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Questions and Answers
What Glasgow Outcome Score indicates a good recovery?
What Glasgow Outcome Score indicates a good recovery?
- 2
- 1
- 5 (correct)
- 4
Brain death can be declared if there is a possibility for recovery of brain function.
Brain death can be declared if there is a possibility for recovery of brain function.
False (B)
List two criteria used to certify brain death.
List two criteria used to certify brain death.
GCS of 3, nonreactive pupils
The absence of __________ is one of the criteria for declaring brain death.
The absence of __________ is one of the criteria for declaring brain death.
Match the following Glasgow Outcome Scores with their descriptions:
Match the following Glasgow Outcome Scores with their descriptions:
What is the primary indication for performing a CT scan in adults within 1 hour after a head injury?
What is the primary indication for performing a CT scan in adults within 1 hour after a head injury?
Children with a Glasgow Coma Scale (GCS) of less than 15 two hours post-injury do not require CT imaging.
Children with a Glasgow Coma Scale (GCS) of less than 15 two hours post-injury do not require CT imaging.
What does GCS stand for?
What does GCS stand for?
In adults, a GCS of _____ or less is an indication to involve a neurosurgeon.
In adults, a GCS of _____ or less is an indication to involve a neurosurgeon.
Match the following indicators with their corresponding time for CT scan in adults:
Match the following indicators with their corresponding time for CT scan in adults:
What is a common clinical finding in an elderly patient with chronic subdural hemorrhage post trivial injury?
What is a common clinical finding in an elderly patient with chronic subdural hemorrhage post trivial injury?
The Kernohan notch phenomenon can result in left-sided hemiparesis due to right-sided brain compression.
The Kernohan notch phenomenon can result in left-sided hemiparesis due to right-sided brain compression.
What investigation is primarily used to diagnose subdural hemorrhage?
What investigation is primarily used to diagnose subdural hemorrhage?
The most common cause of subarachnoid hemorrhage (SAH) is __________.
The most common cause of subarachnoid hemorrhage (SAH) is __________.
Match the following criteria with their respective indications for craniotomy/burr hole:
Match the following criteria with their respective indications for craniotomy/burr hole:
Which method is considered the best for calculating burn percentage?
Which method is considered the best for calculating burn percentage?
1st-degree burns heal without scarring in 2-3 weeks.
1st-degree burns heal without scarring in 2-3 weeks.
What color and tenderness describe a first-degree burn?
What color and tenderness describe a first-degree burn?
The zone of burn characterized by irreversible damage is called the ______.
The zone of burn characterized by irreversible damage is called the ______.
Match the degrees of burns with their description:
Match the degrees of burns with their description:
What is a characteristic of deep burns?
What is a characteristic of deep burns?
The stasis zone is characterized by well-managed tissue that promotes healing.
The stasis zone is characterized by well-managed tissue that promotes healing.
What is the healing time for superficial burns?
What is the healing time for superficial burns?
Which of the following parameters should be maintained in head injury patients? (Select all that apply)
Which of the following parameters should be maintained in head injury patients? (Select all that apply)
Steroids are recommended for managing raised intracranial pressure in all cases of head injury.
Steroids are recommended for managing raised intracranial pressure in all cases of head injury.
What is the recommended minimum mean arterial pressure (MAP) for head injury patients?
What is the recommended minimum mean arterial pressure (MAP) for head injury patients?
In patients with mild head injury, verbal and written head injury advice is part of the discharge criteria, alongside a GCS of _____ and no focal deficits.
In patients with mild head injury, verbal and written head injury advice is part of the discharge criteria, alongside a GCS of _____ and no focal deficits.
What is the primary mechanism of a concussion?
What is the primary mechanism of a concussion?
Match the following interventions with their purpose in trauma management:
Match the following interventions with their purpose in trauma management:
Diffuse Axonal Injury (DAI) is the mildest type of brain injury.
Diffuse Axonal Injury (DAI) is the mildest type of brain injury.
What GCS score range indicates a moderate brain injury?
What GCS score range indicates a moderate brain injury?
A rise in __________ can lead to secondary brain injury.
A rise in __________ can lead to secondary brain injury.
Match the following types of brain injuries with their characteristics:
Match the following types of brain injuries with their characteristics:
Which condition is characterized by a lucid interval following a head injury?
Which condition is characterized by a lucid interval following a head injury?
Chronic subdural hematoma typically affects elderly patients after trivial injuries.
Chronic subdural hematoma typically affects elderly patients after trivial injuries.
What is the formula for calculating Cerebral Perfusion Pressure (CPP)?
What is the formula for calculating Cerebral Perfusion Pressure (CPP)?
