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Semester 5 PMNM Exam 7 > TBI - Medical Management > Flashcards

TBI - Medical Management Flashcards

1
Q

Definition

A

Blow or jolt to the head or a penetrating head injury

Disrupts function of the brain

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2
Q

What is the leading cause of TBI

A

Falls (47% resulting in ED visit, hospitalization, or death

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3
Q

What age group is most common for TBI

A

Children 0-14 (54%)

Adulta over 65 (79%)

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4
Q

TBI - M vs. F

A

M 3 x more likely to die from TBI than women

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5
Q

Mechanisms of brain injury

A 
Acc-Dec 
Direct blow to head
Blow to other body part
Blast waves
Shaking
Head rotation
Penetrating injury
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6
Q

Assessment TBI

A

GCS
Pupillary response
S/S with early vs. late signs

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7
Q

Glascow Coma Scale is used to measure what

A

Gold standard to assess LOC

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8
Q

What is the most useful clinical sign of deterioration

A

Change in LOC

Using the GCS

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9
Q

GCS - unable to use if

A

Hypoglycemic
Hypothermia
Shock
Alcohol/Drug

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10
Q

Pupillary Response - only important when

A

there are changes or deterioration in LOC

Not necessary with a GCS of 15

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11
Q

Pupillary response - if adverse response means what

A

Oculomotor nerve 3 - something is compressing the nerve and causing an adverse response to light

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12
Q

GCS scores range from

A

15 to 3

Lowest 3

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13
Q

GCS what is considered a coma

A

Less than 8

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14
Q

GCS - T or F - A person identified as brain dead can still have a GCS score of 3

A

TRUE

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15
Q

GCS - start with what

A 
least invasive to the most invasive 
(4) observe if they have their eyes open spontaneously 
If not, then try speech (3)
pain (2)
no EO (1)
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16
Q

GCS - verbal response

A 
5 oriented
4 confused
3 inappropriate words
2 incomprehensible words
1 no verbal response (on vent can be 1)
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17
Q

GCS - Motor Response

A

6 obeys commands
5 localizes pain
4 withdrawal to pain
3 abnormal flexion - decorticate posturing
2 abnormal extension - decelerate posturing
1 no motor response

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18
Q

What is typically the most important component of the GCS

A

Motor response

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19
Q

Pupil Response can be

A

Brisk
Sluggish
No rxn

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20
Q

Pupil Response - size

Pupil dilation is ___ to injury

A

Varies

Pupil dilation is ipsilateral to injury

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21
Q

Early s/s neuro deterioration

A 
HA
Drowsiness
Disorientation
Agitation
N/V
Irritability
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22
Q

Late s/s neuro deterioration

A 
Posturing
Seizing
Pupil dilation
Asymmetrical pupil response
Cushings triad
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23
Q

Late s/s neuro deterioration - cushing’s triad

A

Bradycardia
Irregular respirations
HTN, wide pulse pressure

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24
Q

Classification of brain injury is based on what

A

GCS score

Duration of amnesia

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25
Q

Classification of brain injury - Mild - what GCS score and how long amnesia

A

More then or equal to 13

Less than 24 hours

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26
Q

Classification of brain injury - Mild - Clinical presentation

A

Awake, EO, Confusion, Memory and attn deficits, HA, Bx problems

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27
Q

Classification of brain injury - Moderate - what GCS score and how long amnesia

A

9-12 GCS

1-7 days amnesia

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28
Q

Classification of brain injury - Moderate - clinical presentation

A

Lethargic, EO to stimulation, Sleepy, Arousable

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29
Q

Classification of brain injury - Severe - GCS score and how long amnesia

A

Less than or equal to 8

1-4 wks (can last 1-2 months too though)

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30
Q

Classification of brain injury - Severe - Clinical Presentation

A

Coma, EC even with stimulation

31
Q

Classification of brain injury - which ones are hospitalized

A

Moderate to Severe

32
Q

Diagnostic Evaluation includes what

A

CT scan
MRI
EEG

33
Q

Patterns of brain injury - Primary injury

A

Immediate result of direct cellular damage from a traumatic event
Unable to reverse the injury
Types - focal and diffuse

34
Q

Patterns of brain injury - Secondary injury

A

Occurs hrs to days after initial injury
Disruption of blood flow and oxygen to brain
Focus tx on preventing this second injury
It is the damage occuring as a result of the body’s response to the first injury

35
Q

Categories of Primary Injury - Diffuse (global)

A

Concussion - blow to head
Directly impacts consciousness
Diffuse axonal injury

36
Q

Categories of Primary Injury - Focal (local)

A

Skull fractures
Intracranial hemorrhages
Contusion
Indirectly affect consciousness

37
Q

Skull fractures - Types - Linear Basilar

A 
Raccoon eyes (ant fossa)
Battle signs (middle)
CSF otorrhea (middle)
38
Q

Skull Fractures - Types - Depressed Skull Fracture

A

Will have injury underneath - contusion

39
Q

Intracranial hematomas - Epidural

A 
Arterial in origin
Rapid onset
Hx of immediate LOC, awake, and then LOC
Immediate surgery needed
Better outcome if caught early
40
Q

