28. Complete the following:

G7 p.860:105mm

a. What antiemetic is appropriate for the head injury patient?

Tigan

G7 p.860:118mm

b. IV fluid consists of_____.

normal saline and 20 mEq KCl

c. The rate is_____.

100 cc/hr

d. Do we run the patient dry? no, that is obsolete

29. True or False. Routine usage of paralytics in trauma patients may

G7 p.860:170 mm

a. cause Guillain-Barré syndrome

false

b. lead to higher incidence of pneumonia and sepsis

true

c. cause syndrome of inappropriate antidiuretic hormone secretion (SIADH)

false

d. cause increased intensive care unit (ICU) stay

true

30. Complete the following regarding hyperventilation:

G7 p.861:105mm

a. It may exacerbate cerebral_____.

ischemia

b. True or False. It may be used prophylactically.

false

c. PCO₂ must never go below_____mm Hg.

30 mm Hg.

d. Hyperventilation reduces_____.

cerebral blood flow

e. It does not necessarily reduce_____.

when PCO₂ < 30 mmHg

f. Hyperventilation may cause_____,

alkalosis

g. which increases protein binding of_____,

calcium

h. which can result in hypo_____

calcemia

i. and show up clinically as_____.

tetany

31. What conditions are associated with increased risk of posttraumatic seizures?

G7 p.862:125mm

Hint: a to i

a. a_____

alcohol abuse

b. b_____

brain injury

c. c_____

cortical contusion

d. d_____

depressed skull fracture

e. e_____

epidural hematoma

f. f_____

fracture of skull

g. G_____

Glasgow coma scale < 10

h. h_____

hematoma

i. i_____

injured brain

32. True or False. The following conditions are associated with increased risk of posttraumatic seizures:

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a. acute subdural, epidural, or intracerebral hematoma

true

b. open depressed skull fracture with parenchymal injury

true

c. seizure within 24 hours after injury

true

d. GCS < 10

true

e. penetrating brain injury

true

f. history of significant alcohol abuse

true

g. cortical (hemorrhagic) contusion on CT

true

33. What is considered hypotension or hypoxia?

G7 p.863:20mm

a. blood pressure (BP) below_____

90 mm Hg

b. PCO₂ below_____

60 mm Hg

34. What chemical in the brain predisposes the head injury patient to disseminated intravascular coagulopathy (DIC)?

thromboplastin

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35. Complete the following:

G7 p.863:125mm

a. Visual system injury occurs in_____% of head injury patients. 5%

b. Can hypopituitarism occur with head injury?

yes

36. The optic nerve can be divided into four segments.

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a. Give the names and the length of each segment.

     i. segment 1 name_____, length_____

intraocular, 1 mm

     ii. segment 2 name_____, length _____

intraorbital, 25 to 30 mm

     iii. segment 3 name_____, length_____

intracanalicular, 10 mm

     iv. segment 4 name_____, length_____

intracranial, 10 mm

b. Which segment is most commonly damaged with closed head injury?

intracanalicular segment

37. A unilateral blown pupil is on the same side of an epidural hematoma or other extraaxial mass lesion what percent of the time?

> 85%

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38. Complete the following regarding burr hole placement for dilated pupil:

G7 p.865:135mm

a. In cases where no CT scan can be done, list the placement for

     i. burr hole #1

temporal ipsilateral

     ii. burr hole #2

temporal contralateral

     iii. burr hole #3

frontal ipsilateral

     iv. burr hole #4

parietal

     v. burr hole #5

posterior fossa

b. How often were these positive?

56%

c. When positive the first burr hole was positive in_____%.

86%

39. What is the relation between the intracranial pressure (ICP) and the cerebral perfusion pressure (CPP)?

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a. Formula

CPP = MAP* – ICP (cerebral perfusion pressure is the mean arterial pressure minus the intracranial pressure)

b. If your computer does not give you mean arterial pressure (MAP) how can you calculate it? (Hint: dds/3)

*MAP = 1 systolic plus 2 diastolic divided by 3

40. Answer the following:

G7 p.866:167mm

a. What is the normal CPP in adults?