In the context of head trauma, a ______________ injury is associated with coma and no signs of recovery.
In the context of head trauma, a ______________ injury is associated with coma and no signs of recovery.
Match the following features with their corresponding conditions:
Match the following features with their corresponding conditions:
Which of the following are signs of airway burns?
Which of the following are signs of airway burns?
Eschar around the chest does not affect chest expansion.
Eschar around the chest does not affect chest expansion.
What is the immediate required management for airway burns?
What is the immediate required management for airway burns?
Inhalation of smoke can lead to __________ due to airway obstruction.
Inhalation of smoke can lead to __________ due to airway obstruction.
Match the phases of bronchopneumonia with their causative organisms:
Match the phases of bronchopneumonia with their causative organisms:
What is the main fluid resuscitation formula used for burns?
What is the main fluid resuscitation formula used for burns?
Crystalloids should be administered after 24 hours of burn injury.
Crystalloids should be administered after 24 hours of burn injury.
What is the target urine output for infants and young children after a burn injury?
What is the target urine output for infants and young children after a burn injury?
The amount of fluid required in 24 hours is calculated using the formula 4 x Body weight (kg) x % TBSA of burns, excluding __________ burns.
The amount of fluid required in 24 hours is calculated using the formula 4 x Body weight (kg) x % TBSA of burns, excluding __________ burns.
Match the following categories of burns with their corresponding adjusted fluid rates:
Match the following categories of burns with their corresponding adjusted fluid rates:
What is the most common type of bleed following head trauma?
What is the most common type of bleed following head trauma?
A lucid interval is a definitive diagnostic feature of Extradural Hemorrhage.
A lucid interval is a definitive diagnostic feature of Extradural Hemorrhage.
What imaging technique is considered the initial choice for diagnosing intracranial hemorrhages?
What imaging technique is considered the initial choice for diagnosing intracranial hemorrhages?
The middle meningeal artery is responsible for bleeding in __________ hemorrhage.
The middle meningeal artery is responsible for bleeding in __________ hemorrhage.
Match the following characteristics with their corresponding type of hemorrhage:
Match the following characteristics with their corresponding type of hemorrhage:
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Study Notes
Glasgow Outcome Score (Prognostic Score)
- Death is rated 1
- Persistent vegetative state is rated 2
- Severe disability is rated 3
- Moderate disability is rated 4
- Good recovery is rated 5
Brain Death
- Brain death requires certification by experts
- Brain death can be declared if there is no possibility of brain function recovery
- There are 5 criteria:
- Glasgow Coma Scale (GCS) of 3
- Nonreactive pupils
- Absence of brainstem reflexes
- No spontaneous ventilation
- Absence of confounding factors like drug intoxication or hypothermia
- Additional studies like EEG and cerebral angiography may be used
Burns
- 1% of Total Body Surface Area (TBSA) is equivalent to the size of the palm
- Wallace’s Rule of 9 is used for percentage calculation
- Lund & Browder chart is the gold standard for calculating burn percentage
- There are 3 zones of burns:
- Coagulation/necrosis: Tissue damage is irreversible
- Stasis: Unclear in text
- Hyperemia: If poorly managed, results in necrosis; If well managed results in hyperemia
- There are 3 burn degrees:
- 1st Degree: Involves epidermis only, heals without scarring.
- Examples include sunburn
- Superficial: Involves epidermis and papillary dermis.
- Red and tender, may have some blanching
- Deep: Involves epidermis and entire dermis:
- Can lead to hypertrophic scarring and keloids
- Requires wound dressing
- 1st Degree: Involves epidermis only, heals without scarring.
