5.1 J) Surgical Trauma Head Trauma (Neurotrauma) Cameron And Tintinalli

Front 1

List the classification of primary injuries in head trauma

Back 1

1. Skull fracture
2. Concussion
3. Contusion
4. Intracranial haematoma
5. Diffuse axonal injury
6. Penetrating injury

Front 2

List the secondary effects of skull fracture.

Back 2

1. Acute extradural haemorrhage

[temporal bone]
2. secondary infection [base of skull]
3. CSF leak [base of skull]
4. secondary brain injury [ depressed #]
5. secondary epilepsy

Front 3

Which is incorrect regarding Diffuse Axonal

Injury (DAI) ?
1. DAI can be associated with non-specific or minimal changes on CT brain.
2. It is the second-most predominant mechanism of injury in

Neurotrauma , behind intracranial haematoma.

3. It involves shearing and rotational forces on the axonal network.
4. It can result in major structural and functional disturbance at a

microscopic level.
5. It occurs in up to 50% of Neurotrauma patients.

Back 3

2. It is the the predominant mechanism of

injury in neurotrauma

Front 4

Which is not a factor associated with Minimal head injury ?

1. No LOC

2. GCS 14

3. No Neurological deficit

4. No palpable depressed skull #

5. Normal memory and alertness

Back 4

2. = GCS 15

Front 5

What are the features of Minimal head injury in the Neurotrauma severity scale?

Back 5

1. No LOC
2. GCS 15
3. Normal alertness and memory
4. No neurological deficit
5. No palpable depressed # /

other sign of skull #

Front 6

What are the features of MILD head injury in the Neurotrauma Severity Scale?

Back 6

1. Brief LOC [< 5 minutes]
2. Amnesia for event
3. GCS 14 ( < 2 hours) -->15
4. Impaired alertness / memory
5. No palpable depressed skull # /

other sign of skull #

Front 7

What are the features of moderate OR

potentially severe head injury in the

Neurotrauma Severity scale ?

Back 7

1. Prolonged LOC [> 5 min]
2. Persistent GCS < 14
3. Focal Neurological deficit
4. Post traumatic seizure
5. Intracranial lesion on CT brain
6. Palpable depressed skull #

Front 8

What Severity of head injury is the following

features associated with ?
1. Post traumatic seizure
2. LOC > 5 minutes

Back 8

Moderate or potentially severe

Front 9

What are the associated GCS numbers in

relation to the AVPU scale of mentation in

trauma?

Back 9

Alert ===> GCS 14-15
Verbal stimuli ===> GCS 9-13
Painful stimuli ===> GCS 6-8
Unresponsive ===> GCS 3-5

Front 10

What are the greatest risks, in regards to

secondary injury, to the patient with a

moderate-severe head injury ?

Back 10

1. hypoxia
2. hypotension

Front 11

Which is incorrect regarding the secondary survey of the head injured

patient?

1. Coma = GCS 8 or less

2. A non-responsive dilated pupil indicates contralateral herniation

3. A more common cause of abnormal pupillary reactions is the presence of direct ocular trauma.

4. A confused patient with eyes opening to voice, and localisation to pain has a GCS of 12

5. A patient using inappropriate words, with eye opening to pain and withdrawing to pain has a GCS of 9

Back 11

2. Non responsive dilated pupil =

ipsilateral herniation

Front 12

What "High-risk" discriminators { high risk groups} warrant CT scanning in those patients with GCS 14-15?

[ with 'minor' head injury or 'presumed' head injury ]

Back 12

1. Intoxication
2. Elderly {>65}
3. Anticoagulated
4. Demented

Front 13

What are the 5 criteria of the Canadian Head Rules that are "High-risk" for neurosurgical

intervention, in those patients with a head

injury classified as mild, with a GCS 13-15?

Back 13

1. GCS < 15 2 hours after injury
2. Suspected open/depressed skull #
3. Any sign of basal skull #
4. Vomiting > 2 episodes
5. Age > 65

Front 14

Which of the following is incorrect regarding Head injury?
1. Head injury associated with LOC , amnesia and a GCS of 14-15 will have a positive CT scan in approximately 10% of patients.

