GENERAL APPROACH
- Isolated TBI or not
- Phase of illness:
— < 48 hours
— day 2-7
— late - Complications:
— refractory intracranial pressure, VAP, nosocomial infection, ventriculitis
INTRODUCTION
CUBICLE
- long/short stay
- cooling device: refractory ICP
INFUSIONS
- vasopressors: haemodynamic augmentation for CPP
- sedatives
- neuromuscular blockade for management of shivering during cooling
- phenytoin: seizure prophylaxis
- hypertonic saline
- thiopentone infusion: refractory ICP management
 VENTILATOR
- mode
- level of support
- level of oxygenation: FiO2, PEEP (high with chest injuries, aspiration, nosocomial pneumonia, ARDS)
MONITOR
- ICP monitoring: pressure, character
- CPP: >60mmHg
- arterial trace: MAP, swing, pulsus paradoxus, pulse pressure
- ETCO2: 30-40mmHg satisfactory, ask to correlate with a recent PaCO2
- temperature: cooling to < 38.5 C commonly performed if ICP uncontrolled
- CVP: number, waveform
EQUIPMENT
- EVD: CSF pressure prior to drainage, colour, frequency and volume
- Codman:
- EEG: burst suppression if thiopentone required
- tracheostomy
- IDC: colour, volume – jugular venous bulb monitoring
QUESTION SPECIFIC EXAMINATION
- neurological -> head: EVD, craniotomy, midline, 30-45 degrees head up, no neck compression, wounds
-> BOS #: CSF, haemotympanum, otorrhoea, rhinorrhoea, racoon eyes, Battle’s sign
-> unconscious
-> conscious
- hands/arms -> head -> chest -> abdo -> legs/feet -> back (secondary survey)
-> general:
-> cardiovascular:
-> respiratory:
-> abdominal:
- asked to see CT and angiography results
- relevant primary or secondary insults
RELEVANT INVESTIGATIONS
- CT head
- CXR
- electrolytes: paired plasma and urinary
- other organ failures (hepatic and renal)
- ABG: gas exchange, metabolic state
OPENING STATEMENT
=
- isolated TBI or not
- phase of illness
- complications
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