> 50 mm Hg

b. What is the recommended CPP in head trauma?

> 60 mm Hg

c. If CPP is kept in good range is ICP above 20 mm Hg well tolerated?

no, it is detrimental

41. Complete the following:

G7 p.867:15mm

a. The modified_____ hypothesis states that

Monro-Kellie

b. the sum of the intracranial volumes of_____,_____, and_____

blood, brain, and CSF

c. and other components is_____.

constant

d. An increase in any one must be_____

offset

e. by an equal_____ in another

decrease

f. or else_____ will rise.

pressure

g. Pressure is_____ _____throughout the intracranial cavity.

distributed evenly

42. Complete the following:

G7 p.868:50mm

a. At what level of ICP do we treat intracranial (IC) hypertension (HTN)?

20 or greater

b. What is the mortality rate for those whose ICP is kept below 20 mm Hg?

20%

c. If ICP is higher mortality is_____.

also much higher

43. What is considered a “deadly” ICP (i.e., likely to be fatal if not controlled)?

above 25 to 30 mm Hg

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44. CT finding may be correlated with a risk of intracranial hypertension.

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a. After a closed head injury, what % of patients with abnormal CT will have intracranial hypertension?

60%

b. What % of patients with normal CT will have intracranial hypertension?

13%

c. Give three risk factors for intracranial hypertension for patients with normal CT.

     i. age above_____

40 years

     ii. blood pressure below_____

90 mm Hg

     iii. neurological status

decerebration/decortication

d. With normal CT plus two risk factors_____% will have ICP elevation.

60%

e. With normal CT plus only one risk factor_____% will have ICP elevation.

4%

45. Complete the following about ICP monitoring:

G7 p.868:130mm

a. One of the criteria for placement of an ICP monitor is a Glasgow coma scale (GCS) score below_____

8

b. and a CT that is_____, or two of the following:

abnormal

     i. age above_____

40

     ii. systolic blood pressure (SBP) below_____

90

     iii. motor exam shows_____ or_____ _____

decerebrate or decorticate posturing

c. may discontinue monitor when ICP is normal for_____ to_____ hours

48 to 72 hours

46. Complete the following about ICP monitoring:

G7 p.869:75mm

a. A criterion for discontinuing ICP monitoring is normal ICP for_____ to_____ hours.

48 to 72 hours

b. Risk of hemorrhage from ICP monitor placement is

     i. _____% requiring surgery and

0.5 to 2.5

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     ii. _____% incidental finding

1.4

47. True or False. In regard to ICP monitoring, it is permissible to

G7 p.869:145mm

a. use antibiotics

true

b. not use antibiotics

true

c. place monitor in ICU

true

d. place monitor in OR

true

e. Patients who develop hemorrhage while ICP is being placed is 1.4%.

true

48. Complete the following:

G7 p.869:175mm

a. Is the prophylactic change of external ventricular drain 5 days or less after insertion associated with a significant reduction in infection rates?

no

b. Do we need to change the site every 5 days?

no

49. Complete the following regarding conversion of mm Hg and cm H₂O:

G7 p.870:160mm

a. 1 mm Hg equals_____cm of H₂O

1.36 cm

b. 1 cm H₂O equals_____mm of Hg

0.735 mm

c. External auditory canal correlates with what intracranial structure?

foramen of Monro

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50. Lundberg A waves are defined by

G7 p.872:130mm

a. ICP of_____

> 50 mm Hg

b. duration of_____

5 to 20 minutes

c. plus_____

increase in MAP

51. Lundberg B waves are defined by

G7 p.872:150mm

a. ICP of_____

10 to 20 mm Hg

b. duration of_____

30 seconds to 2 minutes

c. varies with_____

periodic respiration

52. Regarding IVC problems, when open to drain, pressure reading from transducer is_____ _____.

not meaningful

G7 p.873:150mm

53. True or False. If an external ventricular catheter no longer functions, all of the following can be performed safely:

G7 p.874:30mm

a. lower drip nozzle

true

b. verify clamps are open and air filter is dry

true

c. flush distal tubing with saline

true

d. flush IVC with up to 5 mL of saline under gentle pressure

false (Up to 1.5 mL of preservative-free saline can be used.)

