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Traumatic Brain Injury Case Scenario Workshop

Traumatic Brain Injury Case Scenario Workshop. Maurizio Berardino Neuroanesthesia and Intensive Care Neuroscience Department San Giovanni Battista Hospital Torino, Italy. Overview. Initial assessment ABCs Neurologic evaluation Treatment Transport Neurologic Deterioration.

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Traumatic Brain Injury Case Scenario Workshop

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  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 patient’s 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. Eye Opening spontaneous - 4 to speech -3 to pain - 2   none - 1 Motor Response obeys - 6 localizes - 5 withdraws - 4 abnormal flexion - 3 extension - 2 none - 1 Verbal Response oriented - 5 confused - 4 inappropriate – 3 incomprehensible - 2 none - 1 Glasgow Coma Scale Full verbal score (5) is assigned for crying after stimulation in children < 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 > 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

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