eyes opening verbal response motor response NOT INDICATIVE OF PARALYSIS what 3 things are involved in the Glasgow coma scale what things need to be looked at in TBI what is the window of seizing after TBI what complicating conditions must be absent before coma and brain death testing

what 3 things are involved in the Glasgow coma scale

name the ratings for verbal response in the GCS what are the patient requirements before coma and brain death testing most common cranial nerve to be damaged name the ratings for eye opening in the GCS

name the ratings for eye opening in the GCS

intubated = T for tubed 22 YO MALE S/P FOUND DOWN GRAND CANYON OR on admit for Decompressive Craniectomy. EVD Placed day 2 due to decline in stability, unable to obtain neuro exam. Experienced severe sympathetic storming for days. what do u do? can u use recoronium and paralytics for TBI what physical exam findings are absent on braindead patients name the ratings for verbal response in the GCS

name the ratings for verbal response in the GCS

3: dorticate posturing (hands go to core) response is higher in brain so its better 2: decerebrate posturing (e for extension) name the ratings for eye opening in the GCS S/P Skateboarding accident Extensive miltifocal intracranial hemorrhage. Bilateral subdural hemorrhage. Multifocal bilateral parenchyma contusions. Possible impending transtentorial herniation. Right decompressive craniectomy name the ratings for motor response in the GCS what are the patient requirements before coma and brain death testing

name the ratings for motor response in the GCS

no (need to do exam) & yes (protect brain) number 1 thing to do to lower ICP early on when patient enters trauma bay should they be on sedatives what is issue of EEG in brain death confirmatory exam what is preferable to IV fluids for patients in head injuries

when patient enters trauma bay should they be on sedatives

fentanyl propofol** (fast acting) what two meds can be used for sedation in traumatic brain injury what is doll's eye here are some pics of gun shot wound to the head what fluid level is indicated in treatment of intracranial hypertension

what two meds can be used for sedation in traumatic brain injury

can they move all 4 extremities GCS score look at pupils name the ratings for motor response in the GCS name the ratings for eye opening in the GCS what are most important things to look at in severe traumatic brain injury what are surgical options for unresponsive intracranial HTN

what are most important things to look at in severe traumatic brain injury

-Type of movement: -Decorticate -Decerebrate what is the importance of GCS? what does a score of 2 or 3 in motor section tell u? placement of external ventricular drains (EVD) what are most important things to look at in severe traumatic brain injury what is the issue of angiography in brain death confirmatory exam

what is the importance of GCS? what does a score of 2 or 3 in motor section tell u?

7 most common cranial nerve to be damaged why/when should pts undergo hyperventilation with intracranial HTN what are the confirmatory tests for braindead what is seen on cerebral radionuclide angiogram (CRAG) (SPECT scan - single photon emission CT) in a brain dead patient? what could be the issue with the test?

most common cranial nerve to be damaged

mental status, speech, cranial nerve, motor, sensory, gaze, CSF leak, cerebellar testing, Hoffman and reflexes can u use recoronium and paralytics for TBI what things need to be looked at in TBI number 1 thing to do to lower ICP early on name the ratings for verbal response in the GCS

what things need to be looked at in TBI

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eyes opening verbal response motor response NOT INDICATIVE OF PARALYSIS

intubated = T for tubed

3: dorticate posturing (hands go to core) response is higher in brain so its better 2: decerebrate posturing (e for extension)

no (need to do exam) & yes (protect brain)

fentanyl propofol** (fast acting)

can they move all 4 extremities GCS score look at pupils

-Type of movement: -Decorticate -Decerebrate

mental status, speech, cranial nerve, motor, sensory, gaze, CSF leak, cerebellar testing, Hoffman and reflexes

-Decorticate: can flex (higher up in brain) = 3 -Decerebrate: can only do extension = 2

Absence of brainstem activity and reflexes - Fixed pupils - no response to light - Absent corneal reflex (CN V1, VII) - Absent oculocephalic (dolls eye) - Absent gag reflex - No cough

asses function of the medulla. The idea is to remove the vent, and watch CO2 rise, proven there is no drive to breathe confirmed w/ no respirations for 2 min with CO2 > 60