54. True or False. Possible causes of an ICP wave form that is dampened include all of the following:

G7 p.874:65mm

a. occlusion of the catheter proximal to the transducer

true

b. catheter pulled out of ventricle

true

c. collapsed ventricle

true

d. air in the system

true

e. intracranial hypertension

false

55. What should happen to the ICP wave form in a patient with a decompressive craniectomy?

It should be dampened.

G7 p.874:88mm

56. Answer the following about arteriojugular venous oxygen content differences:

G7 p.874:145mm

a. True or False. In head trauma the following arteriojugular venous difference in oxygen content (AVDO₂) difference indicates global cerebral ischemia and cerebral hyperemia, respectively:

     i. > 9 mL/dL, < 4 mL/dL

true(With ischemia, the brain is oxygen starved, so more oxygen is extracted and the difference in O₂ between the arterial and venous blood is greater. The opposite is true in hyperemia.)

     ii. < 4 mL/dL, > 9 mL/dL

false

     iii. > 12 mL/dL, < 6 mL/dL

false

     iv. < 6 mL/dL, > 12 mL/dL

false

b. Another term for cerebral hyperemia is_____ _____.

luxury perfusion

57. Complete the following about brain tissue oxygen tension (pBtO₂):

G7 p.874:165mm

a. Treatment threshold is pBtO₂ less than_____ mmHg.

15

b. Death occurs with brief drop below_____ mm Hg.

6

c.

     i. Level of less than_____ mm Hg

10

     ii. For more than_____minutes increases the risk of bad outcome

30

d. A probe should be placed in a patient with

G7 p.874:182mm

     i. traumatic brain injury on the_____ _____side

least injured

     ii. subarachnoid hemorrhage near_____

vasospasm

     iii. intracerebral hemorrhage near the_____

hematoma

58. True or False. All of the following are general goals of ICP management:

G7 p.877:18mm

a. keep ICP < 20 mm Hg

true

G7 p.877:62mm

b. keep CPP > 60 mm Hg (used to be > 70 mm Hg)

true

G7 p.877:125mm

c. avoid SBP < 90 mm Hg

true

d. avoid PO₂ < 60 mm Hg

true

e. keep PCO₂ < 30 mm Hg

false (PCO₂ should be brought down below 30 mm Hg only in an acute ICP crisis and then only briefly.)

59. True or False. The contraindications for administration of mannitol are the following:

G7 p.877:100mm

a. hypovolemia

true

b. hypotension

true

c. serum osmol > 320

true

d. cerebral infarction

false

e. ICP < 20 mm Hg

true

60. Complete the following about ICP treatment measures:

G7 p.878:90mm

a. Which antacid should be avoided if the patient is receiving phenytoin?

cimetidine

b. Why?

drug—drug interaction

c. What occurs?

dramatic elevation of drug concentration

d. Due to?

inhibition of hepatic cytochrome oxidase

e. The best choice may be_____.

sucralfate (Carafate)

61. True or False. Fever should be controlled aggressively in the setting of elevated ICP.

true

G7 p.878:100mm

62. True or False. In traumatic brain injury, the following statements are correct:

G7 p.878:120mm

a. Pressors (e.g., dopamine) should be avoided because there is increased risk of hemorrhage.

false (The blood pressure should be maintained with pressors, if necessary.)

b. The IV fluid of choice is isotonic saline + 20 mEq KCl/L.

true

c. If mannitol is required the patient should be kept slightly hypovolemic to allow the serum osmolality to rise.

false (Hypovolemia decreases cerebral blood flow and may elevate ICP through autoregulatory cerebral vasodilation.)

d. The patient’s temperature is not important.

