EM Trauma 12 (ATLS 3 - Head Trauma)

Question 1

remarks on reticular activating system

Answer 1

located in the midbrain and upper pons
resonsbile for the state of alertness

Question 2

remarks on medulla

Answer 2

vital cardiorespiratory centers reside here

Question 3

remarks on brainstem

Answer 3

even small lesions in the brainstem can be associated with severe neurological deficits

Question 4

Doctrine governing ICP

Answer 4

The Monro-Kellie Doctrine
-the total volume of the intracranial contents must remain constant, because the cranium is a rigid container incapable of expanding

Question 5

remarks on the GCS

Answer 5

use the best motor response to calculate the score, because it is the most reliable predictor of outcome

Question 6

remarks on skull fracture

Answer 6

do not underestimate the significance of a skull fracture, because it takes considerable force to fracture the skull

Question 7

remarks on subdural hematoma

Answer 7

more common than epidural hematomas

damage underlying an acute subdural hematoma is typically much more severe than that associated with epidural hematomas due to presence of concomitant parenchymal injury

Question 8

remarks on intracranial hemorrhage

Answer 8

intracranial hemorrhage cannot cause hemorrhagic shock

Question 9

target SBP for TBI

Answer 9

50-69 y/o: ≥100 mm Hg
15-49, ≥70 y/o: ≥110 mm Hg

Remember, the neurological examination of patients with hypotension is unreliable

Question 10

remarks regarding midline shifts

Answer 10

a shift of 5 mm or greater often indicates the need for surgery to evacuate the blood clot or contusion causing the shift

Question 11

remarks regarding hyperventilation

Answer 11

the risk of severe cerebral vasoconstiction and thus impaired cerebral perfusion is particularly high if the PaCO2 is allowed to fall below 30 mm Hg

Hypercarbia (PaCO2 >45 mm Hg) will promote vasodilation and increase ICP, and therefore be avoided

In general, it is preferable to keep the PaCO2 at approx 35 mmHg, the low end of the normal range (35-45)

Question 12

remarks on HTS

Answer 12

may be preferable for pateints with hypotension, because it does not act as a diuretic

Question 13

remarks on phenytoin

Answer 13

recommended to decrease the incidence of early posttraumatic seizures (PTS)

1g loading dose of phenytoin IV given no faster than 50 mg/min

Question 14

remarks on depressed skull fractures

Answer 14

generally, depressed skull fractures require operative elevation when the degree of depression is greater than the thickness of the adjacent skull, or when they are open and grossly contaminated

less severe depressed fractures can often be managed with closure of the overlying scalp laceration, if present

Question 15

remarks on burr hole craniostomy/craniotomy

Answer 15

involves placing a 10- to 15-mm drill hole in the skull

unfortunately, even in very experienced hands, these drill holes are easily placed incorrectly, and they seldom result in draining enough of the hematoma to make a clinical difference

in patients who need an evacuation, bone flap craniotomy (versus a simple burr hole) is the definitive lifesaving procedure to decompress the brain

Question 16

brain death requires meeting the ff criteria

Answer 16

1) GCS 3
2) Nonreactive pupils
3) absent brainstem reflexes
- oculocephalic
- corenal
- doll’s eyes
- gag reflex

4) no spontaneous ventilatory effor on formal apnea testing
5) absence of confounding factors such as alcohol or drug intoxication or hypothermia