1. What is the primary goal of treating TBI? How is this done? 2. After managing ABCDEs of TBI what MUST be identified if present? How is this done?
... [Show More] 3. Which brain lobes do the following hold: 1. anterior fossa: 2. middle fossa: 3. posterior fossa: preventing secondary brain injury. This is done by maintaining blood pres- sure and providing ade- quate profusion. mass lesion that requires surgical evacuation is crit- ical! this is done with CT. NOTE: obtaining a CT should not delay patient transfer to trauma center. 1. anterior fossa: frontal lobes 2. middle fossa: temporal lobes 3. posterior fossa: lower brainstem and cerebellum 4. What are the 3 layers of the meninges? dura mater, arachnoid mater, pia mater 5. What does the dura mater adhere firmly to? the skull. it is tough and fi- brous 6. What layer of the meninges splits into two leaves as specific sites to enclose large ve- nous sinuses? What do these sinuses do? 7. What is the midline sinus of of the brain that splits into two sinuses: bilateral transverse and sigmoid sinus? What side are these big- ger on? dura mater. these sinuses provide ma- jor venous drainage from the brain. The main sinus enclosed by the dura major is the midline superior sagital si- nus. This splits into the sig- moid and bilateral trans- 8. What are the arteries that lie between the skull and the dura mater (epidural space)? 9. What is the most commonly injured meningeal artery and where is it located? 10. T/F: the arachnoid mater is fused to the dura mater? verse sinuses which are larger on the right side. meningeal arteries. middle meningeal artery. Located over the temporal fossa FALSE: not attached. This produces a potential space for a subdural hematoma 11. In a subdural hematoma, what is the cause? injury to bridging veins that extend from brain surface to the sinuses within the dura. 12. fills the space between the arach- noid and pia mater? 13. What location of brain hemorrhage is fre- quently seen in brain contusion or injury to major blood vessels at base of brain? 14. The and contain the reticular acti- vating system which is responsible for . 15. What important function resides in the medulla? 16. What important functions are in the following brain segments: 1. left hemisphere: 2. frontal lobe: 3. parietal lobe: 4. temporal: CSF. this cushions the brain and spinal cord. subarachnoid. midbrain and upper pons state of alertness cardiorespiratory centers. 1. left hemisphere: lan- guage center 2. frontal lobe: executive function, emotions, motor 3. parietal lobe: sensory function/spatial orientation 4. temporal: memory func- tions 17. What divides the brain into supratentorial and infratentorial compartments? tentorium cerebelli. (tent over cerebellum) 18. What is the physiology behind a blown pupil? blown pupil: dilation of pupil -CN III runs along the ten- torium cerebelli. parasym- pathetic fibers that con- strict the pupil run along CN III (oculomotor). When temporal lobe is herniat- ed, it can compress these fibers. Unapposed sympa- thetic activity causes pupil- lary dilation. 19. What is the tentorial notch/hiatus this is where the midbrain passes through into the in- fratentorial compartment. 20. what part of the brain most commonly herni- ates through the tentorial notch? 21. does weakness occur on the same or oppo- site side of the uncal herniation? 22. state: Ipsilateral/contralateral Uncus (medial part of tem- poral lobe) OPPOSITE. the corti- cospinal tract of the mid- brain is compressed and then crosses at the fora- men magnum. ipsi pupillary dilation associated with contra hemiparesis is the classic sign of uncial her- niation. 23. average ICP is mmHg. 10 24. The monro-kellie doctrine states that the total volume of intracranial contents must remain constant, because the cranium is 25. The monro-kellie doctrine states that and may be compressed out of the skull providing a degree of buffering. 26. What is the equation for CPP (cerebral perfu- sion pressure)? 27. in TBI, Every effort should be made to re- duce , while normalizing , , and . 28. What GCS ranges for the following classes: 1. Minor 2. Moderate 3. Severe 29. What nerve palsy may occur with basilar skull fracture? a rigid, non expandable container. CSF and venous blood. Once the CSF and venous blood reach a certain lev- el of displacement the ICP rapidly increases. CPP=MAP-ICP ICP MAP, oxygenation, in- travascular volume 1. 13-15 2. 9-12 3. 3-8 seventh nerve. 