TBI

Question 1

Grading for TBI?

Answer 1

Mild GCS 13-15
Mod. GCS 9-12
Severe GCS <8

Question 2

Indications for CT head <2 yo?

Answer 2

GCS 14 or palpable skull fracture - yes

scalp hematoma, or LOC >5s or not acting normall - maybe

Question 3

Indications for CT head > 2 yo?

Answer 3

GCS 14 or signs of basil skull fracture - yes

LOC, sever headache or vomiting - maybe

Question 4

Findings of increased ICP?

Answer 4

• Lack of spontaneous motor function

- CT showing diffuse swelling

Question 5

Who requires ICP monitoring?

Answer 5

Children with GCS < 8

• monitoring decreases morbidity

Question 6

What is the goal CPP in pediatric TBI?

Answer 6

40-65 mmHg

Min. 40

Question 7

How do you increase CPP/decrease ICP/decrease secondary injury?

Answer 7

ICP should be maintained below 20 and CPP above 40.

• ventricular Drain to take off CSF
• avoid hypotension
• optimize oxygen delivery

Question 8

Assessment and resuscitation in TBI:

Answer 8

Physical findings in increased ICP:
Coma, lethargy, irritability, seizure, vomiting.
Enlarged head, dilated scalp veins bulging fontanelle, sun-setting eyes.

Give crystalloid without dextrose

Place arterial line, CVP monitor, temp probe, and ICP monitor

Give 3% saline for any indication of increased ICP -> 3-4 ml/kg bolus or continuous infusion 0.1-1 ml/kg/hr. Maintain serum Na 150-170.

Question 9

Sedation in TBI, indications and agents?

Answer 9

Pain responses and coughing from ET tubes increase ICP so sedation should be given.

Agents:
Etomidate, ketamine, barbiturates (only if all else fails)

Question 10

Is hypothermia indicated in TBI?

Answer 10

No current recommendations outside of trial.

Question 11

Should hyperventilation be used to decrease ICP?

Answer 11

Hybocarbia worsens cerebral ischemia and should only be used as a third tier intervention.

Question 12

Who should get seizure prophylaxis?

Answer 12

Unclear but depressed skull fractures, retained foreign body, GCS < 10 and amnesia increase the risk of seizures.

Question 13

When should Craniotomy be performed?

Answer 13

With refractory ICP and space occupying lesion that can be evacuated.

Question 14

indications for surgery with skull fracture?

Answer 14

Fractures that are both open and depressed.

Other indications include - bleeding, or dural tear, CSF leak.

Question 15

Indications to evacuate epi/subdural hematoms:

Answer 15

Neurologic changes with hematoma
Midline shift with neurologic change
Increasing volume on repeat imaging.