CC Neuro Trauma

• alert
• lethargic
• obtunded
• stuporous
• comatose

L= drowsy but verbal arousal/tactile stiumulation

O= verbal AND tactile needed response but fall asleep again easily

S= tactile stimulous needed for any response

• sternal rub
• supraorbital pressure
• trapezius pinch
• mandibular pinch

these all illicit central stimulation

• HypoTN
• Hypoxia
• Hypoglycemia
• Hypotrhermia

• <8 = severe
• 9-12 = moderate
• 13-15 = mild

• 0 no movement
• 1 flicker or trace amount
• 2 can move but not against gravity
• 3 against gravity but not resistance
• 4 weak, but can overcome gravity and mild resistance
• 5 normal

decoticate= hands up, damage above brain stem

decerebrate= worse, hands down, damage to brain stem

Pupil size, reaction, and equality

+ finding is good, brain stem intact, eyes move opposite direction of head movement (continue to watch you)

- finding is bad, brain death possible, eyes remained fixed and do not adjust when head is moved

vital sign assessment

• Inc SBP
• Dec HR
• Dec RR

these indicate INC ICP

EEG= look at brain waves

Evoke= give shocks to illicit response

evaluation of verebral bld flow

• ice h20 against tempanic membrane (ear)
• watch eye response

nl= eyes jerk toward side with h20

abnl= no response OR single eye jerks on opposide side/direction

• hyperO2
• d/c vent and watch for 10 minutes
• at 10, draw ABG's and reconnect vent
• if no respers in to min AND pCO2 is >60, brain death indicated

• brain 80%
• CSF 10
• blood 10

0-15 mmHg

Tx threshold >20 mmHg

O2 delevery to the brain

• nl= 50-70, safe up to 150
• MAP - ICP = CPP

lower CPP is what we worry about

the cerebral bld vessels respond to changes with the cranium

CO2 levels cx brain vessels to constrict/dilate which Inc or Dec ICP, affecting CPP

Hypocapnea (d/t hypervent) cx's constriction -> cerebral ischemia

Hypercapnea -> dilation -> Inc ICP

goal is 35-45 CO2 and 100% O2

Small CO2 = Small vessels (constriction)

Large CO2 = large vessels

Inc BP -> vaso constrict (which is good if Inc ICP)

Dec BP -> dilation (good for cerebral perfusion)

• perfusion pressure
• vascular resistance
• O2 or glucose supply
• metabolic demand

• BP
• ICP

• vasospasm
• thrombosis
• Cerebral edema
• hypocapnea

• hypoxia
• anemia
• hypoglycemia
• CO

• fever
• seizures
• agitation

nl= 20-35 mmHg

• maintained by balancing:
• CPP >50
• ICP <20

• abnl CT
• OR
• nl CT with >2 risk factors

vent caths are most accurate tool

• gold std for ICP monitoring
• invasive
• difficult to place
• draingage of CSF to Tx inc ICP

• bolt placed in subarach
• lower rate of infection
• easier to place
• CSF sampling ONLY
• less accurate

• low risk infect
• easy place
• NO csf access
• low accuracy

• low infect
• easy place
• NO csf access
• low accuracy, can drift d/t no recalibration option

A.weful= large mountainous wavefore

B.ad= prominant peaks and troughs

C.ommon= small, frequent waves. What we want

• acceleration (hit by moving object)
• deceleration (head is moving, falls)
• rotational (car/sports injury's)
• penetrating (gun)

Diffuse injuries do not show up on a CT but Focal injuries do.

so we rule out focal with a CT

happen at the time of impact

• diffuse (all over, not localized)
• focal
• intracranial hemorrhages

• concussion
• Difues axonal Injury (DAI)

• diffuse
• mild, temporary, REVERSIBLE
• Sx= brief LOC, N/V, mem loss, confusion, dizzy, photophobia
• Tx= observation

post-conc= small % of Sx persist for up to 1 yr, usually HA, mem loss

• severe, Permanent shearing of axons  :(
• dx with CT
• Sx= acute and prolonged coma, Cushings tirad, posturing, INC temp
• Tx= medical managment, control ICP and maintain CPP

• specific area of brain
• Pupil and motor respnse for Sx

pupil is on SAME SIDE as injury

motor is on OPPOSITE SIDE of injury

• contusion
• skull fracture

• bruising and swelling
• coup or contracoup r/t to location of injury and/or bounce back of brain
• can be temporal or parietal

damage to midbrain, HIGH risk for epidural hematoma b/c temporal bone easily fractured

sx= contalateral motor and ipsilateral pupil changes, altered LOC

Tx medical management

liner= non-displaced bone, minor

depressed= compression of brain, dura, bone missing

• raccoon's eyes = periorbital brusing
• battle's sign = mastoid bruising behind ear
• CSF leakage = usually via ear or nose (look for halo on gauze)