30. A GCS of is accepted definition of coma? 8 or less 31. How do you assess a GCS of someone with asymmetric responses? 32. Basilar fractures of the skull usually require what type of imaging? 33. What are the typical clinical signs of basilar skull fractures? Use the best possible be- cause this will be the best predictor of outcome this requires CT with bone-window setting. 1. periorbital ecchymosis (raccoon eyes) 2. retroauriculor ecchymo- sis (battle sign) 3. CSF leak from nose or 34. What should be a primary consideration for any patient with a skull fracture, especially a linear skull fracture? 35. What mechanism is common with diffuse ax- onal injury and what is the likely outcome? ears 4. 7th or 8th CN dysfunc- tion (facial paralysis and hearing loss) hematoma. linear skull fracture increases like- lihood of intracranial hematoma by about 400x these injury often occur with high velocity or de- celeration injures. They ap- pear as diffuse cerebral hemorrhage often between grey and white matter. These are associated with variable but often poor out- comes. 36. Epidural hematomas often occur in the temporal area of the skull and result from a tear of the arteries. 37. What is the classic presentation of a epidural hematoma? 38. What are more common brain injury: epidural or subdural? 39. Subdural hematoma occur from tear of . 40. Contusion occur in % of TBI. They often occur in or lobes of brain. They may coalesce to form in as many as 20$%. middle meningeal artery a lucid interval between time of injury and neurolog- ic a deterioration. subdural 30% epidural 0.5% bridging vessels of the cerebral cortex 20-30% frontal or temporal intracerebral hematoma. 41. 41. What is the imaging protocol for a patient with get CT at presentation. cerebral contusion? 42. What factors would require a CT in minor brain injury? 43. How long after discharge should patient with mild brain injury be observed by friend? 44. What type of brain injury requires serial GCS? 45. What imaging is done in all patient with mod- erate brain injury? 46. What factor of ABCDE must be monitored closely in moderate brain injury? 47. What should immediately follow the sec- ondary survey in major/severe brain injury? 48. When assessing ABCDE of severe brain in- jury, when does DPL or FAST come before neuro exam? then get another within 24 hours to assess for coa- lesced hematoma. 1. suspected open skull frac 2. basilar frac 3. >2 episode vomitting 4. pt older than 65 5. LOC >5 min 6. amnesia before impact of >30 min 24 hours ALL. minor. moderate. ma- jor CT Airway and breathing. rapid deterioration may occur. hypoventilation and hyper- capnia may ensue requir- ing intubation. close moni- toring in ICU is required. CT. REMEMBER: CT should never delay patient transfer if the systolic blood pres- sure cannot be brought above 100, DPL or FAST is done first as to assess source of hypotension 49. Spinal cord injury has what result in blood pressure? hypotension. This may also occur in terminal brain in- jury with medullary failure 50. What needs to be cleared before Doll's eye cervical spine must testing is conducted? cleared. 51. What tests should be performed before seda- GCS and pupillary rxn tion? 52. A midline shift of mm or greater on the 5mm CT is indicative of need for neurosurgery to evacuate the clot or contusion causing the shift 53. What type of fluids should be used? hypertonic (ringers lactate or normal saline). NO GLU- COSE. 54. What electrolyte abnormality is associated hyponatremia with brain edema and must be monitored? 55. What are the physiologic consequences of f PaCO2 >45 = vasodilation PaCO2 >45? = inc ICP PaCO2 <30? PaCO2 <30 (hyperventila- tion) = constriction = is- chemia 56. What is the preferred PaCO2 in brain injury? 35 mm Hg 57. If ICP is rapidly increasing, what can be done hyperventilation. NOTE: while preparing for craniotomy? this must be monitored closely and is only done very short periods at a time 58. Does hypertonic saline lower ICP in hypov- No olemia? NO Does mannitol lower ICP in hypovolemia? 59. After administration of mannitol what should be monitored closely? 60. What is the role of muscle relaxants (ve- curonium or succinylcholine) in seizures with TBI? 61. What meningeal tear would a CSF leakage of a head laceration indicate? ICP! mannitol has a sub- stantial rebound effect on ICP NONE. these may mask ton- ic-clonic seizures and pre- vent anticonvulsant inter- vention (30-60 min of seizure = secondary brain injury) dural tear 62. What is the treatment of any intracranial mass Must be evacuated by neu- lesion? 