Neuro Emergencies: Traumatic Brain Injury Flashcards
How are TBI’s classified?
Mild
Moderate
Severe
According to GCS
Mild head injury GCS is?
Moderate head injury GCS is?
Severe head injury GCS is?
13-14
9-12
</= 8
What can cause the initial exam to be altered?
ETOH
Drugs
FOUR Score
Eye Response
4=
3=
2=
1=
0=
Eyelids open or opened, tracking or blinking to command
Eyelids open but not to tracking
Eyelids closed but opens to loud voice
Eyelids closed but opens to painful stimuli
Eyelids remain closed with painful stimuli
FOUR Score
Motor Response
4=
3=
2=
1=
0=
Thumbs up, fist, or peace sign
localizing to pain
flexion to response to pain
extension to response to pain
no response to pain or generalized myoclonus status
FOUR Score
Brainstem Reflexes
4=
3=
2=
1=
0=
Pupil and corneal reflexes present
one pupil wide and fixed
pupil or corneal reflexes absent
pupil and corneal reflexes absent
absent pupil, corneal or cough reflexes
FOUR Score
Respiration
4=
3=
2=
1=
0=
Regular breathing pattern
Cheyne-Stokes breathing pattern
Irregular breathing
Triggers ventilator or breaths above ventilator rate
Apnea or breathes at ventilator rate
FOUR Score
What is it?
Allows examiner to test what?
Can recognize what?
Can detect different stages of what?
Lower scores indicate higher what?
A 16 pt scale that provides greater neurological detail
brainstem reflexes
locked-in syndrome
brain herniation
coma severity
What are Primary Mechanisms of Injury?
Open
Penetrating
Skull fxs
What are Primary Mechanisms of Injury?
Closed
Concussive
Diffuse Axonal Injury (DAI)
Hematomas
Coup-countercoup
What are Secondary Mechanisms of Injury?
Ischemia
Edema
Loss of cerebral vascular autoregulation
Loss of blood brain-barrier
Mass Lesions
Pre-Hospital Care
A meta-analysis of clinical trials demonstrated that what two insults were each associated with poor outcomes?
Both were also associated w/ increase in what?
Hypoxia (PaO2 < 60)
Hypotension (SBP < 90)
Mortality
Emergency Department Care
Initial Evaluation includes?
Imaging?
ATLS (ABCDE)
Head CT
Emergency Department Care
Hearniation or deterioration may require what?
+/- Hyperventilation
+/- Mannitol
+/- Hypertonic Saline
+/- Ventricular drain
Emergency Department Care
Surgical lesion requires?
OR
Emergency Department Care
What level of care is required?
ICU management
Emergency Department Care
Lab/diagnostic test?
CBC
CMP
blood glucose
Coags
BAL
Urine tox
type and screen
d-dimer
Fast Exam
Pertinent imaging
Emergency Department Care
Should perform rapid reversal of what?
coagulopathy
Emergency Department Care
What additional imaging should be considered?
CTA Head and Neck
TBI Management
Hyperventilation
How is it used?
Target?
Acutely until other targeted interventions implemented
PCO2 of 35-40
TBI Management
Osmotic Therapy
Consideration with mannitol?
Consideration with 23.4%?
Consideration with 3% and 5%?
Diuretic effect of mannitol can interfere with systemic resuscitation
23.4% saline requires central access
Can use 3% and 5% saline via peripheral as a bolus
TBI Management
Neurosurgery consult
What’s the likely intervention?
This intervention allows for what?
Advantage of material used?
EVD placement
Continuous CSF diversion in pts with GCS of < 6
Antimicrobial-impregnated catheters
TBI Management
Sedation/Pain Control
Disadvantages? (2)
Should use what?
Can impair neuro exam
May decrease CPP
Short acting opiates
TBI Management
Steroids
Not recommended
High-dose Methylprednisolone assoc. w/ increased mortality and is contraindicated
TBI Management
Prophylactic hypothermia
no benefit
TBI Management
Anticonvulsants
Shown to decrease incidence of Post Traumatic Seizures (PTS) w/n 7 days of injury
TBI Management
Nutritional Support
Start feeding by when? This helps how?
Where is feeding recommended to occur?
At least day 5 to decrease mortality
Post pyloric feeding is recommended to reduce incidence of VAP
TBI Management
Early Tracheostomy
Helps with?
Doesn’t help with?
Reduces mechanical ventilation days
No evidence that it reduces mortality or the rate of nosocomial pneumonia
TBI Management
ICP Monitoring
Indicated for which patients?
ICP > what should be treated?
Patients w/ GCS 3-8 and an abnormal CT scan and/or TBI patients w/ a normal CT scan and tow or more of the following:
1. age > 40
2. unilateral or bilateral posturing
3. SBP < 90 mmHg
22 mmHg
TBI Management
CPP should be maintained where?
between 60-70 mmHg
TBI Management
Advanced Cerebral Monitoring
Jugular bulb monitoring of what may be considered?
Jugular venous saturation of < ? may be a threshold to avoid to reduce mortality and improve outcomes.
Decreases in SjVO2 may be due to what?
arteriovenous oxygen content difference (AVDO2)
<50%
increased O2 consumption (fever or seizure) or decreased O2 delivery (ICP elevation, hypotension, hypoxia, or anemia)
TBI Management
Blood Pressure
Maintaining what SBP is recommended for patients 50-69?
Maintaining what SBP is recommended for patients 15-49 or < 70y/o?
SBP >/=100 mmHg
SBP >/= 110 mmHg
TBI Management
Barbiturates
Administration to induce burst suppression as prophylaxis is or is not recommended?
Administration to control elevated ICPs refractory to maximal medical therapy and surgical treatment, is or is not recommended?
Can cause what?
Is not recommended
Is recommended
Hemodynamic Instability
TBI Management
Therapeutic Hypothermia
Methods of inducing hypothermia include? (5)
What complication should be avoided? how to prevent it?
Water or air cooled blankets above and below patient
NG lavage w/ iced saline
Esophageal cooling device
Bolus of iced saline
Intravascular devices
Shivering; sedation and paralysis
Therapeutic Hypothermia
Target cooling temp is?
Cooling duration should last how long?
Rate of rewarming is?
32-35C
About 48 hrs
1C/hr
Therapeutic Hypothermia
Potential complications include?
Coagulation d/o’s
Cardiac arrhythmias
Electrolyte shifts
Myocardial depression
Infections - primarily pneumonia
Therapeutic Hypothermia
Induced hypothermia has been shown to be effective in improving what?
Problems with the trial?
Decreased risk of what?
Should be limited to patients with?
improving neurological outcome after ventricular fibrillation cardiac arrest
Small sample sizes, low quality trials
death or poor neurological outcomes
refractory elevated ICPs
Decompressive Hemicraniectomy
A bifrontal decompressive hemicraniectomy is not recommended to improve outcomes as measured by the Glasgow Outcome Scale-Extended (GOS-E) score at 6mo post-injury in patients w/ what?
diffuse injury and ICP elevation >20 mmHg for more than 15 min w/n a 1-hr period that are refractory to first-tier therapies?
Decompressive Hemicraniectomy
Bifrontal decompressive hemicraniectomy has been shown to do what?
Decrease ICP and minimize ICU days
Decompressive Hemicraniectomy
If you’re going to do it, make it big!
What size large frontotemporoparietal DC is recommended over a small frontotemporoparietal DC for reduced what? and improved what? in who?
not less than 12 x 15cm or 15cm diameter
reduced mortality
improved neurologic outcomes
in patients with severe TBI
