Neuroanatomy and Trauma: Brain and Skull Injuries, Exams of Health sciences

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ATLS Written Review EXAM 2024-2025 UPDATE ACTUAL EXAM ALL

QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) 100%

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What is the primary goal of treating TBI? How is this done? - ANSWER>>preventing secondary brain injury. This is done by maintaining blood pressure and providing adequate profusion. After managing ABCDEs of TBI what MUST be identified if present? How is this done? - ANSWER>>mass lesion that requires surgical evacuation is critical! this is done with CT. NOTE: obtaining a CT should not delay patient transfer to trauma center. Which brain lobes do the following hold:

1. anterior fossa:
2. middle fossa:
3. posterior fossa: - ANSWER>>1. anterior fossa: frontal lobes
4. middle fossa: temporal lobes
5. posterior fossa: lower brainstem and cerebellum What are the 3 layers of the meninges? - ANSWER>>dura mater, arachnoid mater, pia mater What does the dura mater adhere firmly to? - ANSWER>>the skull. it is tough and fibrous What layer of the meninges splits into two leaves as specific sites to enclose large venous sinuses? What do these sinuses do? - ANSWER>>dura mater. these sinuses provide major venous drainage from the brain. What is the midline sinus of of the brain that splits into two sinuses: bilateral transverse and sigmoid sinus? What side are these bigger on? - ANSWER>>The main sinus enclosed

by the dura major is the midline superior sagital sinus. This splits into the sigmoid and bilateral transverse sinuses which are larger on the right side. What are the arteries that lie between the skull and the dura mater (epidural space)? - ANSWER>>meningeal arteries. What is the most commonly injured meningeal artery and where is it located? - ANSWER>>middle meningeal artery. Located over the temporal fossa T/F: the arachnoid mater is fused to the dura mater? - ANSWER>>FALSE: not attached. This produces a potential space for a subdural hematoma In a subdural hematoma, what is the cause? - ANSWER>>injury to bridging veins that extend from brain surface to the sinuses within the dura. _______ fills the space between the arachnoid and pia mater? - ANSWER>>CSF. this cushions the brain and spinal cord. What location of brain hemorrhage is frequently seen in brain contusion or injury to major blood vessels at base of brain? - ANSWER>>subarachnoid. The ____ and _____ contain the reticular activating system which is responsible for ____.

• ANSWER>>midbrain and upper pons state of alertness What important function resides in the medulla? - ANSWER>>cardiorespiratory centers. What important functions are in the following brain segments:

1. left hemisphere:

2. frontal lobe:
3. parietal lobe:
4. temporal: - ANSWER>>1. left hemisphere: language center
5. frontal lobe: executive function, emotions, motor
6. parietal lobe: sensory function/spatial orientation
7. temporal: memory functions What divides the brain into supratentorial and infratentorial compartments? - ANSWER>>tentorium cerebelli. (tent over cerebellum) What is the physiology behind a blown pupil? - ANSWER>>blown pupil: dilation of pupil

• CN III runs along the tentorium cerebelli. parasympathetic fibers that constrict the pupil run along CN III (oculomotor). When temporal lobe is herniated, it can compress these fibers. Unapposed sympathetic activity causes pupillary dilation. What is the tentorial notch/hiatus - ANSWER>>this is where the midbrain passes through into the infratentorial compartment. what part of the brain most commonly herniates through the tentorial notch? - ANSWER>>Uncus (medial part of temporal lobe) does weakness occur on the same or opposite side of the uncal herniation? - ANSWER>>OPPOSITE. the corticospinal tract of the midbrain is compressed and then crosses at the foramen magnum. state: Ipsilateral/contralateral ____ pupillary dilation associated with _____ hemiparesis is the classic sign of uncial herniation. - ANSWER>>ipsi

contra average ICP is _____ mmHg. - ANSWER>> The monro-kellie doctrine states that the total volume of intracranial contents must remain constant, because the cranium is ___ - ANSWER>>a rigid, non expandable container. The monro-kellie doctrine states that _____ and _____ may be compressed out of the skull providing a degree of buffering. - ANSWER>>CSF and venous blood. Once the CSF and venous blood reach a certain level of displacement the ICP rapidly increases. What is the equation for CPP (cerebral perfusion pressure)? - ANSWER>>CPP=MAP-ICP in TBI, Every effort should be made to reduce ______, while normalizing ____, ___, and _____. - ANSWER>>ICP MAP, oxygenation, intravascular volume What GCS ranges for the following classes:

1. Minor
2. Moderate
3. Severe - ANSWER>>1. 13- 15
4. 9- 12
5. 3- 8 What nerve palsy may occur with basilar skull fracture? - ANSWER>>seventh nerve.