false

63. Answer the following:

G7 p.878:118mm

a. Is it okay to use lactated Ringer solution for head injury patients?

no

b. Why or why not?

it is hypotonic

64. True or False. IV fluids in the head-injured patient

G7 p.878:130mm

a. should be sufficient to avoid hypotension.

true

b. should be limited to “run the patient dry.”

false

c. Euvolemia should be maintained even if mannitol is required.

true

65. True or False. The following can exacerbate intracranial hypertension:

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a. hyperglycemia

true (makes edema worse)

b. hyperventilation

false

c. hyperparathyroidism

false

d. cholestasis

false

66. Complete the following about the use of mannitol:

G7 p.879:98mm

a. Useful for intracranial

hypertension

b.

     i. Usual dose advised is_____ gm/kg

0.25 to 1

     ii. Infused as a_____

bolus

     iii. Over_____ minutes

20

c.

     i. This is followed by_____ gm/kg

0.25

     ii. Infused over_____ minutes

20

d. If ICP remains over_____

20

e. Must cease use if serum osmolarity rises above_____ mOsm/L

320

67. True or False. Second-tier therapy for persistent intracranial hypertension includes all of the following:

G7 p.880:15mm

a. high-dose barbiturate therapy

true

b. hyperventilation

true

c. hypothermia

true

d. decompressive craniectomy

true

68. True or False. Hypothermia as a “second tier” therapy for persistent IC HTN may be associated with all of the following:

G7 p.880:25mm

a. decreased cardiac index

true

b. thrombocytopenia

true

c. elevated creatinine clearance

true

d. seizures

false (Seizures are more apt to occur with fever, not hypothermia.)

e. pancreatitis

true

69. To treat refractory increased ICP a decompressive craniectomy

G7 p.880:35mm

a. must be at least_____cm in diameter

12 cm

b. should include a_____

duraplasty

70. Complete the following:

G7 p.880:65mm

a. True or False. In decompressive surgery for head injury, the following set of values describes the appropriate limits of temporal tip resection for the dominant and nondominant temporal lobes, respectively:

     i. 1 to 2 cm, 3 to 4 cm

false

     ii. 2 to 4 cm, 8 to 10 cm

false

     iii. 4 to 5 cm, 6 to 7 cm

true

     iv. 6 to 8 cm, 10 to 12 cm

false

     v. 0 cm, 4 to 5 cm

false

b. What other lobectomy may be performed?

frontal lobectomy

c. Are these very helpful?

they have shown no great therapeutic promise

71. Complete the following about PCO₂:

G7 p.881:82mm

a. Normocarbia is between_____ and_____ mm Hg.

35 to 40

b. Usual hyperventilation range is between_____ and_____ mm Hg.

30 to 35

c.

     i. This will reduce ICP by_____to_____%

25 to 30%

     ii. in about_____seconds

30

     iii. and will last for_____minutes.

5 to 20

d. A level of PCO₂ below_____mm Hg risks ischemia.

30

72. Complete the following about PCO₂ in the head-injured patient:

G7 p.881:95mm

a. Normocarbia is considered to be_____mm Hg.

35 to 40 mm Hg—use routinely

b. Hyperventilation to PCO₂ of_____ mm Hg.

30 to 35 mm Hg—brief use only

73. True or False. When using mannitol it is best to

G7 p.882:23mm

a. use intermittent bolus

true

b. use continuous infusion

false

c. use doses of 3g/kg

false

d. avoid hypotension below 90 systolic

true

e. maintain euvolemia

true

f. monitor serum osmolality

true

g. limit serum osmolality to below 320mOsm/L

true

74. True or False. Mannitol lowers the ICP within a few minutes of administration by

G7 p.882:47mm

a. decreasing the production of cerebrospinal fluid (CSF)

false

b. reducing the hematocrit and blood viscosity

true (The rapid effect of mannitol is not explained by an osmotic effect. Instead, mannitol increases the intravascular volume and lowers the hematocrit, thus lowering the blood viscosity. The brain responds to the increased blood flow through autoregulatory vasoconstriction, decreasing the volume of the intravascular blood compartment in the brain and lowering the ICP.)

c. causing an immediate diuresis and decrease in the intravascular volume

false

d. raising the serum osmolarity to establish an osmotic gradient between the blood and brain

false (Osmotic effect takes 15 to 30 minutes.)

