Head Trauma: General Information, Grading, and Initial Management Flashcards
Brain injury from trauma results from two distinct processes which are primary brain injury and secondary brain injury. Focus is on prevention of secondary injuries which requires good general medical care and an understanding of intracranial
pressure. Which of the following are included in the secondary brain injury?
● A. Intracranial hematomas and edema
● B. Hypoxemia
● C. Ischemia (primarily due to elevated intracranial pressure
or from shock)
● D. Vasospasm
● E. All of the above
E. All of the above
A patient is being transferred to a neurosurgery facility and is consulted with a neurosurgeon prior to transfer about the possible factors that should be assessed and stabilized. What factors need to be stabilized and kept in mind before transfer of the patient?
● A. Hypoxia or hypoventilation
● B. Hypotension or hypertension
● C. Anemia and seizures
● D. Infection or hyperthermia and spinal stability
● E. All of the above
E. All of the above
A patient with GCS 14 or GCS 15 plus brief loss of consciousness for less than 15 minutes or impaired alertness is categorized as mild head injury. When a patient will be categorized as moderate head injury?
● A. A patient with GCS 9–13
● B. A patient with loss of consciousness for more than 5 minutes
● C. A patient with focal neurologic deficit
● D. A, B, and C
● E. A patient with GCS 3–8
D. A, B, and C
Hypotension, BP less than 90 mmHg, doubles the mortality while hypoxia (apnea or cyanosis or PaO2 less than 60 mmHg on ABG) also increases the mortality. The combination of both increases the risk of bad outcome and increases mortality by
how much?
● A. Two times
● B. Three times
● C. Four times
● D. The patient cannot survive for more than a few hours with this combination
● E. None of the above
B. Three times
Sedatives and paralytics may lead to higher incidence of pneumonia, longer ICU stays, and possible sepsis. These agents also impair neurologic assessment and are reserved for cases with clinical evidence of intracranial hypertension. All of the following are clinical signs of intracranial hypertension except?
● A. Pupillary dilation (unilateral or bilateral)
● B. Asymmetric pupillary reaction to light
● C. Absence of corneal reflex
● D. Decerebrate or decorticate posturing
● E. Progressive deterioration of neurologic examination not attributable to extracranial factors
C. Absence of corneal reflex
A patient who is unable to maintain airway or who is hypoxic despite supplemental O2 needs to be intubated. What are the other indications for intubation?
● A. Depressed level of consciousness with GCS less than or equal to 8
● B. Need for hyperventilation
● C. Severe maxillofacial trauma
● D. Need for pharmacologic paralysis for evaluation or management like for irritable patient to send him/her for plain CT of brain
● E. All of the above
E. All of the above
Hyperventilation and mannitol (0.25–1 g/kg over less than 20 minutes) (after adequate volume resuscitation) are reserved in the acute setting for patients with signs of transtentorial herniation or progressive neurologic deterioration not attribut-
able to extracranial causes. Hyperventilation (PaCO2 less than or equal to 25 mmHg) is not recommended prophylactically as it may exacerbate cerebral ischemia or may cause hypocalcemia with tetany. What are the indications of mannitol in emergency?
● A. Evidence of intracranial hypertension (clinical signs of intracranial hypertension)
● B. Evidence of mass effect (focal deficit or hemiparesis)
● C. Sudden deterioration prior to CT of brain (including pupillary dilatation)
● D. After CT of brain that identifies the lesion which is causing raised ICP or after CT of brain if going to the OR
● E. All of the above
E. All of the above
Routine use of prophylactic antiseizure medications in traumatic brain injury is ineffective in preventing the late development of post-traumatic seizures, that is, epilepsy. ASMs (e.g., phenytoin, valproate, or carbamazepine) may be used to decrease the incidence of early post-traumatic seizures (within 7
days of TBI). Conditions with increased risk of post-traumatic seizures and require ASMs include which of the following?