63. for a penetrating object such as an arrow or screw driver into the skull, test should be performed and what should be done with the object? 64. What clinical signs are the criteria for brain death? 65. Which vertebrae is most susceptible to in- jury? 66. What nerve and cervical spine level would cause apnea and results in death in 1/3 of patient with upper cervical spine injury rosurgeon. transfer if not available. need CT, Xray for trajecto- ry, and angiography. leave the object in place. Remov- ing the object lead to fatal vascular injury. GCS of 3, nonreactive pupil, absent brainstem reflexes, no spontaneous ventilatory effort Cervical. NOTE: in peds this ac- counts for only 1% of ver- tebral injury phrenic nerve C1 67. 67. At what age do cervical spine differences be- gin to normalize? at what age does cervical spine look like that of an adult? 68. When a dislocation-fracture of the vertebrae occurs, almost always the result is . 69. T/F: the thoracolumbar junction is extremely strong and rarely incurs injury? 70. At what levels do the spinal cord begin and end? marked differences in cer- vical spine occur until age 8 and steadily decline until age 12 when they are sim- ilar complete spinal cord injury FALSE: the flexible tho- racic meeting the rigid lum- bar make this area a com- mon place for injury (15% of all spinal injuries) begins at foramen mag- num at terminal end of the medulla oblongata and end at L1 71. What is sacral sparing? this is a sign of incomplete spinal cord injury where some sensation below an injury to spinal cord is preserved. In the case of sacral sparing, sensation and rectal sphincter tone is preserved. 72. What function does the dorsal column have? What tests can be done to assess function? position, vibration, light touch, all from same side of body. TESTS: positioning of bent toes/fingers, vibration with tuning fork. 73. What function does the spinothalamic tract have? what tests can be done to assess func- tion? 74. What function does the corticospinal tract have? what tests can be done to assess func- tion? 75. What type of gastric tube should be placed when cribiform plate fx or mid face fracture is present? 76. When fluids must be administered what is the best route, and which type of catheter is best? 77. 77. pain and temperature to opposite side of body TESTS: pinprick and light touch Motor power on same side of body TESTS: voluntary muscle contract or involuntary re- sponse to pain orogastric. nasopharyngeal intrumen- tation is potentially danger- ous -peripheral route it pre- ferred with antecubital or forearm. -if peripheral route is not accessable central vein ac- cess in any of the typical areas is acceptable. (in this case a short fat catheter should be used) What anatomical change is common in the third trimester of pregnancy? 78. What pulmonary complication is common with blunt trauma and PaCO2 <35? 79. Chest tube is indicated for which of the fol- lowing? -tension pneumo -hemothorax -ruptured bronchus -pulmonary contusion -mass hemothorax 80. What is the initial bolus for fluid resuscitation when a small child is in shock? 81. What are the chest tube blood volume output parameters that would require a thoracoto- my? 82. How can one determine the appropriate tube depth for pediatric intubation? 83. In pediatrics: once past the glottic opening, the ETT should be positioned to cm below the level of the vocal cords and then carefully secured. 84. Fluid resuscitation of an infant begins with (amount and type). And then pro- gresses to . (amount and type) widening of the symphasis pubis pulmonary contusion. All EXCEPT pulmonary contusion 20mL/kg ringers lactate >1500mL immediatley evacuated OR 200mL/hr for 2-4hrs NOTE: thoractomy is not indicated unless a surgeon qualified by training and ex- perience is present ETT tube size x 3 Ex: 4.0 ETT would be prop- erly positioned at 12 cm from the gums 2-3 cm 20mL/kg Ringers lactate. (may give up to three of these boluses initially) 85. For a patient who is not breathing what inter- vention is indicated? 86. What should be used when vocal chords can- not be visualized on direct laryngoscopy? For the third bolus consider PRBCs at 10mL/kg orotracheal intubation gum elastic bougie. in place when you feel clicks. can be inserted blindly be- yond epiglottis 87. What is the acronym BURP? backward, upward and rightward pressure used in external laryngeal manipu- lation with orotracheal intu- bation 88. what is the most common life threatening in- jury in children? 