Preventing Secondary Brain Injury: Understanding the Mechanisms and Treatment, Exams of Nursing

Download Preventing Secondary Brain Injury: Understanding the Mechanisms and Treatment and more Exams Nursing in PDF only on Docsity! ATLS Written Review Latest Exam 2024 Graded (A+). What is the primary goal of treating TBI? How is this done? Correct ans - preventing secondary brain injury. This is done by maintaining blood pressure and providing adequate profusion. After managing ABCDEs of TBI what MUST be identified if present? How is this done? Correct ans - mass lesion that requires surgical evacuation is critical! this is done with CT. NOTE: obtaining a CT should not delay patient transfer to trauma center. Which brain lobes do the following hold: 1. anterior fossa: 2. middle fossa: 3. posterior fossa: Correct ans - 1. anterior fossa: frontal lobes 2. middle fossa: temporal lobes 3. posterior fossa: lower brainstem and cerebellum What are the 3 layers of the meninges? Correct ans - dura mater, arachnoid mater, pia mater What does the dura mater adhere firmly to? Correct ans - the skull. it is tough and fibrous What layer of the meninges splits into two leaves as specific sites to enclose large venous sinuses? What do these sinuses do? Correct ans - dura mater. these sinuses provide major venous drainage from the brain. What is the midline sinus of of the brain that splits into two sinuses: bilateral transverse and sigmoid sinus? What side are these bigger on? Correct ans - The main sinus enclosed by the dura major is the midline superior sagital sinus. This splits into the sigmoid and bilateral transverse sinuses which are larger on the right side. What are the arteries that lie between the skull and the dura mater (epidural space)? Correct ans - meningeal arteries. What is the most commonly injured meningeal artery and where is it located? Correct ans - middle meningeal artery. Located over the temporal fossa T/F: the arachnoid mater is fused to the dura mater? Correct ans - FALSE: not attached. This produces a potential space for a subdural hematoma In a subdural hematoma, what is the cause? Correct ans - injury to bridging veins that extend from brain surface to the sinuses within the dura. _______ fills the space between the arachnoid and pia mater? Correct ans - CSF. this cushions the brain and spinal cord. What location of brain hemorrhage is frequently seen in brain contusion or injury to major blood vessels at base of brain? Correct ans - subarachnoid. The ____ and _____ contain the reticular activating system which is responsible for ____. Correct ans - midbrain and upper pons state of alertness What important function resides in the medulla? Correct ans - cardiorespiratory centers. What important functions are in the following brain segments: 1. left hemisphere: 2. frontal lobe: 3. parietal lobe: 4. temporal: Correct ans - 1. left hemisphere: language center 2. frontal lobe: executive function, emotions, motor 3. parietal lobe: sensory function/spatial orientation 4. temporal: memory functions What divides the brain into supratentorial and infratentorial compartments? Correct ans - tentorium cerebelli. (tent over cerebellum) What is the physiology behind a blown pupil? Correct ans - blown pupil: dilation of pupil -CN III runs along the tentorium cerebelli. parasympathetic fibers that constrict the pupil run along CN III (oculomotor). When temporal lobe is herniated, it can compress these fibers. Unapposed sympathetic activity causes pupillary dilation. What is the tentorial notch/hiatus Correct ans - this is where the midbrain passes through into the infratentorial compartment. what part of the brain most commonly herniates through the tentorial notch? Correct ans - Uncus (medial part of temporal lobe) does weakness occur on the same or opposite side of the uncal herniation? Correct ans - OPPOSITE. the corticospinal tract of the midbrain is compressed and then crosses at the foramen magnum. state: Ipsilateral/contralateral ____ pupillary dilation associated with _____ hemiparesis is the classic sign of uncial herniation. Correct ans - ipsi contra average ICP is _____ mmHg. Correct ans - 10 The monro-kellie doctrine states that the total volume of intracranial contents must remain constant, because the cranium is ___ Correct ans - a rigid, non expandable container. The monro-kellie doctrine states that _____ and _____ may be compressed out of the skull providing a degree of buffering. Correct ans - CSF and venous blood. Spinal cord injury has what result in blood pressure? Correct ans - hypotension. This may also occur in terminal brain injury with medullary failure What needs to be cleared before Doll's eye testing is conducted? Correct ans - cervical spine must cleared. What tests should be performed