75. Mannitol works by two mechanisms.

G7 p.882:69mm

a. Mechanism l

     i. This is a rapid mechanism that_____ _____ _____ by

increases plasma volume by dilution

     ii. which improves_____

rheology

     iii. thereby improving_____ and_____delivery,

CBF and O₂

     iv. which produces_____.

vasoconstriction

b. Mechanism II

     i. This is a slower_____ _____.

osmotic effect

     ii. Hypertonic plasma draws in_____ _____

edema fluid

     iii. from the_____,

brain

     iv. which takes_____ to_____ minutes to begin.

15 to 30

76. The protocol for mannitol administration is

G7 p.882:100mm

a. bolus

     i. dose_____ per kilogram

1 gram

     ii. infuse over_____ minutes

30 (rapidly)

     iii. onset_____ minutes

1 to 5

     iv. peaks_____

minutes 20 to 60

b. long term

     i. dose_____ per kilogram

0.25 to 0.50 gram

     ii. infuse over_____ minutes

30 to 60

77. True or False.

G7 p.882:115mm

a. Administer mannitol best as a bolus.

true

b. Administer mannitol best as a continuous drip.

false

c. A continuous drip aggravates vasogenic edema.

true

d. It is better to stop mannitol by tapering the dose.

true

e. It is better to stop mannitol when it is no longer needed.

false

f. Taper prevents rebound.

true

G7 p.882:128mm

78. Three drugs used in the same patient can produce a fatal syndrome.

G7 p.882:130mm

a. Name the three medications.

(Hint: Dms)

     i. D_____

Dilantin

     ii. m_____

mannitol

     iii. s_____

steroids

b. Name the syndrome: h_____ n_____ s_____

hyperosmolar nonketotic state

79. What is the mechanism of renal injury associated with mannitol therapy for high ICP (serum Osm > 320 mOsm/L)?

acute tubular necrosis

G7 p.882:143mm

80. True or False. Glucocorticoids have little impact on cytotoxic cerebral edema due to head trauma.

true (at least not at the doses that have been tried)

G7 p.883:97mm

81. True or False. Steroids are not recommended to treat patients with traumatic brain injury because

G7 p.883:107mm

a. they work on vasogenic edema of tumors.

true

b. they do not work on cytotoxic edema of traumatic brain injury (TBI).

true

c. they have significant side effects.

true

d. they increase the incidence of

     i. coagulopathies

true

     ii. hyperglycemia

true

     iii. infection

true

     iv. hypotension

false

82. True or False. Theoretical benefits of barbiturates in head injury include the following:

G7 p.883:158mm

a. vasoconstriction in normal areas

true

b. decreased metabolic demand

true

c. free radical scavenging

true

d. reduced intracellular calcium

true

e. reduced extracellular calcium

false

f. stabilized lysosomal activity

true

83. True or False.

G7 p.883:180mm

a. When using pentobarbital for ICP control, the limiting factor is systemic hypertension.

false (Hypotension due to reduction of sympathetic tone is the limiting factor.)

b. In those patients who respond mortality is lower.

true (Mortality in those who respond is 33%; mortality in those who do not respond is 75%.)

84. Complete the following about barbiturate coma:

G7 p.884:25mm

a. The goal is

     i. to reduce the cerebral metabolic rate of_____

CMRO₂

     ii. and cerebral b_____ f_____.

blood flow

b. The protocol is pentobarbital IV

     i. A loading dose of_____ mg/kg

10

     ii. Over_____ minutes

30

     iii. Then_____ mg/hr for 3 doses

5

     iv. Then_____ mg/hr

1

85. The goals of barbiturate therapy are

G7 p.885:30mm

a. electroencephalogram (EEG) showing_____ _____.

burst suppression

b. serum level of_____% pentobarbital.

