1. Traumatic Brain Injury Case Scenario Workshop Maurizio Berardino Neuroanesthesia and Intensive Care Neuroscience Department San Giovanni Battista Hospital Torino, Italy

2. Maurizio Berardino, MD Overview §Initial assessment §ABCs §Neurologic evaluation §Treatment §Transport §Neurologic Deterioration

3. Maurizio Berardino, MD Case Presentation §21 year old male §Unrestrained driver, single vehicle MVC §70 KPH, sedan vs. concrete barrier §No airbag §Windshield starred

4. Maurizio Berardino, MD Primary Survey §The patient had a clear airway and was speaking spontaneously §Bilateral breath sounds §A strong radial pulse at 100 §BP 120/80

5. Maurizio Berardino, MD Primary Survey §A 3x5 cm hematoma / contusion on the patient’s left superior forehead / frontal area §The patient was found walking near the accident scene alert but confused §PERRL ~ 3 mm §What is his GCS score?

6. Maurizio Berardino, MD Glasgow Coma Scale Verbal Response oriented - 5 confused - 4 inappropriate – 3 incomprehensible - 2 none - 1 Motor Response obeys - 6 localizes - 5 withdraws - 4 abnormal flexion - 3 extension - 2 none - 1 Eye Opening spontaneous - 4 to speech -3 to pain - 2 none - 1 Full verbal score (5) is assigned for crying after stimulation in children < 2yrs.

7. Maurizio Berardino, MD Priorities ? §Assessment / Treatment –Airway –Breathing –Circulation –Cervical Spine –Disability –Exposure

8. Maurizio Berardino, MD Secondary Survey §No change in A, B, C, D §Mild bleeding left forehead §No other injuries discovered

9. Maurizio Berardino, MD Treatment / Interventions §Interventions –IV –0 2 NRB FM §Immobilization –C spine collar –Back board

10. Maurizio Berardino, MD Transport Issues §Destination –Emergency Department –Trauma Center §Status / Expediency

11. Maurizio Berardino, MD After the Primary & Secondary Survey §While asking the patient about the accident his: –Speech becomes inappropriate –Eyes remain open –Localizes to tactile stimuli §What is his GCS Score? §Pupils PERRL 3mm §What is your next action?

12. Maurizio Berardino, MD Priorities ? §Assessment / Treatment –Airway –Breathing –Circulation –Cervical Spine –Disability –Exposure

13. Maurizio Berardino, MD Glasgow Coma Scale §En route, 10 minutes from destination hospital §Eye – no opening §Motor – flexion §Verbal – non-verbal §What is his GCS score?

14. Maurizio Berardino, MD Priorities ? §Assessment / Treatment –Airway –Breathing –Circulation –Cervical Spine –Disability –Exposure

15. Maurizio Berardino, MD Reassessment §Patient is unresponsive –No verbal effort –No eye opening –Extensor posturing to nail bed pressure §What is his GCS score? §Pupils –R > 5 mm (non-reactive) –L 2 mm (reactive)

16. Maurizio Berardino, MD Treatment / Interventions §Indications for intubation / hyperventilation –Dilated unreactive pupil (s) –Extensor posturing

17. Maurizio Berardino, MD Ventilation §Normal ventilation is defined as approximately: –10 breaths per minute (bpm) for adults –20 bpm for children –25 bpm for infants

18. Maurizio Berardino, MD Hyperventilation §Routine prophylactic hyperventilation can cause cerebral ischemia & should be avoided §Hyperventilation is defined as approximately: –20 breaths per minute (bpm) for adults –30 bpm for children –35 bpm for infants

19. Maurizio Berardino, MD Agitation §Patient becomes agitated / combative, pulling at ETT with freed hand §Near self extubation §P 100 §BP 130 / 80 §Bilateral equal breath sounds §O2 sat 99%

20. Maurizio Berardino, MD Agitation (Causes) §Hypoxemia §Hypovolemia §Drugs §Alcohol §Hypoglycemia §Patient discomfort §Traumatic brain injury

21. Maurizio Berardino, MD Hypoglycemia §Can be a cause of trauma or accident §Pupillary asymmetry §Altered mental status §Focal neurologic deficits §Diaphoresis §Coma

22. Maurizio Berardino, MD Destination §Level I trauma center with the following capabilities: –24 hour available CT scanning –24 hour available operating room –Prompt neurosurgical care –Ability to monitor intracranial pressure –Ability to treat intracranial hypertension

23. Maurizio Berardino, MD Summary §Head trauma patients require frequent reassessments §A single GCS score does not predict outcomes §Indications for hyperventilation include dilated unreactive pupil (s), extensor posturing §Moderate and severe TBI patients require transport to a neurotrauma center