Head Trauma Flashcards by tcarlso 3

What are the GSC scores for mild, moderate, and severe TBIs?

Mild = 14+
Moderate = 9-13
Severe = Less than 9

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What is the equation for Cerebral perfusion pressure?

CPP = MAP - ICP

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What is the equation for MAP?

DBP +[(SBP-DBP)/3]

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What is the lower limit of viable CPP?

60 mmHg

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In the absence of an ICP monitor, what proxy should be used to guide BP management to maintain CPP? What should the goal for this measure be?

MAP over 80 mmHg

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What is the triad of the Cushing’s reflex?

HTN
Bradycardia
Respiratory irregularity

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What is the secondary brain injury that occurs with TBIs?

Massive release of neurotransmitters into the presynaptic space, causing damage

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What is an uncal herniation?

When the uncus of the temporal lobe is displaced inferiorly through the tentorium

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What are the s/sx of an uncal herniation? (2)

Ipsilateral fixed and dilated pupil

- Contralateral motor paralysis from compression of the pyramidal tract

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What are the s/sx of a central transtentorial herniation? (2)

bilateral pinpoint pupils
Bilateral babinski’s sign
Increased muscle tone

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What are the s/sx of a cerebellar tonsillar herniation? (3)

Pinpoint pupils,
Flaccid paralysis
Sudden death

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What are the components and score for the eye part of GCS?

4 = spontaneous
3 = to speech
2 = to pain
1 = none

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What are the components and score for the verbal part of GCS?

5 = alert and oriented
4 = Disoriented conversation
3 = Speaking, but nonsensical
2 = Moans
1 = none

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What are the components and score for the Motor part of GCS?

6 = follow commands
5 = Localized pain
4 = withdraws to pain
3 = decorticate flexion
2 = decerebrate extension
1 = none

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Bilateral fixed and dilated pupils in the setting of head trauma suggests what etiology?

Increased ICP with poor brain perfusion

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What are the meds of choice for sedating a combative trauma patient?

Midazolam (1-2 mg IV) or propofol (titrate 20 mg / sec to effect)

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What is the major drawback to using the New Orleans or Canadian head CT rules?

Need to have LOC to use rules, but some brain injuries do not cause LOC

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Who should you not apply the Canadian Head CT rules to? (2)

Children

- Blood thinners

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Why should hyperventilation for preoxygenation prior to intubation not be done in the case of head trauma?

Hyperventilation will cause cerebral vasoconstriction, and worsen brain ischemia

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What is the goal pCO2 on capnography for patient with head trauma?

35-45 mmHg

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What, generally, are the s/sx of increased ICP?

Pupillary findings
Focal neuro deficits
Change in mental status

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What happens to ICP with sedation and analgesia?

Decreases

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What is the general treatment for increased ICP?

Control:

Hypotension
Hypoxemia
Hypercarbia
Hyperglycemia

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What is the goal SBP for head traumas?

over 90 mmHg

What should be done prior to intubating a head trauma patient to use for trending?

GSC

What is the dose of mannitol for increased ICP? What is the back up?

1 g/kg IV bolus | Hypertonic saline 250 mL/30 minutes

If you suspect a basilar skull fracture, what sort of airway should never be used?

Nasal airway or NG tube--Nothing in the nose.

What is the goal oxygen saturation and pO2 for head trauma pts? PCO2?

Over 90% PaO2 over 60 pCO2 35-45

What is the goal MAP for head trauma pts?

80 mmHg

What must you ensure prior to elevating the head to control ICP?

Map is above 80 mmHg (otherwise head may not see the needed 80 mmHg)

True or false: Elevating the head of the bed to 30 degrees can be safely accomplished even when the spine has not been cleared, as long as neck movement is secured

True

What is the goal blood glucose for head trauma pts?

100-180 mg/dL

When should prophylactic phenytoin be given to head trauma pts?

- If GSC less than 10 - Abnormal head CT - Acute seizure after injury

What is the dose of phenytoin for seizure prophylaxis?

18 mg/kg IV at 25 mg/min

What is the rate of mannitol administration?

0.25 - 1 g /kg given as repetitive boluses

What must you ensure prior to, and when giving mannitol?

make sure they're not volume down | Monitor Ins and outs

An ICP over what amount increase mortality?

20 mmHg

If the GSC is less than what, should placement for an intracranial bolt or drain be done?

If you cannot control scalp bleeding with direct pressure alone, what should you do?

Irrigate with lidocaine+epi, and clamp or ligate bleeding vessels

What should be done prior to closing scalp lacerations?

Check for skull fx

What, generally, determines if a skull fracture needs operative repair?

If it is depressed by more than the thickness of the skull

What are the s/sx of a basilar skull fracture? (6)

``` Battle signs Raccoon eyes Hemotympanum Hearing loss 7th nerve palsy Vertigo ```

If you send otorrhea or rhinorrhea in for analysis to r/o a basilar skull fracture, what molecule is being looked for?

Beta-transferrin

What is the general approach to treating a patient who has a basilar skull fracture?

Abx if CSF leak Consult neuro Monitor ICP

True or false: cerebral hemorrhage can occur days after the blunt injury

True

What is the most common CT finding in patients with moderate to severe TBI?

SAH

What are the s/sx of SAH?

HA Photophobia Meningeal signs

What is the general prognosis for an epidural hematoma?

If blood is evacuated prior to the development of neuro s/sx, or herniation, generally good.

Where is the bleeding from in an epidural and subdural hematoma?

``` Epi = middle meningeal artery (generally) Sub = Bridging veins ```

Which is generally associated with underlying brain parenchymal damage: epidural or subdural hematoma?

Subdural

Who is more susceptible to developing a subdural hematoma, and why?

Elderly and alcoholics d/t atrophy

How long can it take for subdural bleeds to present clinically?

days to weeks

What is diffuse axonal injury?

Disruption of the fibers in the white matter and brainstem, usually caused be shearing forces from sudden deceleration

What is the classic and usual findings of diffuse axonal injury?

``` Classic = punctate hemorrhages Usually = normal ```

True or false: you should leave impaled objects in the brain in place until surgical removal

True

True or false: the presence of amnesia with a TBI is associated with more severe injury

True

What is second impact syndrome?

If you experience another head trauma after a concussion, severe and sudden onset cerebral edema occurs

What are the most common s/sx of a mild TBI?

Subtle impairments in cognitive function

When can athletes return to play after a concussion?

Let the PCP decide with more extensie outpatient testing (checklists, balance eval, etc)