2. The subsequent craniotomy rate for the above scenario is < 1%.
3. The Canadian CT Head Rules are applicable for

minor head injury only.
4. Reliable risk stratification is difficult for head injury and CT scanning.
5. All CT head rules in minor head injury produce an increase in the

frequency of CT scanning.

Back 14

2. Craniotomy rate = 1-3%

1. = 7-12%

Front 15

What are the categories for Eye Opening in the GCS scoring system?

Back 15

1. Spontaneously = 4
2. To verbal command = 3
3. To pain = 2
4. Nil = 1

Front 16

What are the categories for Best Verbal

response in the GCS scoring system ?

Back 16

1. Orientated = 5
2. Confused = 4
3. Inappropriate words = 3
4. Incomprehensible sounds = 2
5. Nil = 1

Front 17

What are the categories for Best Motor

Response in the GCS scoring system ?

Back 17

1. Obeys Command = 6
2. Localises to pain = 5
3. Withdraws to pain = 4
4. Abnormal flexion to pain = 3
5. Abnormal extension to pain = 2
6. Nil = 1

Front 18

Which is incorrect regarding the use of mannitol in head injury ?
1. It can be used as an osmotic diuretic as a temporizing measure to

enable a patient with a surgically remedial lesion to get to theatre.
2. The dose is 1g/kg
3. It produces a sustained decrease in ICP.
4. It is contraindicated in renal failure and hypovolaemia
5. Complications include hypovolaemia and rebound cerebal oedema

Back 18

3. short-term reduction in ICP.

Front 19

List the specific management options for

moderate-severe head injury in the ED.

Back 19

1. Correct hypoxia
2. Correct hypovolaemia
3. Elevate head of bed 30 degrees
4. Anticonvulsant prophylaxis
5. Antibiotic prophylaxis [compound fractures]
6. General supportive therapy.
a. Maintain thermoregulation
b. Maintain hydration
c. Address pressure care and nutrition

Front 20

What are the indications for intubation and

ventilation of the neurotrauma patient?

Back 20

1. Inadequate ventilation / gas exchange
a. hypercarbia
b. hypoxia
c. apnoea
2. Inability to maintain airway

(loss of protective reflexes)
3. Agitated /combative patient
4. Transport of patient with potentially

unstable airway
a. interhospital
b. CT / angiography

Front 21

Which is incorrect regarding the head injured

patient?
1. Albumin, saline and Hartmanns are all safe in the severely head

injured patient.
2. Relatively higher systolic blood pressures are required in patients with elevated intracranial pressure from head injury.
3. A combative , agitated head injured patient should be considered for intubation.
4. The routine use of hyperventilation in head injured patients is

contraindicated.
5. Elevation of the head of the bed to 30 degrees will reduced ICP modestly in head injury.

Back 21

1. Albumin has been shown to have

detrimental effects

Front 22

In regards to the disposition of the head injured patient, which is incorrect?
1. Isolated (Rural) Emergency Departments should have a low threshold for transfer of the mildly head injured patient to a Neurosurgical centre.
2. The presence of pneumocephalus precludes unpressurised high

altitude flight.
3. Patients with moderate-severe head injury require hospital admission.
4. There is no consistent agreement on the duration of the "safe" period of observation, for the minimal-mild head injured patient.
5. There are no outcome data for the head injured patient that has delays to the appropriate facility.

Back 22

5. Worse outcome is associated with :

a. prolonged pre-hospital time
b. Delay of transfer to the appropriate facility
c. Admission to an inappropriate facility.
d. Delay in definitive surgical treatment

Front 23

Which is incorrect regarding severe head injury?
1. Early neurological abnormalities are NOT reliable prognostic factors
2. Mortality in severe head injury is 35%
3. Low GCS at presentation is associated with a worse outcome.
4. 50% patients with GCS < 11 for > 6 hours will die.
5. The vast majority of deaths are associated with Diffuse axonal injury and acute subdural haematomas.

Back 23

4. GCS < 9 for > 6 hours = 50% mortality

Front 24

(Tintinalli)
What is the equation for Cerebral Blood Flow?

Back 24

CPP = MAP - ICP

Cerebral Perfusion Pressure

Front 25

(Tintinalli)
List the Secondary insults that may worsen the Clinical Outcome of head Injury.

