TBI Acute - Fraser Flashcards
"Examining the Three T's of Brain Trauma Treatment: Time, Team, and Technique".
Three T’s in TBI
- Time
- Team
- Technique
What is the Glasgow Coma Scale
Eye opening: 1. None, 2. to pain, 3. to speech 4. spontaneous
Verbal: 1. None 2. Incomprehensible 3. Innapropriate 4. confused 5. Oriented
Motor 1. None 2. Extensor (decerebrate) 3. Flexor (decorticate) 4. withdraws to pain 5. localizes to pain 6. follows commands
Max possible if intubated:
Operational definition of Coma:
10T
< or = 8
GCS: No eye opening/speech, withdraws only
6
GCS: Intubated, opens eyes to speech, follows commands
9T
GCS: Intubated, Flexor posturing, Does not open eyes.
4T
GCS: opens eyes, localizes to pain, incoherent
9
GCS history: First described: Inter-rater reliability: Sensitivity: Specificity:
- 1974
- 88.5-98%
- 79-97% sensitive
- 84-97% specific
How is GCS used (treatment decisions)
intubation
ICP monitoring
Dicision for surgery
Cerebral perfusion pressure:
CPP = MAP - ICP
Normal Adult ICP
<10-15mmHg
Normal Adult Central perfusion pressure (CPP)
> 50mmHg
Indication to treat ICP?
Sustained ICP > or = 20-25mmHg
What is Cushing’s Triad?
Percentage of time present in patient’s with high ICP?
- HTN 2. Bradycardia 3. Irreg respirations
33% of the time.
Indications for ICP monitor (3)
- GCS < or = 8 (confounded by abnl head CT or age > 40yoa, SBP <90mmHg, or flexor/extesnor posturing or possibly if not following commands)
- Multiple organ tissue damage requiring treatments that increase ICP or compromise neuro exam
- subsequent to removal of intracranial mass/hemorrhage
Routine interventions for elevated ICP (4)
- HOB 30-45 degrees
- Normotension
- pCO2 35-40mmHg
- Noncon head CT
Interventions for persistently elevated ICP (4)
- Hyperosmolar solution (mannitol vs HTS)
- EVD drainage
- Pentobarbital coma - barbituates decrease cerebral metabolic rate and thereby lower CBV and ICP. Free-radical mediated cell injury may also be limited.
- Surgical decompression
Most common entry point for ventriculostomy? Measurements?
Kocher’s point: 11cm posterior to nasion and 3cm lateral to midline
For brain tissues oxygenation, keep MAP > ?
Why?
What if MAPs are 150mmHg?
60mmHg
At this MAP the cerebral vessels are maximally dilated. (vasodilatory cascade zone). below this, ischemia occurs; MAP >150mmHg can lead to ischemia, disruption of BB barrier, and increased ICP.
Ideal location for LICOX device:
What does it do?
- Arterial watershed; pneumbra through burrhole
- easures Oxygen tension and temperature through one probe. Has a semipermeable membrane which allows O2 to pass through and combines with a solution which produces electrical stimulus. Can measure an area of 18mm squared. (reserved for GCS <8 or those high risk for vasospasm)
- normal PbtO2 25-35mmHg.
Types of skull fracture (3)
Linear
Depressed
Basal
Surgical indications to repair depressed skull fractures: (4)
- > 8-10mm depression
- Underlying deficit
- CSF leak
- +/- open fracture
Four clinical signs of basal skull fx
Radiograph findings?
- otorrhea/rhinorrhea
- hemotympanum
- Battle’s sign “raccoon eyes”
- CN injury (I/II/VI/VII/VIII)
Sinus opacification
pneumocephalus
Most common source of epidural bleed?
Presentation?
- middle meningeal artery
2. LOC, lucid interval, obtundation
What is Kernohan’s Phenomenon?
Associated with?
- Ipsilateral hemiparesis due to uncal herniation causing compression of the contralateral cerebral peduncle.
- epidural hematoma
Underlying brain injury worse in SDH or EDH
SDH
What accounts for majority of penetrating brain injuries?
Gunshot wounds
What are the late complications of GSW brain injuries? (4)
- abscess
- aneurysm
- Seizures
- Migrating bullet fragments
In peds, if ICP monitor placed in <4hrs:
shorter LOS and ICU stay
Difference between early and late tracheostomy
Shorter ICU stays 19 +/- 7.7 days vs 25.8 +/- 11.8.
No difference between groups in ventilator days, mortality, incidence of PNA, total hospital stay, discharge to rehab,or total cost.
