Preventing Brain Injury: Understanding Lesions, Dura Mater, Arteries, and Veins, Exams of Nursing

Download Preventing Brain Injury: Understanding Lesions, Dura Mater, Arteries, and Veins and more Exams Nursing in PDF only on Docsity! ADVANCED ATLS WRITTEN REVIEW EXAM QUESTIONS AND ANSWERS What is the primary goal of treating TBI? How is this done? - CORRECT ANSWER -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 ANSWER -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 ANSWER -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 ANSWER -dura mater, arachnoid mater, pia mater What does the dura mater adhere firmly to? - CORRECT ANSWER -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 ANSWER -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 ANSWER -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 ANSWER -meningeal arteries. What is the most commonly injured meningeal artery and where is it located? - CORRECT ANSWER - middle meningeal artery. Located over the temporal fossa T/F: the arachnoid mater is fused to the dura mater? - CORRECT ANSWER -FALSE: not attached. This produces a potential space for a subdural hematoma In a subdural hematoma, what is the cause? - CORRECT ANSWER -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 ANSWER -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 ANSWER -subarachnoid. The ____ and _____ contain the reticular activating system which is responsible for ____. - CORRECT ANSWER -midbrain and upper pons state of alertness What important function resides in the medulla? - CORRECT ANSWER -cardiorespiratory centers. What important functions are in the following brain segments: What nerve palsy may occur with basilar skull fracture? - CORRECT ANSWER -seventh nerve. A GCS of ___ is accepted definition of coma? - CORRECT ANSWER -8 or less How do you assess a GCS of someone with asymmetric responses? - CORRECT ANSWER -Use the best possible because this will be the best predictor of outcome Basilar fractures of the skull usually require what type of imaging? - CORRECT ANSWER -this requires CT with bone-window setting. What are the typical clinical signs of basilar skull fractures? - CORRECT ANSWER -1.periorbital ecchymosis (raccoon eyes) 2. retroauriculor ecchymosis (battle sign) 3. CSF leak from nose or ears 4. 7th or 8th CN dysfunction (facial paralysis and hearing loss) What should be a primary consideration for any patient with a skull fracture, especially a linear skull fracture? - CORRECT ANSWER -hematoma. linear skull fracture increases likelihood of intracranial hematoma by about 400x What mechanism is common with diffuse axonal injury and what is the likely outcome? - CORRECT ANSWER -these injury often occur with high velocity or deceleration injures. They appear as diffuse cerebral hemorrhage often between grey and white matter. These are associated with variable but often poor outcomes. Epidural hematomas often occur in the _____ area of the skull and result from a tear of the _______ arteries. - CORRECT ANSWER -temporal middle meningeal artery What is the classic presentation of a epidural hematoma? - CORRECT ANSWER -a lucid interval between time of injury and neurologic a deterioration. What are more common brain injury: epidural or subdural? - CORRECT ANSWER -subdural 30% epidural 0.5% Subdural hematoma occur from tear of _________. - CORRECT ANSWER -bridging vessels of the cerebral cortex Contusion occur in ___% of TBI. They often occur in _____ or ______ lobes of brain. They may coalesce to form ______ in as many as 20$%. - CORRECT ANSWER -20-30% frontal or temporal intracerebral hematoma. What is the imaging protocol for a patient with cerebral contusion? - CORRECT ANSWER -get CT at presentation. then get another within 24 hours to assess for coalesced hematoma. What factors would require a CT in minor brain injury? - CORRECT ANSWER -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 How long after discharge should patient with mild brain injury be observed by friend? - CORRECT ANSWER -24 hours What type of brain injury requires serial GCS? - CORRECT ANSWER -ALL. minor. moderate. major What imaging is done in all patient with moderate brain injury? - CORRECT ANSWER -CT What factor of ABCDE must be monitored closely in moderate brain injury? - CORRECT ANSWER -Airway and breathing. rapid deterioration may occur. hypoventilation and hypercapnia may ensue requiring intubation. close monitoring in ICU is required. What should immediately follow the secondary survey in major/severe brain injury? - CORRECT ANSWER -CT. REMEMBER: CT should never delay patient transfer When assessing ABCDE of severe brain injury, when does DPL or FAST come before neuro exam? - CORRECT ANSWER -if the systolic blood pressure cannot be brought above 100, DPL or FAST is done first as to assess source of hypotension Spinal cord injury has what result in blood pressure? - CORRECT ANSWER -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 ANSWER -cervical spine must cleared. What tests should be performed before sedation? - CORRECT ANSWER -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 ANSWER -5mm At what levels do the spinal cord begin and end? - CORRECT ANSWER -begins at foramen magnum at terminal end of the medulla