Traumatic Brain Injury Case Scenario Workshop

1
Traumatic Brain InjuryCase Scenario Workshop

• Maurizio Berardino
• Neuroanesthesia and Intensive Care
• Neuroscience Department
• San Giovanni Battista Hospital
• Torino, Italy

2
Overview

• Initial assessment
• ABCs
• Neurologic evaluation
• Treatment
• Transport
• Neurologic Deterioration

3
Case Presentation

• 21 year old male
• Unrestrained driver, single vehicle MVC
• 70 KPH, sedan vs. concrete barrier
• No airbag
• Windshield starred

4
Primary Survey

• The patient had a clear airway and was speaking
  spontaneously
• Bilateral breath sounds
• A strong radial pulse at 100
• BP 120/80

5
Primary Survey

• A 3x5 cm hematoma / contusion on the patients
  left superior forehead / frontal area
• The patient was found walking near the accident
  scene alert but confused
• PERRL 3 mm
• What is his GCS score?

6
Glasgow Coma Scale
Full verbal score (5) is assigned for crying
after stimulation in children lt 2yrs.
7
Priorities ?

• Assessment / Treatment
• Airway
• Breathing
• Circulation
• Cervical Spine
• Disability
• Exposure

8
Secondary Survey

• No change in A, B, C, D
• Mild bleeding left forehead
• No other injuries discovered

9
Treatment / Interventions

• Interventions
• IV
• 02 NRB FM
• Immobilization
• C spine collar
• Back board

10
Transport Issues

• Destination
• Emergency Department
• Trauma Center
• Status / Expediency

11
After the Primary Secondary Survey

• While asking the patient about the accident his
• Speech becomes inappropriate
• Eyes remain open
• Localizes to tactile stimuli
• What is his GCS Score?
• Pupils PERRL 3mm
• What is your next action?

12
Priorities ?

• Assessment / Treatment
• Airway
• Breathing
• Circulation
• Cervical Spine
• Disability
• Exposure

13
Glasgow Coma Scale

• En route, 10 minutes from destination hospital
• Eye no opening
• Motor flexion
• Verbal non-verbal
• What is his GCS score?

14
Priorities ?

• Assessment / Treatment
• Airway
• Breathing
• Circulation
• Cervical Spine
• Disability
• Exposure

15
Reassessment

• Patient is unresponsive
• No verbal effort
• No eye opening
• Extensor posturing to nail bed pressure
• What is his GCS score?
• Pupils
• R gt 5 mm (non-reactive)
• L 2 mm (reactive)

16
Treatment / Interventions

• Indications for intubation / hyperventilation
• Dilated unreactive pupil (s)
• Extensor posturing

17
Ventilation

• Normal ventilation is defined as approximately
• 10 breaths per minute (bpm) for adults
• 20 bpm for children
• 25 bpm for infants  

18
Hyperventilation

• Routine prophylactic hyperventilation can cause
  cerebral ischemia should be avoided
• Hyperventilation is defined as approximately
• 20 breaths per minute (bpm) for adults
• 30 bpm for children
• 35 bpm for infants

19
Agitation

• Patient becomes agitated / combative, pulling at
  ETT with freed hand
• Near self extubation
• P 100
• BP 130 / 80
• Bilateral equal breath sounds
• O2 sat 99

20
Agitation (Causes)

• Hypoxemia
• Hypovolemia
• Drugs
• Alcohol
• Hypoglycemia
• Patient discomfort
• Traumatic brain injury

21
Hypoglycemia

• Can be a cause of trauma or accident
• Pupillary asymmetry
• Altered mental status
• Focal neurologic deficits
• Diaphoresis
• Coma

22
Destination

• Level I trauma center with the following
  capabilities
• 24 hour available CT scanning
• 24 hour available operating room
• Prompt neurosurgical care
• Ability to monitor intracranial pressure
• Ability to treat intracranial hypertension

23
Summary

• Head trauma patients require frequent
  reassessments
• A single GCS score does not predict outcomes
• Indications for hyperventilation include dilated
  unreactive pupil (s), extensor posturing
• Moderate and severe TBI patients require
  transport to a neurotrauma center