● A. Acute subdural, epidural, and intracerebral hematoma
● B. Open depressed fracture with parenchymal injury
● C. Seizure within the first 24 hours after injury or GCS less than 10
● D. Penetrating brain injury or cortical contusion on CT or history of alcohol abuse
● E. All of the above
E. All of the above
A patient with head trauma needs neurologic examination which includes cranial nerve examination (second, sixth, and seventh), level of consciousness (GCS), motor examination, sensory examination, and reflexes. A patient presents with racoon eye (periorbital ecchymoses), battles sign (postauricular ecchymoses), CSF rhinorrhea, and hemotympanum (laceration of external auditory canal). Where is the suspected injury in this patient?
● A. Frontal bone fracture of skull
● B. Fracture of occiput and frontal bone
● C. Fracture of base of skull
● D. Fracture of facial bones
● E. Fracture of frontal, parietal, and occipital bones of skull
C. Fracture of base of skull
Brain CT is needed for the initial evaluation in traumatic brain injury patients with which of the following risk factors?
● A. GCS less than or equal to 14 or unresponsiveness
● B. Coagulopathy including antiplatelet and anticoagulants drugs and seizure
● C. Penetrating skull trauma or focal neurologic deficit
● D. Polytrauma, suspected nonaccidental trauma (child abuse), or deteriorating neurologic status
● E. All of the above
E. All of the above
All of the following are true regarding Marshall CT classification of traumatic brain injury severity score except?
● A. Category 1 is diffuse injury with no visible pathology and mortality of 6.4%
● B. Category 2 is diffuse injury with midline shift of 0 to 5 mm, no high or mixed density lesion of more than 25 mL, and mortality in this case is 11%
● C. Category 3 is diffuse injury (swelling) with midline shift of 0 to 5 mm, basal cisterns compressed or completely effacedwith no high density or mixed density lesion of more than 25 mL, and mortality of 29%
● D. Category 4 is diffuse injury (shift) with midline shift of more than 5 mm and no high or mixed density lesion of more than 25 mL and mortality of 30%
● E. Category 5 is evacuated mass lesion with mortality of 30%
D. Category 4 is diffuse injury (shift) with midline shift of more than 5 mm and no high or mixed density lesion of more than 25 mL and mortality of 30%
Rotterdam scores 2, 3, 4, and 5 have mortality of 6.8, 16, 26, and 53%, respectively. Which of the following statements is correct regarding Rotterdam score?
● A. Midline shift of more than 5 mm has 1 point
● B. Presence of epidural mass has 1 point
● C. Basal cisterns compressed has 1 point while absence has 2 points
● D. Presence of intraventricular blood or traumatic SAH has 1 point
● E. All of the above
E. All of the above
What is the criterion for observation at home for a head injury patient?
● A. Head CT is not indicated or it is normal if indicated
● B. Initial GCS more than or equal to 14
● C. Patient is now neurologically intact
● D. Patient is accompanied by responsible, sober adult and has reasonable access to return to the hospital
● E. All of the above
E. All of the above
Indirect optic nerve injury during trauma injury can cause transient visual loss. Mega dose steroids can be used as an adjunct to diagnosis and treatment. What is the most common segment of the optic nerve which is damaged during optic
nerve injury?
● A. Intraocular (1 mm in length)
● B. Intracranial (10 mm in length)
● C. Intraorbital (25–30 mm)
● D. Intracanalicular (10 mm)
● E. None of the above
D. Intracanalicular (10 mm)
Where should the first burr hole be placed in case of emergency exploratory burr hole placement?
● A. Temporal burr hole ipsilateral to the side of pupillary dilatation
● B. Frontal burr hole toward ipsilateral burr hole
● C. Parietal burr hole
● D. Occipital burr hole
● E. Temporal burr hole opposite to the side of pupillary dilatation
A. Temporal burr hole ipsilateral to the side of pupillary dilatation