before sedation? Correct ans - GCS and pupillary rxn A midline shift of _____mm or greater on the CT is indicative of need for neurosurgery to evacuate the clot or contusion causing the shift Correct ans - 5mm What type of fluids should be used? Correct ans - hypertonic (ringers lactate or normal saline). NO GLUCOSE. What electrolyte abnormality is associated with brain edema and must be monitored? Correct ans - hyponatremia What are the physiologic consequences of PaCO2 >45? PaCO2 <30? Correct ans - f PaCO2 >45 = vasodilation = inc ICP PaCO2 <30 (hyperventilation) = constriction = ischemia What is the preferred PaCO2 in brain injury? Correct ans - 35 mm Hg If ICP is rapidly increasing, what can be done while preparing for craniotomy? Correct ans - hyperventilation. NOTE: this must be monitored closely and is only done very short periods at a time Does hypertonic saline lower ICP in hypovolemia? Does mannitol lower ICP in hypovolemia? Correct ans - No NO After administration of mannitol what should be monitored closely? Correct ans - ICP! mannitol has a substantial rebound effect on ICP What is the role of muscle relaxants (vecuronium or succinylcholine) in seizures with TBI? Correct ans - NONE. these may mask tonic-clonic seizures and prevent anticonvulsant intervention (30-60 min of seizure = secondary brain injury) What meningeal tear would a CSF leakage of a head laceration indicate? Correct ans - dural tear What is the treatment of any intracranial mass lesion? Correct ans - Must be evacuated by neurosurgeon. transfer if not available. 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? Correct ans - need CT, Xray for trajectory, and angiography. leave the object in place. Removing the object lead to fatal vascular injury. What clinical signs are the criteria for brain death? Correct ans - GCS of 3, nonreactive pupil, absent brainstem reflexes, no spontaneous ventilatory effort Which vertebrae is most susceptible to injury? Correct ans - Cervical. NOTE: in peds this accounts for only 1% of vertebral injury What nerve and cervical spine level would cause apnea and results in death in 1/3 of patient with upper cervical spine injury Correct ans - phrenic nerve C1 At what age do cervical spine differences begin to normalize? at what age does cervical spine look like that of an adult? Correct ans - marked differences in cervical spine occur until age 8 and steadily decline until age 12 when they are similar When a dislocation-fracture of the vertebrae occurs, almost always the result is _____. Correct ans - complete spinal cord injury T/F: the thoracolumbar junction is extremely strong and rarely incurs injury? Correct ans - FALSE: the flexible thoracic meeting the rigid lumbar make this area a common place for injury (15% of all spinal injuries) At what levels do the spinal cord begin and end? Correct ans - begins at foramen magnum at terminal end of the medulla oblongata and end at L1 What is sacral sparing? Correct ans - 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. What function does the dorsal column have? What tests can be done to assess function? Correct ans - position, vibration, light touch, all from same side of body. TESTS: positioning of bent toes/fingers, vibration with tuning fork. What function does the spinothalamic tract have? what tests can be done to assess function? Correct ans - pain and temperature to opposite side of body TESTS: pinprick and light touch What function does the corticospinal tract have? what tests can be done to assess function? Correct ans - Motor power on same side of body TESTS: voluntary muscle contract or involuntary response to pain What type of gastric tube should be placed when cribiform plate fx or mid face fracture is present? Correct ans - orogastric. nasopharyngeal intrumentation is potentially dangerous When fluids must be administered what is the best route, and which type of catheter is best? Correct ans - -peripheral route it preferred with antecubital or forearm. -if peripheral route is not accessable central vein access 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? Correct ans - widening of the symphasis pubis What pulmonary complication is common with blunt trauma and PaCO2 <35? Correct ans - pulmonary contusion. Chest tube is indicated for which of the following? -tension pneumo -hemothorax -ruptured bronchus -pulmonary contusion -mass hemothorax Correct ans - All EXCEPT pulmonary contusion What is the initial bolus for fluid resuscitation when a small child is in shock? Correct ans - 20mL/kg ringers lactate What are the chest tube blood volume output parameters that would require a thoracotomy? Correct ans - >1500mL immediatley evacuated OR 200mL/hr for 2-4hrs NOTE: thoractomy is not indicated unless a surgeon qualified by training