Back 25

1. Cerebral Oedema
2. Elevated ICP
3. Hypoxia
4. Hypotension
5. Anaemia.

Front 26

(Tintinalli)
List the 3 High risk Patient groups at greater risk of Traumatic Brain Injury (TBI)

Back 26

1. Elderly
2. Paediatric
3. Alcoholics

Front 27

(Tintinalli)
In regards to Mild TBI , list the High risk

subgroup factors on Hx / Ex / Ix

Back 27

1. Drug / alcohol intoxication
2. Age > 60
3. Large subgaleal haematoma /swelling
4. Focal Neurological findings
5. Coagulopathy
6. Skull fracture

Front 28

(Tintinalli)
Which of the following is incorrect regarding TBI?
A. The typical location of a basal skull fracture is the petrous temporal bone.
B. The mortality of severe TBI (GCS < 9 ) is < 40%
C. In Children, linear skull fractures resulting from a fall < 4 feet can be

associated with Clinically significant intracranial lesions.
D. TBI is classified as Mild, moderate and severe. (As well as "Minimal" )

Back 28

C. Paediatric Linear Skull fractures Tend not to develop Clinically significant intracranial lesions.

Front 29

(Tintinalli)
Which of the following is incorrect regarding TBI?
A. Traumatic SAH may be the most common CT abnormality in patients with moderate - severe TBI.
B. A fixed and dilated pupil, with ipsilateral hemiparesis is a classic late finding of epidural haematoma.
C. A common location for cerebral contusions is the frontal cortex.
D. Patients with brain atrophy are more susceptible to SDH.

Back 29

B. Ipsilateral fixed and dilated pupil +

CONTRALATERAL hemiparesis.

Front 30

(Tintinalli)
Which is incorrect regarding Subdural Haematoma?
A. Lethargy can be a presentation of SDH.
B. A SDH is a collection of venous blood between the inner table of the skull and the dura mater.
C. In infants, SDH has a strong association with NAI.
D. Chronic SDH = > 2 weeks.

Back 30

B. SDH = Blood Between the dura mater and the arachnoid.

An Epidural (extradural) is a collection of blood (arterial / venous) between the inner table of the skull and the dura mater.

Front 31

(Tintinalli)
What are the 3 common locations for Cerebral contusions?

Back 31

1. Frontal poles
2. Subfrontal cortex
3. Temporal lobes

Front 32

(Tintinalli)
A decreasing conscious level, with Bilateral

pinpoint pupils, Bilateral Babinski signs, and

increased muscle tone, are indicative of which type of herniation?

Back 32

Central Transtentorial Herniation.

Progresses to Fixed midpoint pupils and

decorticate posturing.

Front 33

(Tintinalli)
In comparing the New Orleans and Canadian CT Head rules, which is correct?
A. The Canadian CT Head Rule is more Sensitive but less specific.
B. For Neurosurgical Intervention, The New Orleans is more Sensitive, but less specific.
C. The Canadian rule is more specific for both positive CT findings, and the need for Neurosurgical Intervention.
D. The Canadian CT rule is 38% Specific for CT + findings, but 100%

Specific for N/Surg intervention.

Back 33

C. New Orleans : 100% Sensitive but 5%

specific for both Positive CT findings and

neurosurgical intervention.

Canadian : 83% Sensitive for + CT 38% specific
100% Sensitive for N/Surg intervention
37% Specific

A. New Orleans more Sensitive but less specific
B. Both 100% sensitive for Neurosurgical intervention
D. Canadian CT Head Rule = 37%Specific for N/Surg intervention.

Front 34

List as many components of the

Neuroprotective strategy as possible, for the patient with a traumatic intracranial

haemorrhage.

Back 34

1. Intubate [ for airway control and CO2 Mx)

2. Maintain PCO2 35-40 (low normal) Prevent hypercarbia

3. Maintain Normoxia - Aim PO2 80-100

SaO > 95% Prevent Hyperoxia / Hypoxia

4. Maintain MAP > 80 mmHg Prevent hypotension / Hypertension

5. Head of bed at 30 degrees elevation

6. Loosen any neck ties / restriction to venous return

7. Maintain normothermia Prevent hyperthermia

8. Maintain normoglycemia Prevent hypoglycaemia

9. Maintain Na+ high-normal

10. Maintain adequate sedation / paralysis