Trauma - Cranial

Question 1

Monro-Kellie Doctrine

Answer 1

• cranial vault is a fixed space

- filled with tissue, blood, CSF

Question 2

Skull - out to in

Answer 2

• dura mater: fibrous, thick
• arachnoid mater: spider, impermeable to drugs
• subarachnoid space: vessels, CSF
• pia mater: intimate, lays on brain tissue

Question 3

Hematomas

Answer 3

• epidural: arterial bleed, lucid period followed by rapid deterioration
• subdural: venous bleed, slow deterioration
• intracerebral

*elderly are better able to compensate due to atrophy of brain tissue

Question 4

Cushing’s Triad

Answer 4

-brain herniation

• HTN
• bradycardia
• irregular respirations

Question 5

what herniation is the worst?

Answer 5

brainstem herniation

Question 6

cranial trauma - anesthesia considerations

Answer 6

• induction: RSI, avoid hypo/hypertension, reduce CMRO2 (Propofol, thiopental, etomidate), avoid increases in ICP (succinylcholine, ketamine), opioids increase CO2 threshold so use short-acting
• maintenance: arterial line, keep MAC <1 to preserve autoregulation (robin hood effect), no nitrous, hyperventilation?
• emergence: no coughing/bucking

Question 7

goal CPP

Answer 7

60-70 mmHg

Question 8

ICP Monitoring: indications and contraindications

Answer 8

-for severe TBI

• INR > 1.6
• plt < 100,000

Question 9

cranial trauma: fluid management

Answer 9

• isotonic crystalloid
• no albumin
• no dextrose
• mannitol
• hypertonic saline

Question 10

mannitol

Answer 10

• associated with hypotension and coagulopathies
• 0.25-1 g/kg over 20 min, filter for crystals
• osmolality management <320 mOsm

Question 11

TBI coagulopathy

Answer 11

• DIC

- releases thromboplastin (activates extrinsic pathway)

Question 12

cranial trauma: glucose management

Answer 12

• hyperglycemia=increased mortality

- goal = 100-180 mg/dL

Question 13

cranial trauma: therapeutic hypothermia

Answer 13

-CMRO2 decreases 6-7% per 1 degree Celsius of core temperature change