NICE Guidelines: For Head Injury
- Cervical spine injury should be ruled out in all patients
- GCS is monitored:
- Every 30 minutes in the first 2 hours
- Every 1 hour for the next 4 hours
- Every 2 hours after 6 hours
- CT scan criteria for adults:
- Within 1 hour:
- GCS less than 13 at any point
- GCS less than 15 at 2 hours
- Focal neurological deficit
- Suspected open, depressed or basal skull fracture
- More than one episode of vomiting
- Post-traumatic seizure
- Loss of consciousness
- Within 8 hours:
- Over 65 years old
- Retrograde amnesia greater than 30 minutes
- Within 1 hour:
- CT scan criteria for children:
- Suspicion of non-accidental injury (NAI)
- First seizure
- GCS less than 14 or less than 15 in under-ones
- GCS less than 15 at 2 hours post injury
- Neurological surgeon involvement criteria:
- GCS ≤8
- Fall in GCS score after admission
- Unexplained confusion longer than 4 hours
- Loss of consciousness, seizure, or more than 1 episode of vomiting
- Focal neurological signs
Trauma
- Kernohan Notch Phenomenon:
- Occurs when there is a left temporal lobe epidural hematoma (EDH)
- Increased intracranial tension
- Temporal lobe/uncal herniation
- Compression of the Kernohan notch on the right side
- Compresses the right corticospinal tract
- Leads to left-sided hemiparesis
- Can be falsely localized as a right-sided bleed
- Chronic Subdural Hemorrhage (SDH)
- Types based on duration: Acute - less than 21 days
- Mechanism of Chronic SDH: Trivial injury
- Caused by bleeding in bridging veins
- Clinical findings: Elderly patient with trivial injury, normal for a few days/weeks then altered sensorium
- Investigations: CT scan
- Concavo convex or crescenteric hemorrhage
- Blood between dura and arachnoid
- No restriction by suture lines
- Increased extent of brain injury
- Indications for Craniotomy/Burr Hole:
- Clot thickness greater than 1 cm
- Midline shift greater than 5 mm
- 2 or more point drop in GCS score
- OR
- ICP greater than 20 mmHg
- Fixed dilated pupil
- Traumatic Subarachnoid Hemorrhage (SAH)
- Most common cause of a SAH is trauma
- Management is typically conservative
Trauma Management
- Management of raised ICT in trauma:
- Adeqaute oxygen
- Adequate perfusion: Systolic blood pressure greater than 100 mmHg
- Avoid dextrose solutions as hyperglycemia can worsen cerebral edema
- Give 1/V Mannitol
- Hyperventilation in moderate amounts
- Slight head elevation
- Steroids do not play a role in management
- Key parameters to maintain in head injury patients:
- Paco₂: 4.5-5.0 kPa
- CPP greater than 60 mmHg
- PaO₂: Greater than 11 kPa
- MAP: 80-90 mmHg
- [Na⁺]: Greater than 140 mmol/L
- [K⁺]: greater than 4 mmol/L
- ICP less than 20 mmHg
- Prophylactic use of phenytoin or valproate:
- Not recommended for late post-traumatic seizures (PTS)
- Used for early PTS
Discharge Criteria for Mild Head Injury
- GCS score of 15/15 without focal deficits
- Normal CT brain if indicated
- Patient is not under the influence of drugs or alcohol
- Patient is accompanied by a responsible adult
- Verbal and written head injury advice
- Seek medical attention if:
- Persistent or worsening headache despite analgesia
- Persistent vomiting
- Drowsiness
- Visual disturbances
- Limb weakness or numbness
Brain Injury
- Types of Brain Injury:
- Primary injury: Injury due to impact
- Secondary injury: Injury due to a rise in intracranial pressure (ICT)
- Severity and GCS score:
- Minor: GCS 15/15, no loss of consciousness (LOC)
- Mild: GCS 14/15, LOC (+)
- Moderate: GCS 9 - 13
- Severe: GCS ≤ 8
- Concussion:
- Severity: Mildest type of primary brain injury
- Mechanism: Contact sports
- Colorado Classification (subdivided into grades)
- Grade 1: Confusion
- Grade 2: Amnesia
- Grade 3: LOC
- Possible complications:
- Multiple Concussions
- Chronic Traumatic Encephalopathy
- Diffuse Axonal Injury (DAI):
- Severity: Most severe type
- Mechanism: High velocity injury, shearing force between gray and white matter
- Symptoms:
- Coma
- No improvement in GCS score
- Symptoms:
- Imaging Findings:
- NCCT: Normal
- MRI: Shows punctate hemorrhages of gray and white matter junction
- Management:
- Avoid contact sports
- Hypotension should raise suspicion of other areas of bleeding (thorax, pelvis, abdomen, long bones)
- DAI can also indicate spinal injury (neurogenic bladder) or late stage brain herniation
Head Trauma
- Summary table of EDH, Chronic SDH and Diffuse Axonal injury:
EDH Chronic SDH Diffuse axonal injury History Usually young patient, High velocity impact Usually elderly patient, Trivial injury High velocity impact Features Lucid interval Normal for a few weeks, then altered sensorium Coma; No signs of recovery CT Bi convex hemorrhage Concavo convex - Secondary Brain Injury:
- Mechanism: Rise in ICT
- Image describes normal state (normal ICP) and decompensated state (increased ICP)
- Clinical Features:
- Increased MAP:
- Increased systolic blood pressure
- Decreased heart rate
- Altered respiration
- Cushing’s Reflex:
- Site: Acid producing areas of stomach
- Type: Stress ulcers
- Increased MAP:
- Intracranial volume-pressure Curves:
- Cerebral Perfusion Pressure (CPP) is required to perfuse brain parenchyma
- CPP = mean arterial pressure - Intracranial pressure
- Normal= 260 mmHg
- Graph shows intracranial pressure plotted against volume of mass
- Cerebral Perfusion Pressure (CPP) is required to perfuse brain parenchyma
CIRCULATION
- Pathophysiology of Burns:
- Burns lead to release of inflammatory mediators
- Vasodilation
- With 10% TBSA, increased evaporation occurs, vascular leak leads to edema within the 1st 24-48 hours
- Localized immune response
- Generalized immune response: Dehydration occurs as albumin is lost to the extravascular space
- 3rd space fluid loss
- Fluid resuscitation:
- Colloids are used after 24 hours and are calculated using Muir & Barclay formula
- Crystalloids are used mainly with Ringer lactate and are calculated using the Parkland formula
- 4 x Body weight (kg) x % TBSA of burns (excluding 1º burns) = Amount of fluid required in 24 hrs.
