PFC TBI

Question 1

What GCS scores would indicate a mild TBI?

Answer 1

13-15

Question 2

What GCS scores would indicate a moderate TBI?

Answer 2

9-12

Question 3

What GCS scores would indicate a severe TBI?

Answer 3

3-8

Question 4

What are some TBI redflags?

Answer 4

Witnessed LOC
Two or more blast exposures within 72 hours
Unusual behavior or combative
Unequal pupils
Seizures
Repeated vomiting
Double vision or loss of vision
Worsening headache
weakness on one side of the body
Cannot recognize people or disoriented to place
Abnormal speech

Question 5

what measurement may indicate ICP when conducting an optic nerve sheath diameter (ONSD) ultrasound?

Answer 5

> 5.2mm

Question 6

When examining with an ophthalmoscope, what finding may indicate ICP?

Answer 6

absence of spontaneous venous pulsations (SVPs)

Question 7

What is the goal EtCO2 in TBI patients?

Answer 7

35-40mmHg

Question 8

What exam findings may indicate Cushing’s Triad?

Answer 8

Increased SBP/Widening pulse pressure
Bradycardia
Irregular respiration

Question 9

What the goal SBP to maintain in the TBI patient?

Answer 9

> 110 mmHg

Question 10

What is the goal urinary output in polytrauma patients?

Answer 10

30-50 mL/hour

Question 11

What types of fluids should be avoided in the TBI patient?

Answer 11

Colloids and hetastarches

Hypotonic fluids including LR

Question 12

What positive endexpiratory pressure (PEEP) should be used in a TBI patient?

Answer 12

5cmH2O

Question 13

What can PEEP be safely increased to, in order to improve SpO2?

Answer 13

15cmH2O

Question 14

What can be placed in patients who are being ventilated in order to decrease gastric decompression?

Answer 14

Nasogastric tube (NGT)

Question 15

What fluids should be administered the TBI patient with suspected increased ICP?

Answer 15

3% NaCl 250mL bolus over 20 minutes; repeat every 3 hours as needed
Mannitol can used if there is no sign of bleeding and SBP >110mmHg

Question 16

What is the dose of Mannitol in the patient with suspected increased ICP?

Answer 16

1g/kg/ IV/IO over 20 minutes

repeat at 0.5g/kg/ IV/IO

Question 17

What medication can be given to the TBI patient to alleviate pain/anxiety?

Answer 17

Ketamine 20mg IV/IO
Hydromorphone 0.5-2mg IV/IO
Fentanyl 25-50 micro units IV/IO
can consider 1-2 mg IV/IO Midazolam for anxiety

Question 18

What intervention should be taken if you supsect impending herniation?

Answer 18

Hyperventilate 20 breath per minute (breath ever 3 sec) for no more than 20 minutes to an EtCO2 target of 30mmHg

Question 19

What antibiotics are recommended for open or penetrating TBI?

Answer 19

Abx that have strong CNS penetration:
Ceftriaxone 2g IV/IO every 8 hours
Metronidazole 500mg IV/IO every 8 hours
Ertapenem does not penetrate CNS well

Question 20

What temperature range should be maintained in the TBI patient?

Answer 20

96 - 99.5 degrees

Question 21

What is the target serum sodium level in TBI patients?

Answer 21

145mmol/L - 160mmol/L

Question 22

What blood glucose level should be targeted in the TBI patient?

Answer 22

180mg/dL

Question 23

What should be administered in the TBI patient with a blood glucose less <100mg/dL

Answer 23

20g of oral glucose (5 teaspoons of sugar, 4 teaspoons of honey)
or 25mg (50mL) dextrose 50% water (D50)

Question 24

What are some transport considerations for TBI patients?

Answer 24

Head of bead elevated 30 degrees
Head toward front to minimize G-forces transmitted to brain
>8,000 feet can lead to hypobaric hypoxia and high altitude cerebral edema