Intracranial hematomas - Subdural

A

Venous in origin
Acute or chronic onset
Worst outcome
Supportive or Surgical evacuation

41
Q

Intracranial hematomas - Intraparenchymal

A

Bleeding in brain tissue, small large, single or multipl
Edema is pronounced
Supportive management

42
Q

Monitoring

A

CR
Arterial line
Central venous pressure
ICP and cerebral profusion pressure

43
Q

Indication for ICP monitoring

A

GCS score less than 8 AND an abnormal CT scan
Two of the following:
Symptomatic with bilateral motor posturing
Syst BP less than 90
Age over 40

44
Q

Pathophysiology - Intracranial vault consists of what components

A

Brain tissue (80%)
Blood (10%)
CSF (10%)

45
Q

Pathophysiology - Monroe Kellie Hypothesis

A

If volume in any component changes, the other areas have to compensate
If unable to compensate, the ICP will inc

46
Q

ICP measures what

A

Pressure exerted by brain tissue, blood, and CSF within the cranial vault

47
Q

ICP measures - normal

A

0 to 10 mmHg

48
Q

ICP measures - abnormal

A

Greater than 20 for more than 5 minutes

You will initiate tx if greater than 20

49
Q

Cerebral perfusion pressure - is what

A

Pressure at which the brain is perfused

Regulates cerebral blood flow - indirect measure of cerebral blood flow

50
Q

Cerebral perfusion pressure - how to calculate

A

CPP = MAP minus ICP

51
Q

CPP - normal range

A

Adult over 70

52
Q

CPP - what level will lead to hypoperfursion of the brain and lead to ischemia

A

Less than 40

53
Q

Cerebral blood flow - is regulated why

A

to supply brain with oxygen and glucose

If not maintained, ischemia occurs to the brain

54
Q

Factors for regulating CBF

A 
CPP
ICP
BP (MAP)
Autoregulation to changes in BP
Chemoregulation responst of BVs to hypoxia, CO2
55
Q

CBF - if you have high carbon dioxide what happens

A

Vasodilate - inc CBF - inc ICP

56
Q

CBF - if low carbon dioxide what happens

A

Vasoconstrict - dec CBF

57
Q

Tx goal of TBI

A

Focus on factors that cause further injury

Intervention to reduce risk of secondary injury

58
Q

Early management

A 
Airway/Cervical Spine precautions
Breathing
Circulation
Disability (GCS)
Exposure
59
Q

TBI management - Airway/Breathing

A

Intubate if GCS less than 8
We want SaO2 95% or higher
Maintain PaCO2 35-40

60
Q

TBI management - Circulation

A

Control bleeding
Maintain adequate BP (IV fluids, Blood administration, Vasopressor)
Normovolemia - maintain CVP between 5 and 10

61
Q

TBI management - optimize positioning to improve venous return

A

Head of bed raised 30 degrees
Neutral head position
Ensure C collar is not too tight
Avoid extreme hip flexion

62
Q

TBI management - decrease metabolic rate

A 
Reduce environmental stimulation
Sedation meds
Analgesia meds for pain
NM blockade (paralytics)
Normothermia
63
Q

TBI management - Lowering ICP

A

External ventricular drain

Hyperosmolar therapy

64
Q

TBI management - Lowering ICP - External ventricular drain

A

Drains CSF to reduce intracranial volume

Measures ICP at same time too

65
Q

TBI management - Lowering ICP - Hyperosmolar Therapy

A

Dec cerebral edema
Meds - mannitol, hypertonic saline
These meds pull extra fluid from the brain down to decrease ICP

66
Q

TBI Management - surgical management

A

Evacuate hematoma

Decompressive craniotomy

67
Q

TBI management - surgical management - tier 2 is what

A

Decompressive craniotomoy - Remove part of cranium to allow brain to swell - place bone flap once edema resolved
Usually not done unless all other measures fail

68
Q

TBI management - max swelling usually occurs when

A

72 hours is usually when it peaks and it can last 1 to 2 weeks

69
Q

TBI management - Reduce cerebral metabolic demands

A

Tier 2
Induced hypothermia
Barbituate coma to reduce brain activity

70
Q

Systems management

A 
Stable electrolytes and blood sugar
Stress ulcer prophylaxis
Anticonvulsants to prevent seizures
Venous thrombosis prophylaxis
Nutrition
Skin breakdown prevention
Bowel and bladder regime
Tracheostomy 
Social
71
Q

Complication

A

Sepsis
Renal failure
Pulmonary failure

72
Q

Predicting outcome

A 
Duration of unconsciousness
Initial GCS
CT scan results
ICP results
Pupillary response
Age of patient
73
Q

Long term neurobehavioral sequela

A

Cog deficits
Bx and personality changes
Psychiatric disorders

Semester 5 PMNM Exam 7 (7 decks)

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