Traumatic Brain InjuryCase Scenario Workshop
Maurizio Berardino
Neuroanesthesia and Intensive Care
Neuroscience Department
San Giovanni Battista Hospital
Torino, Italy
Maurizio Berardino, MD
Overview
§ Initial assessment
§ ABCs
§ Neurologic evaluation
§ Treatment
§ Transport
§ Neurologic Deterioration
Maurizio Berardino, MD
Case Presentation
§ 21 year old male
§ Unrestrained driver, single vehicle MVC
§ 70 KPH, sedan vs. concrete barrier
§ No airbag
§ Windshield starred
Maurizio Berardino, MD
Primary Survey
§ The patient had a clear airway and was speaking spontaneously
§ Bilateral breath sounds
§ A strong radial pulse at 100
§ BP 120/80
Maurizio Berardino, MD
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?
Maurizio Berardino, MD
Glasgow Coma ScaleVerbal Response
oriented - 5
confused - 4
inappropriate – 3
incomprehensible - 2
none - 1
Motor Response
obeys - 6
localizes - 5
withdraws - 4
abnormal flexion - 3
extension - 2
none - 1
Eye Opening
spontaneous - 4
to speech -3
to pain - 2
none - 1
Full verbal score (5) is assigned for crying after stimulation in children < 2yrs.
Maurizio Berardino, MD
Priorities ?
§ Assessment / Treatment– Airway– Breathing – Circulation– Cervical Spine– Disability– Exposure
Maurizio Berardino, MD
Secondary Survey
§ No change in A, B, C, D
§ Mild bleeding left forehead
§ No other injuries discovered
Maurizio Berardino, MD
Treatment / Interventions
§ Interventions– IV
– 02 NRB FM
§ Immobilization– C spine collar– Back board
Maurizio Berardino, MD
Transport Issues
§ Destination– Emergency Department– Trauma Center
§ Status / Expediency
Maurizio Berardino, MD
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?
Maurizio Berardino, MD
Priorities ?
§ Assessment / Treatment– Airway– Breathing – Circulation– Cervical Spine– Disability– Exposure
Maurizio Berardino, MD
Glasgow Coma Scale
§ En route, 10 minutes from destination hospital
§ Eye – no opening
§ Motor – flexion
§ Verbal – non-verbal
§ What is his GCS score?
Maurizio Berardino, MD
Priorities ?
§ Assessment / Treatment– Airway– Breathing – Circulation– Cervical Spine– Disability– Exposure
Maurizio Berardino, MD
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)
Maurizio Berardino, MD
Treatment / Interventions
§ Indications for intubation / hyperventilation– Dilated unreactive pupil (s)– Extensor posturing
Maurizio Berardino, MD
Ventilation
§ Normal ventilation is defined as approximately:– 10 breaths per minute (bpm) for adults– 20 bpm for children– 25 bpm for infants
Maurizio Berardino, MD
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
Maurizio Berardino, MD
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%
Maurizio Berardino, MD
Agitation (Causes)
§ Hypoxemia§ Hypovolemia§ Drugs§ Alcohol§ Hypoglycemia§ Patient discomfort§ Traumatic brain injury
Maurizio Berardino, MD
Hypoglycemia
§ Can be a cause of trauma or accident
§ Pupillary asymmetry
§ Altered mental status
§ Focal neurologic deficits
§ Diaphoresis
§ Coma
Maurizio Berardino, MD
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