3 to 5 mg%

86. Complete the following:

G7 p.885:30mm

a. If a patient is treated with pentobarbital coma how long does it take for baseline neurofunction to return?

2 days

b. What decreased level of pentobarbital in the blood will permit a valid brain death assessment?

less than 10 μg/mL

87. Complete the following:

G7 p.885:50mm

a. The loading dose of thiopental is_____ mg/kg over _____,

5 mg/kg over 10 minutes

b. followed with_____ mg/kg for_____.

5 mg/kg for 24 hours

88. Complete the following:

G7 p.885:87mm Also G7 p.25:25mm

a. The most commonly reported side effect of propofol is _____.

hypotension—due to myocardial depression (rarely causes pancreatitis)

b. It is used for neuroprotection in _____.

aneurysm surgery

89. True or False. All of the following are indications for elevating a depressed skull fracture:

G7 p.885:165mm

a. fracture depressed full thickness of skull

true

b. deficit relating to underlying brain injury

true

c. open fracture

false (Depressed bone compressing sinus is not an indication for elevating that depressed fracture.)

d. dural laceration

true

e. depressed bone compressing sinus

false

90. True or False. Regarding skull fracture:

G7 p.886:95mm

a. There is no evidence that elevating a depressed skull fracture will reduce the subsequent development of seizure.

true

b. CN VI palsy can occur after a clivus fracture.

true

c. Antibiotics should incontrovertibly be given in the case of basal skull fracture, especially with CSF fistula.

false (Giving antibiotics with skull fracture, even CSF leak, is controversial. Very limited data may suggest that the incidence of meningitis is not reduced and that resistant organisms may be selected by routine use of antibiotics.)

d. Intracranial passage of a nasogastric (NG) tube carries 64% mortality.

true

e. Recall that the SSS is often to the_____ of the sagittal suture.

right

G7 p.887:128mm

f. Bone fragments that may have lacerated a sinus should be removed.

last

G7 p.887:146mm

91. True or False. CT is very sensitive in the detection of basal skull fractures.

false (Plain x-ray and clinical exam are more sensitive.)

G7 p.887:180mm

92. Complete the following regarding basal skull fractures:

G7 p.888:20mm

a. True or False. Pneumocephalus may be seen on plain skull x-rays.

true

b. Postauricular ecchymosis is called_____.

Battle sign

c. True or False. Anosmia can be associated with temporal bone fractures.

false (with frontal bone fracture)

d. Sixth nerve palsy can occur with_____ fracture.

clival

93. True or False. The following are clinical signs of basal skull fracture:

G7 p.888:30mm

a. CSF otorrhea or rhinorrhea

true

b. hemotympanum

true

c. depressed level of consciousness

false

d. Battle sign

true

e. injury to cranial nerve VII

true

94. True or False. The following cranial nerves can be injured in basal skull fractures:

G7 p.888:50mm

a. CN I

true

b. CN II

true

c. CN III

true

d. CN IV

true

e. CN V

true

f. CN VI

true

g. CN VII

true

h. CN VIII

true

     i. CN IX

true

j. CN X

true

k. CN XI

true

l. CN XII

true

95. True or False. Complications seen with basal skull fractures include

G7 p.888:115mm

a. traumatic aneurysms

true

b. carotid cavernous fistula

true

c. meningitis

true

d. facial palsy

true

e. CSF fistula

true

96. True or False. Otorrhea and rhinorrhea are clinical indications for emergent treatment of basal skull fractures.

false (Only persistent CSF leaks from basal skull fractures warrant investigation and treatment.)

G7 p.888:120mm

97. Complete the following regarding basilar skull fracture involving the petrous part of the temporal bone:

G7 p.888:163mm

a. longitudinal fracture

     i. incidence is_____%

70 to 90%

     ii. complication_____

leak of CSF

b. horizontal (transverse) fracture