Traumatic Brain Injury

Question 1

best time to manage traumatic brain injury?

Answer 1

within the hour

“golden hour”

Question 2

general advanced trauma life support (ATLS) in traumatic brain injury?

Answer 2

manage airway with C spine control
breathing 
circulation
ABCDE
assess via GCS, pupils etc
check C spine

Question 3

what are the 3 categories of GCS?

Answer 3

eye opening
verbal
motor

Question 4

levels of eye opening?

Answer 4

open spontaneously
open to speech
open to pain
no eye opening

Question 5

levels of verbal?

Answer 5

orientated
confused
inappropriate
incomprehensible
no verbal

Question 6

levels of motor?

Answer 6

obeying
localising
flexing
abnormal flexing
extending
no motor response

Question 7

how is head injury classified via GCS?

Answer 7

mild = 14, 15 or brief loss of consciousness
moderate = 9-13
severe = 3-8

Question 8

who must be given a CT scan within 1 hour of head injury?

Answer 8

GCS <13 in initial assessment
GCS <13 2 hrs after injury
suspected open or depressed skull fracture
sign of basal skull fracture
post traumatic seizure
focal neuro deficit
more than 1 vomiting episode
suspicion of NAI

Question 9

CT should be given to which people if they also have had some loss of consciousness of amnesia?

Answer 9

65+
coagulopathy
dangerous mechanism of injury

Question 10

classic presentation of extradural haematoma?

Answer 10

injury with loss of consciousness
lucid interval recovery
rapid progression of neuro symptoms

Question 11

acute vs chronic subdural haematoma on imaging?

Answer 11

acute = hyperdense crescent (pale area)
chronic = hypodense crescent (darker area)

Question 12

what does diffuse axonal injury look like on imaging?

Answer 12

little white blobs

Question 13

initial neurosurgical role in traumatic brain injury?

Answer 13

prevent secondary insults

• hypoxia
• hypotension
• mass lesions
• control ICP and CPP

Question 14

principles of neurosurgery?

Answer 14

patient must be intubated, ventilated and sedated

control ICP

Question 15

how is raised ICP managed medically?

Answer 15

sedation (Propofol, benzodiazepines)
maximise venous drainage (tilt head of bed, cervical collar, ET tube ties)
CO2 control
osmotic diuretics (mannitol, hypertonic saline)
CSF release

Question 16

why must CO2 be controlled in raised ICP?

Answer 16

increased arterial CO2 = increased cerebral blood flow

Question 17

head of the bed should be raised to what angle in raised ICP?

Answer 17

30 degrees

Question 18

what is used in extreme cases of raised ICP?

Answer 18

decompressive craniectomy

- part of skull removed to allow expansion of brain

Question 19

cerebral perfusion pressure (CPP) is equal to what?

Answer 19

MAP - ICP

Question 20

what is the danger of seizure in traumatic brain injury?

Answer 20

post traumatic seizures can occur (early or late) which can cause secondary insult on the brain

Question 21

do antiepileptics reduce risk of post traumatic seizure?

Answer 21

only early, not late, seizure

still risk of secondary insult

Question 22

effect of nutrition after traumatic brain injury?

Answer 22

every 10 kcal/kg deficit = 30-40% increase in mortality rate

must have nutrition

Question 23

what happens in diffuse axonal injury?

Answer 23

sheering forces tears axons apart/twists them/compresses them
causes excitotoxicity and apoptosis in nerves and inflammatory mediator release (cytokines, interleukins, IL-6)

Question 24

where is diffuse axonal injury most likely to occur?

Answer 24

grey/white matter interface (where density difference is at its greatest)

Question 25

describe excitotoxicity in nerves?

Answer 25

excitatory amino acids (glutamate) released
activates NMDA receptors
calcium mediated activation of proteases and lipases
causes further secondary cell death

Question 26

what can improve outcome at the cellular level in humans and what makes it worse?

Answer 26

no chemical compound known to improve

steroids make it worse

Question 27

signs of brainstem death?

Answer 27

no pupil response
no corneal reflex
no gag reflex
no vestibulo-ocular reflex
no motor response
no respiration

Question 28

how can brain stem death be confirmed?

Answer 28

must have 2 doctors confirm (1 consultant)