89. What is the most common acid-base distur- bance in the injury child and what is it caused by? 90. What are the options to establish an airway when bag-mask ventilation and attempts at orotracheal intubation fail for a child? 91. 91. tension pneumothorax Respiratory acidosis caused by hypoventilation. LMA, or intubating LMA, or needle cricothyroidotomy. -needle-jet insufflation is an appropriate temporizing technique for oxygenation but does not provide ade- quate ventilation. NOTE: surgical cric is RARELY indicated for in- fants an small children. usually it is an adop- tion when the cricothyroid membrane is easily palpa- ble around the age of 12. A local area of frost bite should be rewarmed with what temperature and in what waY? 92. What is the main utility of ECG during resus- citation? 93. What does PaCO2 of 35-40 mmHg indicate in late pregnancy? 94. Other than maternal death, what is the lead- ing cause of fetal death? Symptoms? 95. What type of monitoring should be initiated in fetus of gestation age >20 wks 96. What are the two extra precautions during primary survey of pregnant woman? 40C (104F) should be done in whirlpool. not dry heat. detecting rhythm abnor- malities impending respiratory fail- ure. hypocapnia (around 30) is typical in late preg- nancy due to inc tidal vol- ume. abruptio placentae (70%) suggested by vaginal bleeding, uterine tender- ness, uterine contractions, uterine tetany, and irri- tability of uterus (contracts when touched) continuous monitoring with tocodynamometer. monitor should be done for 6 hours with no symptoms, and 24 with abruptio symptoms. 1. uterus should be dis- placed manually to the left to relive pressure not he in- ferior vena cava. 2. early initiation of crystalloid fluids due to moms compensatory mechanisms masking fe- tal distress associated with hypovolemia 97. FALSE. diaphragmatic breathing=c-spine injury T/F? Diaphragmatic breathing in a patient who is unconscious is not a sign of C-Spine injury 98. What is used to evaluate a suspected urethral injury? What is used to evaluate a bladder rupture? 99. What are the abdominal structures that may not be detected on DPL? 100. In a severe trauma where facial anatomy is distorted and an ETT cannot be placed, what is the next step to provide ventilation? 101. What hold urine output be maintained at after a crush injury to prevent kidney injury? 102. Is operation ever indicated in first hour after injury of multiple injured patient? 103. What class of shock are there NO clinical signs of inadequate organ perfusion? 104. What is suggested if chest tube placement for suspected pneumothorax results in incom- retrograde urethrogram cystogram duodenum, ascending/de- scending colon, rectum, biliary tract, and pancreas Next would be a transchri- cothyroid needle-jet insuf- flation. this is attached to high pressure oxygen, but can only be provided for around 30-45min due to CO2 accumulation. -the definitive after this would be a surgi- cal chricothyroidotomy or an emergent tracheoto- my. (emergent tracheoto- my is not preferred be- cause complication and time consuming) 100 mL/hr yes. especially if class 3 or 4 hemorrhagic shock is present Class I. <14% blood vol- ume loss. (<750mL) This suggests tracheo- bronchial injury such as plete lung expansion and air leak with bub- bling? What imaging confirms? 105. Why do chest injuries have a high priority in the multiply injured person? 106. What is the physiology behind neurogenic shock? 107. What is another name for Central Venous Pressure? When is it elevated? 108. What would be expected on ABG abnormali- ties for pulmonary contusion? 109. t/f vomitus in the posterior oropharynx sug- gests esophageal intubation. 110. t/f: major head injury rarely causes shock by itself 111. What are the vital signs to be expected when ICP increases? 112. 112. ruptured bronchus. -a second chest tube may need to be placed -this is confirmed with broncoscopy they often result in hypoxia loss of vascular tone Basically the same as Right atrial pressure. -Elevated in cardiac failure, tamponade, tension pneu- mo, disrupted thoracic aor- ta. PaO2 <65 mm Hg (sat <90) would suggest need for in- tubation and in the pres- ence of flail chest is more suggestive false. signs include: epigastric fullness, absent end ti- tle CO2, absent breath sounds, audible borboryg- mi sounds over abdomen true decreased respirations and HR, increased systolic and pulse pressure Urethral injury should be suspected in the presence of what three things? 