• epidural
• subdural
• intracerebral
• subarachnoid

• ARTERIAL bleed
• (E is close to A)
• b/w skull and Dura layer

• Sx= dec LOC followed by lucid period, then coma. Pupil and motor changes
• Tx= surgery. good prgonosis

• Venous Bld
• (S is close to V)
• b/t dura and arachnoid (below dura mater)

• Sx= gradual dec LOC, acute, subacute, or chroni onset. motor and pupil changes
• Tx= surgery. prognosis is 30-60% mortality r/t REbld risk

• most often from stroke
• bld collection w/n brain tissue

• Sx= depends on location and size
• Tx= medical, always control ICP and optomize CPP

usually an Aneurysm

Sx= Thundering HA (worst ever!), photophobia, dec LOC, N/V, nuchal rigidity

Dx= CT, Lumbar Puncture (bld in CSF), angioplasty

Tx= clip it off

• high risk 30-60yrs
• high rik for arterial vasospasms (70% of all cases)
• peaks around 5-14 days

Sx= vision changes, hemiparesis, seizures, aphasia, dec LOC

• Dx= Transcranial doppler
• Tx= Ca blocker to prevent spasms
• Double HH therapy

• HTN= induce HTN to keep vessels open with vasopressors
•  =goal is >200 SBP

• Hemodilution= dec bld viscosity with IV crystaloids and colloids
•  = goal is Hct of 30%

• progression of initial injury d/t cellular and toxic changes
• what happens as a result of initial injury

• hypoxia
• hypercapnea
• hypoTN
• sustained HTN
• cerebral edema (most common cx)
• herniation

peaks 3-5 days after injury

temporal lobe forced into tentorial notch (brain stem) which compresses brain stem

• un=unilateral --> focal injury
• central= Bilateral --> diffuse injury

• fixed, blown pupil
• comatose
• loss of cranial nv and motor response
• cushings triad
• (-) dolls eyes
• C-V collapse, death

• ICP <20
• stable of inproving neurons

• CPP= 50-70, avoid <50
• SO2= 100%
• PO2= >100-150
• cO2= 35-45
• sbp= >90
• MAP= >70-90

• ABCD's
• airway and protect spine
• OG tube ONLY (NEVER INTER THE NOSE WITH A TBI)
• ETT for GCS <9

• goal is euvolemia and perfusion
• labs values similar to perfusion/o2 delivery goals
• Arterial lines are best for fluid and labs
• Central Line for CVP (6-8)

thorough neuro checks and brain CT scan w/n 15 minutes to give a good baseline

give Mannitol rescure dose of 0.25-1.0 Gm/kg

• Mannitol= osmotic diuretic (hypertonic)
•  =raise tonicity of bld
•  =pulls fluid into vasc space and out via kidney

• save the brain
• dec metab and O2 demand

• fever** (Tx aggressivly, even if only 1 degree over)
• hypoxemia
• agitation
• pain
• shivering
• vent asynchrony
• seizures

p= elevate HOB, head and neck alignment

s= space out b/c everything we do to them will increase ICP

bp= Tx HTN to avoid ICP

n= b/c fever inc metab and oO2 demand

v= no PEEP >5, hyperO2 is OK

• Pulm= Suct. only as needed and hyperO2
•  =prophylact anti-bios w/ intubation
•  =early trach to dec vent days
•  =early extubate does NOT inc pneumonia

• f= giuded by CVP and or of indicates of fluid status
•  =ASSESS for AHD imbalance

D= SCD's, Heparin drip as proph

s= anti-convulsants

n= begin within 7 days

after we have tried other Tx

• drain CSF via vent cath
• osmotic therapy, but watch for dehydration

• sedation with high dose barbiturates
• NO PROPOFOL in high dose or longer than 48hrs
• Hypervent for more than 24 hrs b/c dec CO2 =vasocontriction
• craniectomy
• organ donotion

• Diabetes Insipides
• more urine out than bld level
• inc Na in bld and dec u. gravity

• SIAHD decreases UO
• dec Na in bld and inc Na in urine

D= hypotonic solutions, replace ADH with vbasopressin or DDAVP

• S= fluid restriction
• hypertonic fluids