1. Neurologic Emergencies

2. An intervention that may decrease ICP during transport is:
Positioning the pt in the Trendelenberg position
Utilizing towel rolls to maintain extension of the head and neck
Elevating the head of bed or backboard 30 degrees, in the absence of trauma
Performing frequent deep oral and tracheal suctioning to maintain a patent airway
In the absence of trauma a pt may be placed with the HOB elevated 30 degrees. Positioning a pt in trendelenberg position will increase ICP and increase the risk of aspiration. Correct positioning of pts includes maintaining a midline position avoiding flexion or extension of the neck. Procedures that are known to increase ICP such as suctioning and turning should be kept to a minimum.

3. Cerebral Perfusion Pressure is the measurement of perfusion to the brain. It is measured by:
DBP x 2 + SBP/3
ICP-MAP
MAP-ICP
SBP x 2 + DBP/3
The correct calculation of CPP is to take the MAP and subtract the ICP. Emphasis is now shifted from primary focus of decreasing ICP to increasing or maintaining the CPP between mm Hg. If the ICP is greater than the MAP, minimal or no perfusion to the brain exists.

4. A normal range of ICP is:
60-70 mm Hg
0-15 mm Hg
20-30 mm Hg
35-45 mm Hg
Normal ICP that is measured when a pt is supine at the Foramen of Monroe is 0-15 mm Hg

5. The Monroe-Kellie Theory describes:
An auto-regulation process that modifies brain, CSF or blood volumes to maintain a constant ICP
An auto-regulation process that increases the PVR (peripheral vascular resistance) to increase CPP
A crisis process that decreases ICP via vasodilation
A complex chemical reaction that prevents free radicals from attacking the brain
Auto-regulatory mechanisms work to maintain a balance so if there is an increase in the volume of one component (such as blood or CSF) it is balanced by a reciprocal decrease in the volume of the other. An increase of PVR may aid in increasing the MAP which ultimately improves CPP but is not the Monroe-Kellie Theory. There is no identified crisis process that decreases ICP via vasodilation. Chemical reaction to prevent free radicals does not describe the Monroe-Killie Theory.

6. Cushing’s Response includes:
Hypotension, bradycardia, irregular respiration patterns
Hypertension, tachycardia, tachypnea
Hypotension, tachycardia, bradypnea
Hypertension, bradycardia, irregular respiration patterns
Cushing’s triad is a late sign of cerebral edema. Hypertension is a attempt to maintain the CPP and bradycardia is caused by compression of the lower midbrain are respiratory changes are from pressure on the respiratory centers in the medulla. Neither hypotension nor tachycardia is noted in Cushing’s triad.

7. Acute cerebral strokes are not commonly caused by:
Aneurysms
Vascular malformations
Thrombosis
Metabolic disturbance
80-90% of cerebral strokes are ischemic in nature % is hemorrhagic. Hemorrhagic stroke occur from rupture of a small artery from an aneurysm or vascular malformation. Metabolic disturbances may cause altered neurologic presentations, but are unlikely to actually cause a stroke.

8. An appropriate transport intervention for subarachnoid hemorrhage (SAH) is:
Aggressively decreasing SBP to prevent further bleeding
Maintaining SBP at a slightly hypertensive level to improve CPP
Withholding narcotics so as to not mask acute neurologic changes
Induce systemic hypothermia to decrease metabolic oxygen consumption
It is appropriate to maintain the BP at slightly hypertensive levels with general guidelines being 185/95-200/100. The intent is to maintain adequate CPP. Aggressive reduction in BP will result in inadequate CPP. Narcotics will prevent increased ICP. Although hypothermia may decrease O2 consumption there is no evidence of improved outcome.

9. The most common cause of spinal cord injury (SCI) is:
Motor vehicle crashes
Acts of violence
Falls
Recreational sports
Motor vehicle crashes account for the most common cause of SCI. A high level of suspicion should accompany the assessment of any pt that has been involved in a MVC. In descending frequency the next most common incidence of SCI is acts of violence (GSW), falls and finally recreational sports.

10. Recommended protocols for high dose steroid therapy to treat blunt SCI is:
Bolus 54 mg/kg over 30 minutes, then 3 mg/kg/hr for the next 23 hours
Bolus 18 mg/kg IV over 30 minutes, then 9 mg/kg/hr for the next 23 hours
Bolus 30 mg/kg IV over 30 minutes, then 5.4 mg/kg/hr for the next 23 hours
Bolus 300 mg/kg IV over 30 minutes, then 54 mg/kg/hr for the next 23 hours
Physician orders and protocols may vary but standard dosing of high dose steroid therapy is an IV bolus of 30 mg/kg over minutes and then a drip of 5.4 mg/kg/hr for the next 23 hours post injury. Most protocols begin high dose steroid therapy within 8 hours of the time of injury.

11. An epidural hematoma
Is a common injury
Causes menigeal irritation, fever
Is caused by injury to the bridging veins
Is caused by an arterial bleed
An epidural hematoma is the result of an arterial bleed that accumulates above the dura, usually from the middle meningeal artery.

12. Which symptoms indicate basilar skull fractures?
Menigeal irritation, fever, sepsis
Voluntary muscle fatigue and seizure activity
Sunset eyes and a shrill cry
Periorbital ecchymosis (raccoons sign) and mastoid ecchymosis (battle sign)
Periorbital and mastoid ecchymosis are often not evident for hours to days after the initial injury as well as rhinorrhea and ottorrhea. Meningeal irritation and fever are more likely due to cerebral infection. Fatigability of voluntary muscles are signs of myasthenia gravis. Sunset eyes and a shrill cry in children is an indication of meningeal irritation.

13. To maintain optimal cerebral perfusion pressure, in the absence of signs of impending herniation, maintain ETCO2 at:
25-30 mm Hg
35-40 mm Hg
40-45 mm Hg
45-50 mm Hg
Maintain ETCO2 at mm Hg to promote adequate cerebral blood perfusion mm Hg is too low of a ETCO2 and results in cerebral vasoconstriction and decreased cerebral blood flow. If controlled hyperventilation is initiated for signs of herniation, the goal is a PCO2 of mm Hg. An ETCO2 of is within the normal baseline parameters of, mm Hg, however, the Brain Trauma Foundation recommends the goal of mm Hg. ETCO2 of mm Hg represents hypercarbia which results in higher cerebral blood flow but also more edema related to vasodilation.

14. A pt presents to the ER after a MVC
A pt presents to the ER after a MVC. He has a large head laceration found in the temporal area. The pt states that he had a brief loss of consciousness after the accident, but he now has a GCS of 15. An hour later the pt is unresponsive. What is the most likely diagnosis?
Epidural hematoma
Subdural hematoma
Basilar skull fracture
Ischemic brain injury
An epidural hematoma is clotted blood between the skull and the dura. There is usually a delay in treatment in most cases due to a regain of consciousness shortly after trauma, leading to a 90% mortality rate. It is most likely seen in trauma to the temporal area.