113. What test is used to confirm the integrity of the urethra before a catheter is inserted? 114. What physical exam is essential before pass- ing a urethral catheter 115. What is the best guide for adequate fluid re- suscitation in a burn patient? 116. The LEAST likely cause of a depressed level of consciousness in the multisystem injured patient is a. shock. b. head injury. c. hyperglycemia. d. impaired oxygenation. e. alcohol and other drugs. 117. For a patient bleed profusely from a wound not he medial thigh where should pressure be applied? 118. What is one characteristic shared by all SUR- VIVORS of traumatic aortic disruption? 1. blood at the meatus 2. perineal ecchymosis 3. high riding or non-palpa- ble prostate retrograde urethrogram examine the rectum and perineum urine output adults: 0.5mL/kg/hr >30kg: 1mL/kg/hr NOTE: parkland is only for estimating and should be adjusted in accordance with urinary output. fluids should not be slowed at 8 hours if urine output is not adequate c hyperglycemia. pressure should b applied directly to the wound. Do not apply pressure to the proximal femoral artery at the groin contained hematoma 119. What does x ray showing widened medi- astinum and obliteration of the aortic knob suggest? 120. What is the sensitivity and specificity of CT in aortic disruption? traumatic aortic disruption around 100%. NOTE: CT angiography should only be used to further identi- fy site of disruption (not an initial test) 121. What three X-ray views are most important for c-spine, chest, pelvis a person with multiple trauma? 122. Pulse oximetry provides information about and but does not provide informa- tion about 1. O2 sat 2. peripheral perfusion 3. adequacy of ventilation 123. Carboxyhemoglobin levels greater than % 10% in burn patient indicate inhalation injury and require transport and/or intubation if trans- port is prolonged. 124. An 18-year-old man is brought to the hospital after smashing his motorcycle into a tree. He is conscious us and alert, but paralyzed in hypovolemic shock with flu- ids. NOTE: airway is OK be- both arms and legs. His skin is pale and cold. cause he is talking even He complains of thirst and difficulty in breath- ing. His airway is clear. His blood pressure is 60/40 and his pulse rate is 140 beats per minute. Breath sounds are full and equal bi- laterally. He should be treated for what first? 125. What is the most important principle in the early management of someone with TBI and increasing ICP? 126. For a trauma patient that requires a chest tube, the tube is placed and 1600mL of blood returns. What is the next step in manage- ment? though he complains of trouble breathing. prevent hypotension prepare for exploratory tho- racotomy 127. What are the symptoms with anterior crod syndrome? 128. What are the symptoms of central cord syn- drome? 129. What are the symptoms of Brown-Sequard syndrome? paraplegia and loss of tem- perature and pain sen- sation, with preservation of position and vibratory senses and deep pressure sense. WORSE PROGNOSIS disproportionate motor strength loss greater in up- per extremities than low- er with varying degree of sensory loss.(the arms and hands are most severely affected) Think of a cut from anterior to posterior of the cord. -ipsilateral motor loss, and loss of position of and vi- bratory sense -contralateral loss of pain/temperature sense beginning 1-2 levels down from lesion. 130. What is the primary concern in flail chest? pulmonary contusion re- sulting in hypoxia 131. prevention of hypo perfusion and hypoxia are most important for optimal outcome in . 132. What imaging is required for a patient dis- playing basilar skull fracture: hemotympa- num, raccoon eyes, CSF otorrhea, battle sign? TBI CT! also age >65, GCS<15 2hours post injury, sus- pected depressed skull frac, committing more than two episodes, LOC >5 min, amnesia before im- 133. T/F: bony injury in pediatrics is more com- mon than in adults? 134. Compare the specificity and sensitivity of DPL and CT in blunt abdominal trauma. pact (more than 30 min), dangerous mechanism. FALSE: because bones are more pliable you will often find internal organ damage without overlying bone damage. DPL- high sens (98), low spec CT - high sens (92-98), high spec (95) [Show Less]