Neurologic Emergencies and Stabilization

Question 1

formula for CPP

Answer 1

CPP = MAP - ICP

Question 2

Hallmark of severe TBI

Answer 2

Coma
The second key clinical manifestation is the development of intracranial hypertension

Question 3

Cranial nerve dysfunction in intracranial hypertension

Answer 3

6th nerve palsy (lateral rectus palsy)
3rd cranial nerve compression
- anisocoria
- ptosis
- down-and-out position of globe

Question 4

Conditions with “talk-and-die” scenario

Answer 4

1. Epidural hematoma
2. Diffuse cerebral edema

Question 5

Peak ICP generally is seen ______ after TBI

Answer 5

48-72 hours

Question 6

Conditions that may present with coma without increased ICP

Answer 6

Axonal injury
Brainstem injury

Question 7

Age-dependent CPP targets

Answer 7

2-6 y/o: 50 mm Hg
7-10 y/o: 55 mm Hg
11-16 y/o: 65 mm Hg

Question 8

First-tier therapy for intracranial hypertension

Answer 8

1. Elevation of the head of the bed
2. Midline positioning of the head
3. Controlled mechanical ventilation
4. Analgesia and sedation
5. Neuromuscular blockade
6. CSF drainage
7. Osmolar agents (HTS, mannitol)

Question 9

Dose of mannitol

Answer 9

0.25 - 1.0 g/kg IV

Question 10

Dose of HTS

Answer 10

3% solution, 5-10 mL/kg IV
Use of hyperteonic saline is more common and has stronger literature support than mannitol, although both are used; these 2 agents can be used concurruently

Question 11

When using osmolar agents, avoid serum osmality more than

Answer 11

320 mOsm/L

Question 12

Second-tier therapies for refractory raised ICP

Answer 12

1. Decompressive craniectomy
2. Barbiturate (pentobarbital) infusion
3. Mild hypothermia
4. Hyperventilation
5. Lumbar CSF drainage (only considered if a functioning ventriculostomy catheter is in place and basal cisterns are open)

Question 13

Remarks on posttraumatic seizures

Answer 13

1. Early posttraumatic seizures (<7 days) - anticonvulsant prophylaxis may be given with fosphenytoin, carbamazepine, or levetiracetam
2. Late posttraumatic seizures (≥7 days) are NOT prevented by prophylactic anticonfulsants

Question 14

Remarks on antifibrinolytic agents

Answer 14

Antifibrinolytic agents (tranexamic acid) reduce hemorrhage size, as well as the development of new focal ischemic cerebral lesions, and improve survival in adults with severe TBI
Most effective within 1 hour, effective up to within 3 hours after injury (CRASH-2 trial)