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Prolonged Field Care > TBI Management > Flashcards

TBI Management Flashcards

1
Q

What two vital sign findings more than double the risk of death from a brain injury?

A

SBP <90mmHg

SpO2<90%

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2
Q

When tracking a brain injury over time, what are some early signs of rising ICP?

A

worsening headache
focal neurologic deficit
declining neurologic exam

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3
Q

What GCS is considered mild?

A

13-15

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4
Q

What GCS is considered moderate?

A

9-12

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5
Q

What GCS is considered severe?

A

3-8

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6
Q

What are some red-flags with TBIs?

A 
Witnessed LOC
Two or more blast exposures in 72 hours
Unusual behavior or combative
Unequal pupils
Seizures
Repeated vomiting 
Double vision or loss of vision
Worsening headache
Weakness on one side of body
Cannot recognize people or place
Abnormal speech
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7
Q

How can ultrasound be used to assess TBI?

A

Measuring Optic Nerve Sheath Diameter (ONSD)

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8
Q

What ONSD measurement can indicated elevated ICP?

A

> 5.2mm

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9
Q

In the PFC setting, what is considered “best” when it comes to monitoring?

A

Portable monitor of vitals
Foley to measure UOP
EtCO2 with capnometer
Pupillary response with GCS every hour

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10
Q

If you have the capability, how often is ONSD measured in the TBI patient?

A

every 30 minutes
change in neuro exam
to check for response of interventions

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11
Q

What is the goal EtCO2 in the TBI patient?

A

35-40mmHg

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12
Q

What is the target SBP in TBI patients?

A

> 110mmHg

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13
Q

What should you be concerned about in the hypotensive TBI patient?

A

bleeding or tension pneumothorax

hypotension is usually not caused by TBI except as a late finding due to herniation

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14
Q

What is the goal UOP in poly-trauma?

A

30-50mL

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15
Q

What IV fluids have demonstrated a trend toward worsening outcomes of TBI patients?

A

Colloids (albumin)

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16
Q

What fluids can make brain swelling worse?

A

hypotonic fluids including lactated ringers

17
Q

In a PFC setting, what is considered “best” in airway, oxygenation, and ventilation management?

A

Circ or ETT with continuous sedation are airway maintenance
SpO2>95% and EtCO2 35-40mmHg
Arterial blood gas within 30 minutes of intubation
PEEP of 5cmH20

18
Q

What can PEEP be turned up to in the TBI patient to improve SpO2?

A

15cmH20

19
Q

What GCS score requires an advanced airway?

A

<8

20
Q

What can be done to help with gastric distention in the ventilated patient?

A

Nasogastric tube placement

21
Q

What are some general measures to reduce ICP?

A 
Elevate head of bed 30-60 degrees
Maintain neck in midline
maintain SpO2 >90%
Maintain EtCO2 35-40mmHG
Maintain temp between 96-99.5
Prevent or rapidly manage seizure activity 
hyperventilate 
analgesia/sedation 
Hypertonic saline (HTS)
Mannitol if no signs of bleeding
22
Q

How long can you hyperventilate a patient for?

A

20 minutes, maintain EtCO2 of 30mmHg

23
Q

How often can a TBI patient be hyperventilated?

A

duration and frequency not known, seek guidance by teleconsultation

24
Q

How is HTS administered to the TBI patient with signs of ICP?

A

3% NaCl 250 mL bolus over 20 minutes, repeat every 3 hours as needed

25
Q

How is Mannitol administered in the TBI patient with signs of increased ICP?

A

If no signs of bleeding, SBP>90mmHg:
1g/kg - IV/IO over 20 minutes
Repeat 0.5/kg ever 3 hours

26
Q

What is the approximate duration of hypertonic saline (HTS)?

A

3 hours

27
Q

What are some concerns with administering Mannitol in the TBI patient?

A

it’s a diuretic that might lower blood pressure

repeated use can damage the blood-brain barrier and worsen ICP

28
Q

What antibiotics should be administered for the patient with a CNS penetrating injury?

A

Ceftriaxone 2gm IV/IO every 24 hours or Cefazolin 2g IV/IO every 8 hours x 5 days
Add metronidazole 500mg IV/IO x 5 days in woulds that are grossly contaminated with organic debris

29
Q

Whats considered the minimum treatment for the TBI patient having a seizure?

A

Midazolam 5mg IV/IO/IM q 5 minutes until seizure stops

30
Q

What are some alternate benzodizepines that can be given for TBI patients have seizures?

A

diazepam 5mg q5min

lorazepam 4mg q5min

31
Q

In addition to a benzodiazpine, what other medications can be considered in the TBI patient?

A

antiepilepsy drugs:
Levetiracetam
Phenytoin
Phenobarbital

32
Q

What is the target sodium level in patients with severe TBI?

A

145-160 mmol/L

33
Q

What should you do before administering more than two bags of hypertonic saline to a patient with severe TBI?

A

obtain telemedicine consultation

34
Q

What are some conditions in the patient with severe TBI that can lower or raise serum sodium levels?

A

cerebral salt wasting
syndrome of inappropriate autidiuretic hormone secretion
diabetes insipidus

35
Q

How often should you check blood glucose in the TBI patient?

A

every 6 hours

36
Q

How would you treat the TBI patient with a blood glucose <100mg/dL?

A

20g oral glucose
5 teaspoons of sugar or 4 of honey
25g (50mL) D50 solution IV/IO
recheck blood glucose in 1 hour

37
Q

During air-transport, what altitudes risk additional complication in the TBI patient?

A

> 8,000 ft

38
Q

What finding on ophthalmscopic exam might suggest increased ICP?

A

loss of spontaneous venous pulsations (SVPs)

Prolonged Field Care (17 decks)

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