ATLS Head Trauma 2 — Questions and Answers
Question 1: A patient arrives with a GCS of 6 after a fall. CT shows an acute epidural hematoma >30 mL with 8 mm of midline shift. What is the most appropriate management?
- Medical management with mannitol and hyperventilation
- Emergent craniotomy for evacuation (Correct answer)
- Serial CT scans every 6 hours
- Intracranial pressure monitor placement only
Correct answer: Emergent craniotomy for evacuation
An epidural hematoma >30 mL with significant midline shift and depressed GCS requires emergent surgical evacuation.
Epidural hematomas typically result from middle meningeal artery injury. Surgical indications include: thickness >15 mm, midline shift >5 mm, or GCS <9 with pupillary abnormalities. Medical management is a temporizing bridge, not definitive treatment.
Question 2: What is the initial target for cerebral perfusion pressure (CPP) in a patient with severe traumatic brain injury?
- 40-50 mmHg
- 60-70 mmHg (Correct answer)
- 80-90 mmHg
- Above 100 mmHg
Correct answer: 60-70 mmHg
The recommended CPP target in severe TBI is 60-70 mmHg.
CPP = MAP - ICP. CPP below 60 mmHg is associated with cerebral ischemia. Targeting above 70 mmHg with aggressive vasopressors increases ARDS risk without proven benefit.
Question 3: A patient with a GCS of 14 and brief loss of consciousness undergoes CT showing a small subdural hematoma with no midline shift. What is the most appropriate management?
- Emergent craniotomy
- Neurological observation with repeat CT in 6-8 hours (Correct answer)
- Immediate burr hole placement
- Discharge with return precautions
Correct answer: Neurological observation with repeat CT in 6-8 hours
A small subdural hematoma without significant mass effect in an alert patient is managed with neurological observation and repeat imaging.
Non-operative management is appropriate when: thickness <10 mm, midline shift <5 mm, GCS >8, and no neurological deterioration. Approximately 20-30% of initially non-operative SDH require delayed surgery.
Question 4: Which finding on clinical examination is the earliest sign of uncal herniation?
- Bilateral fixed dilated pupils
- Ipsilateral pupillary dilation (Correct answer)
- Contralateral hemiplegia
- Decerebrate posturing
Correct answer: Ipsilateral pupillary dilation
Ipsilateral pupillary dilation from CN III compression against the tentorial edge is the earliest sign of uncal herniation.
Uncal herniation compresses CN III first (dilated pupil), then the ipsilateral cerebral peduncle (contralateral hemiparesis), then the brainstem (bilateral posturing, bilateral fixed dilated pupils).
Question 5: Hyperventilation to a PaCO2 of 30-35 mmHg in severe TBI should be used in which situation?
- Routinely to prevent intracranial hypertension
- As a temporizing measure for acute signs of herniation (Correct answer)
- Continuously for the first 48 hours
- Only after ICP above 40 mmHg
Correct answer: As a temporizing measure for acute signs of herniation
Brief hyperventilation is a temporizing measure for acute herniation signs, as cerebral vasoconstriction reduces ICP rapidly but can cause ischemia if prolonged.
Hyperventilation reduces PaCO2, causing cerebral vasoconstriction and decreased cerebral blood volume. PaCO2 should not be reduced below 30 mmHg. The effect diminishes within 6-24 hours. Routine prophylactic hyperventilation worsens outcomes.
Question 6: What is the GCS score for a patient who opens eyes to pain, makes incomprehensible sounds, and exhibits flexion withdrawal to pain?
- GCS 7
- GCS 8 (Correct answer)
- GCS 9
- GCS 10
Correct answer: GCS 8
Eye opening to pain (E2) + incomprehensible sounds (V2) + flexion withdrawal (M4) = GCS 8.
E2 + V2 + M4 = 8. GCS 8 is clinically significant as the threshold for severe TBI and endotracheal intubation. Note: flexion withdrawal (M4) is different from abnormal flexion/decorticate (M3).
ATLS Head Trauma 2
A patient arrives with a GCS of 6 after a fall.
CT shows an acute epidural hematoma >30 mL with 8 mm of midline shift.
What is the most appropriate management?