No motor function to central stimulus except: spinal reflexes triple: pinch toe, and pulls leg back lazarus: arc back

angiography, Nuc med, EEG

min of 2 providers (PA or MD)

hypoxia (O2 < 90), hypotension (SBP < 90) hyperglycemia (increased edema)

pressers once euvolemic

Euvolemic or slightly hypervolemic using normal saline usually

no; it has low sodium

Decrease ICP by enhancing venous outflow and lowers mean carotid pressure

high risk within 7 days

7 days max (no benefit past that)

phenytoin Levetiracetam Lacosamide

Acute SDH, EDH, IPH (sizable and/or surgical lesion) - Open depressed skull fracture with parenchymal injury - Sz. Within first 24 hr. - GCS < 10 - EtOH - Penetrating trauma

measure the pressure in the ICP and allows you to pull fluid off

Placement is a Kocher's point -11 cm from nasion 2-3 cm off midline aiming at the medial canthus and EAM

missing too far lateral will cause a bleed in the basal ganglia, too deep injures brainstem, can hit corpus collusum

use if ICP is high even after sedation reduced hct and blood viscosity to expand plasma, it also is a free radical scavenger has an osmotic effect

SBP < 90 - Osmolality of > 320 (high sodium)

osmotic diuretic that pulls fluid into the vasculature; use when pt is resistant to mannitol

given via central line to fix hyponatremia very quickly

145ish (160 is dangerously high)

never hyperventilate in first 24 hours; only do if brief rapid deterioration can allow decreased blood flow to brain and decreased ICP

PaCO2 from 35 to 29 mm Hg lowers ICP 25-30%

peaks at 8 minutes, no longer than 60 minutes

Review your basics and check labs (Glucose, Na, neck position) - Possible seizure activity (EEG) Repeat the CT (Expanding edema or hematoma, CVA, Post op hematoma) - Rebound from 3% and/or Mannitol - Transfuse (Consider until Hgb > 10 (brain tissue O2 tension)

CVA from IC-HTN - ABG (End PCO2 can be wrong) - EVD stopped working - Sedation change or increase - Temperature/systemic infection - CNS Infection (Check CSF)

pentobarbital coma: Vasoconstriction in normal area and shunts blood to ischemic tissue and decreases metabolic demand -Potent at lowering ICP - Limiting therapy is usually hypotension

compressive craniotomy

Core temp >36 (96.8) - SBP >100 mm Hg - No drugs that could simulate brain death - Blood etoh <0.08 - absent complication conditions

Hypothermia - No evidence of remediable exogenous or endogenous intoxication. - Shock and anoxia - SBP >100mmHg - Immediate post resuscitation - Pentobarbital coma

Doesn't detect brain stem activity -Time and experience tech

May miss minimal flow to the brain - Hollow skull sign confirms brain death - this is bob rob's fav confirmatory test

cost, time, invasive

MCC is self inflicted; but can be accidental

Any bleed could show up Look for the bilateral hygroma (seen in pictures) /chronic SDH Retinal hemorrhage Neurological injury with minimal external signs Skulls fracture in multiple sites

L side acute subdural holohemispheric hematoma with mass effect take subdural out and lead skull off

1. Multifocal intracranial hemorrhage. Subarachnoid hemorrhage is seen within cortical sulci of both cerebral hemispheres more abundant on the left than the right. 2. Multifocal subdural hemorrhage on the left seen along the falx as well as over the left frontal and temporal lobes measuring up to maximum of 3 mm in thickness. No significant mass effect.

rim frontal acute right subdural hematoma just observe swelling on right is subgalia hematoma

left picture: bilateral acute frontoparietal subdural hematoma with right to left midline shift and effacement of the sulci right picture: scant subarachnoid hemorrhagic and darkened brain consistent with anoxia and effacement of the cisterns

when the eyes follow you even when you turn the head present in braindead patient s

sedation: propofol, fentanyl

not yet because hinders ability to do physical exam

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