- 1/2 amount over 8 hrs, 1/2 amount over 16 hrs
- Modified Parkland/Brooke formula:
- 2 x Body weight (kg) x %TBSA
- Burn resuscitation fluid rate and target urine outputs:
Category of burn Age and weight Adjusted fluid rates Urine output Flame or scald Adults and older children (≥ 14 years) 3 mL LR x kg x % TBSA 0.5 mL/kg/hr Children (< 14 years) 3 mL LR x kg x % TBSA 30-50 mL/hr Infants and young children (≤ 30 kg) 3 mL LR x kg x % TBSA 1 mL/kg/hr Electrical injury All ages 4 mL LR x kg x % TBSA until urine clears 1-1.5 mL/kg/hr until urine clears - Maintenance fluids in children:
- 100 mL/kg for first 10 kg
- 50 mL/kg for next 10 kg
- 20 mL/kg for every kg after 20 kg.
- Galveston formula: Used for crystalloid solutions, also used in children
THERMAL INJURIES
- Burns Unit Emergency Management:
- Referral criteria:
- Burns involving face, hands, genitalia
- Chemical burns
- Electrical burns
- Inhalation injury
- Partial thickness burns over 10% TBSA (Total Body Surface Area)
- Full thickness (3rd degree) burns
- Referral criteria:
- AIRWAY:
- Signs of airway burns:
- Singed nasal hair
- Hoarseness of voice
- Carbonaceous deposits in sputum
- Airway burns require prophylactic intubation
- Due to rapid airway collapse
- Stages:
- Acute pulmonary insufficiency: Hypoxia
- Acute Respiratory Distress Syndrome-like picture (24-48 hrs) : Bilateral lung infiltrates, hypoxia
- Management:
- Intubation
- Bronchodilators
- Signs of airway burns:
- ACLS guidelines for management of burns:
- Airway
- Breathing
- Circulation
- Disability
- Exposure
- Determine cause of burns and extent of area burned
- Stages of Bronchopneumonia:
Phase Duration Causative Organism Early 1-3 days S.aureus Late > 3 days Gram-negative bacteria - Causes of hypoxia:
- Inhalation of smoke
- Airway collapse
- CO poisoning:
- CO increases affinity to hemoglobin, decreasing oxygen transportation
- Eschar around the chest:
- Restricts chest expansion
- Requires escharotomy
Intracranial Hemorrhages
- Contusion (Intra Parenchymal Bleed)
- Mechanism: Most common type of bleed following head trauma
- Location: Temporal lobe (more common than frontal lobe)
- Imaging: Non-contrast CT (NCCT)
- Management: Conservative management, control ICT
- Extradural Hemorrhage (EDH)
- Incidence: Common in young patients
- Mechanism: High velocity impact injuries
- Etiology: Bleeding from the middle meningeal artery (MMA)
- Lucid Interval: A temporary period of lucidity that is followed by decreased consciousness (this isn't a diagnostic feature)
- Imaging: NCCT
- Appearance: Biconvex/lens-shaped hemorrhage, restricted between the skull and dura, crossing cranial sutures
- Management:
- Surgical: Craniotomy, Burr hole
- Site: Location near the pterion
- Indications for surgery:
- Clot size greater than 30 cc
- Midline shift greater than 0.75 cm
- Clot thickness greater than 1.5 cm
- Choosing the site for surgery:
- NCCT: The site of the bleed on the NCCT is considered
- If NCCT is unavailable: Check the pupil dilation - Affected side corresponds to the bleeding side
- Important Considerations:
- Normal phenomenon: Left EDH → Right-sided hemiparesis
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