oblongata and end at L1 What is sacral sparing? - CORRECT ANSWER -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 ANSWER -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 ANSWER -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 ANSWER -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 ANSWER -orogastric. nasopharyngeal intrumentation is potentially dangerous When fluids must be administered what is the best route, and which type of catheter is best? - CORRECT ANSWER --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 ANSWER -widening of the symphasis pubis What pulmonary complication is common with blunt trauma and PaCO2 <35? - CORRECT ANSWER - pulmonary contusion. Chest tube is indicated for which of the following? -tension pneumo -hemothorax -ruptured bronchus -pulmonary contusion -mass hemothorax - CORRECT ANSWER -All EXCEPT pulmonary contusion What is the initial bolus for fluid resuscitation when a small child is in shock? - CORRECT ANSWER - 20mL/kg ringers lactate What are the chest tube blood volume output parameters that would require a thoracotomy? - CORRECT ANSWER ->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 ANSWER -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 ANSWER -2-3 cm Fluid resuscitation of an infant begins with _______(amount and type). And then progresses to ______. (amount and type) - CORRECT ANSWER -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 ANSWER -orotracheal intubation What should be used when vocal chords cannot be visualized on direct laryngoscopy? - CORRECT ANSWER -gum elastic bougie. in place when you feel clicks. can be inserted blindly beyond epiglottis What is the acronym BURP? - CORRECT ANSWER -backward, upward and rightward pressure used in external laryngeal manipulation with orotracheal intubation what is the most common life threatening injury in children? - CORRECT ANSWER -tension pneumothorax What is the most common acid-base disturbance in the injury child and what is it caused by? - CORRECT ANSWER -Respiratory acidosis caused by hypoventilation. What are the options to establish an airway when bag-mask ventilation and attempts at orotracheal intubation fail for a child? - CORRECT ANSWER -LMA, or intubating LMA, or needle cricothyroidotomy. -needle-jet insufflation is an appropriate temporizing technique for oxygenation but does not provide adequate ventilation. NOTE: surgical cric is RARELY indicated for infants an small children. usually it is an adoption when the cricothyroid membrane is easily palpable around the age of 12. What is another name for Central Venous Pressure? When is it elevated? - CORRECT ANSWER -Basically the same as Right atrial pressure. -Elevated in cardiac failure, tamponade, tension pneumo, disrupted thoracic aorta. What would be expected on ABG abnormalities for pulmonary contusion? - CORRECT ANSWER -PaO2 <65 mm Hg (sat <90) would suggest need for intubation and in the presence of flail chest is more suggestive t/f vomitus in the posterior oropharynx suggests esophageal intubation. - CORRECT ANSWER -false. signs include: epigastric fullness, absent end title CO2, absent breath sounds, audible borborygmi sounds over abdomen t/f: major head injury rarely causes shock by itself - CORRECT ANSWER -true What are the vital signs to be expected when ICP increases? - CORRECT ANSWER -decreased respirations and HR, increased systolic and pulse pressure Urethral injury should be suspected in the presence of what three things? - CORRECT ANSWER -1. blood at the meatus 2. perineal ecchymosis 3. high riding or non-palpable prostate What test is used to confirm the integrity of the urethra before a catheter is inserted? - CORRECT ANSWER -retrograde urethrogram What physical exam is essential before passing a urethral catheter - CORRECT ANSWER -examine the rectum and perineum What is the best guide for adequate fluid resuscitation in a burn patient? - CORRECT ANSWER -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 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 ANSWER -c hyperglycemia. For a patient bleed profusely from a wound not he medial thigh where should pressure be applied? - CORRECT ANSWER -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 ANSWER - contained hematoma What does x ray showing widened mediastinum and obliteration of the aortic knob suggest? - CORRECT ANSWER -traumatic aortic disruption What is the sensitivity and specificity of CT in aortic disruption? - CORRECT ANSWER -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 ANSWER -c- spine, chest, pelvis Pulse oximetry provides information about _____ and ____ but does not provide information about ____ - CORRECT ANSWER -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 ANSWER -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 ANSWER -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 ANSWER -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 ANSWER -prepare for exploratory thoracotomy What are the symptoms with anterior crod syndrome? - CORRECT ANSWER -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 ANSWER -disproportionate motor strength loss greater in upper extremities than lower with varying degree of sensory loss.(the arms and hands are most severely affected)