; effect of Rapid shallow breathing?
decrease Alveolar ventilation and collapse

Question 13

Q. How to confirm Brainstem death?

Answer 13

1. Confirm Hx (mechanism of injury)
2. Rulo-out complication conditions (ex; hypothermia, shock, locked-in synd, intoxication)
3. Two neuro exam show no brain function; NO ( corneal, gag, papillary reflex, response to pain)
4. Confirm test EEG`