and experience is present How can one determine the appropriate tube depth for pediatric intubation? Correct ans - ETT tube size x 3 Ex: 4.0 ETT would be properly positioned at 12 cm from the gums 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. Correct ans - 2-3 cm Fluid resuscitation of an infant begins with _______(amount and type). And then progresses to ______. (amount and type) Correct ans - 20mL/kg Ringers lactate. (may give up to three of these boluses initially) For the third bolus consider PRBCs at 10mL/kg For a patient who is not breathing what intervention is indicated? Correct ans - orotracheal intubation What should be used when vocal chords cannot be visualized on direct laryngoscopy? Correct ans - gum elastic bougie. in place when you feel clicks. can be inserted blindly beyond epiglottis What is the acronym BURP? Correct ans - backward, upward and rightward pressure used in external laryngeal manipulation with orotracheal intubation what is the most common life threatening injury in children? Correct ans - tension pneumothorax What is the most common acid-base disturbance in the injury child and what is it caused by? Correct ans - Respiratory acidosis caused by hypoventilation. >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 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. Correct ans - c hyperglycemia. For a patient bleed profusely from a wound not he medial thigh where should pressure be applied? Correct ans - pressure should b applied directly to the wound. Do not apply pressure to the proximal femoral artery at the groin What is one characteristic shared by all SURVIVORS of traumatic aortic disruption? Correct ans - contained hematoma What does x ray showing widened mediastinum and obliteration of the aortic knob suggest? Correct ans - traumatic aortic disruption What is the sensitivity and specificity of CT in aortic disruption? Correct ans - around 100%. NOTE: CT angiography should only be used to further identify site of disruption (not an initial test) What three X-ray views are most important for a person with multiple trauma? Correct ans - c- spine, chest, pelvis Pulse oximetry provides information about _____ and ____ but does not provide information about ____ Correct ans - 1. O2 sat 2. peripheral perfusion 3. adequacy of ventilation Carboxyhemoglobin levels greater than ___% in burn patient indicate inhalation injury and require transport and/or intubation if transport is prolonged. Correct ans - 10% 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 both arms and legs. His skin is pale and cold. He complains of thirst and difficulty in breathing. 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 bilaterally. He should be treated for what first? Correct ans - hypovolemic shock with fluids. NOTE: airway is OK because he is talking even though he complains of trouble breathing. What is the most important principle in the early management of someone with TBI and increasing ICP? Correct ans - prevent hypotension For a trauma patient that requires a chest tube, the tube is placed and 1600mL of blood returns. What is the next step in management? Correct ans - prepare for exploratory thoracotomy What are the symptoms with anterior crod syndrome? Correct ans - paraplegia and loss of temperature and pain sensation, with preservation of position and vibratory senses and deep pressure sense. WORSE PROGNOSIS What are the symptoms of central cord syndrome? Correct ans - disproportionate motor strength loss greater in upper extremities than lower with varying degree of sensory loss.(the arms and hands are most severely affected) What are the symptoms of Brown-Sequard syndrome? Correct ans - Think of a cut from anterior to posterior of the cord. -ipsilateral motor loss, and loss of position of and vibratory sense -contralateral loss of pain/temperature sense beginning 1-2 levels down from lesion. What is the primary concern in flail chest? Correct ans - pulmonary contusion resulting in hypoxia prevention of hypo perfusion and hypoxia are most important for optimal outcome in _____. Correct ans - TBI What imaging is required for a patient displaying basilar skull fracture: hemotympanum, raccoon eyes, CSF otorrhea, battle sign? Correct ans - CT! also age >65, GCS<15 2hours post injury, suspected depressed skull frac, committing more than two episodes, LOC >5 min, amnesia before impact (more than 30 min), dangerous mechanism. T/F: bony injury in pediatrics is more common than in adults? Correct ans - FALSE: because bones are more pliable you will often find internal organ damage without overlying bone damage. Compare the specificity and sensitivity of DPL and CT in blunt abdominal trauma. Correct ans - DPL- high sens (98), low spec CT - high sens (92-98), high spec (95)