A GCS of ___ is accepted definition of coma? - ANSWER>>8 or less How do you assess a GCS of someone with asymmetric responses? - ANSWER>>Use the best possible because this will be the best predictor of outcome Basilar fractures of the skull usually require what type of imaging? - ANSWER>>this requires CT with bone-window setting. What are the typical clinical signs of basilar skull fractures? - ANSWER>>1.periorbital ecchymosis (raccoon eyes)

2. retroauriculor ecchymosis (battle sign)
3. CSF leak from nose or ears
4. 7th or 8th CN dysfunction (facial paralysis and hearing loss) What should be a primary consideration for any patient with a skull fracture, especially a linear skull fracture? - ANSWER>>hematoma. linear skull fracture increases likelihood of intracranial hematoma by about 400x What mechanism is common with diffuse axonal injury and what is the likely outcome? - ANSWER>>these injury often occur with high velocity or deceleration injures. They appear as diffuse cerebral hemorrhage often between grey and white matter. These are associated with variable but often poor outcomes. Epidural hematomas often occur in the _____ area of the skull and result from a tear of the _______ arteries. - ANSWER>>temporal middle meningeal artery What is the classic presentation of a epidural hematoma? - ANSWER>>a lucid interval between time of injury and neurologic a deterioration.

What are more common brain injury: epidural or subdural? - ANSWER>>subdural 30% epidural 0.5% Subdural hematoma occur from tear of _________. - ANSWER>>bridging vessels of the cerebral cortex Contusion occur in ___% of TBI. They often occur in _____ or ______ lobes of brain. They may coalesce to form ______ in as many as 20$%. - ANSWER>>20-30% frontal or temporal intracerebral hematoma. What is the imaging protocol for a patient with cerebral contusion? - ANSWER>>get CT at presentation. then get another within 24 hours to assess for coalesced hematoma. What factors would require a CT in minor brain injury? - ANSWER>>1. suspected open skull frac

2. basilar frac

3. 2 episode vomitting

4. pt older than 65
5. LOC >5 min
6. amnesia before impact of >30 min How long after discharge should patient with mild brain injury be observed by friend? - ANSWER>>24 hours What type of brain injury requires serial GCS? - ANSWER>>ALL. minor. moderate. major What imaging is done in all patient with moderate brain injury? - ANSWER>>CT

What factor of ABCDE must be monitored closely in moderate brain injury? - ANSWER>>Airway and breathing. rapid deterioration may occur. hypoventilation and hypercapnia may ensue requiring intubation. close monitoring in ICU is required. What should immediately follow the secondary survey in major/severe brain injury? - ANSWER>>CT. REMEMBER: CT should never delay patient transfer When assessing ABCDE of severe brain injury, when does DPL or FAST come before neuro exam? - ANSWER>>if the systolic blood pressure cannot be brought above 100, DPL or FAST is done first as to assess source of hypotension Spinal cord injury has what result in blood pressure? - ANSWER>>hypotension. This may also occur in terminal brain injury with medullary failure What needs to be cleared before Doll's eye testing is conducted? - ANSWER>>cervical spine must cleared. What tests should be performed before sedation? - ANSWER>>GCS and pupillary rxn A midline shift of _____mm or greater on the CT is indicative of need for neurosurgery to evacuate the clot or contusion causing the shift - ANSWER>>5mm What type of fluids should be used? - ANSWER>>hypertonic (ringers lactate or normal saline). NO GLUCOSE. What electrolyte abnormality is associated with brain edema and must be monitored? - ANSWER>>hyponatremia What are the physiologic consequences of PaCO2 >45?

PaCO2 <30? - ANSWER>>f PaCO2 >45 = vasodilation = inc ICP PaCO2 <30 (hyperventilation) = constriction = ischemia What is the preferred PaCO2 in brain injury? - ANSWER>>35 mm Hg If ICP is rapidly increasing, what can be done while preparing for craniotomy? - ANSWER>>hyperventilation. NOTE: this must be monitored closely and is only done very short periods at a time Does hypertonic saline lower ICP in hypovolemia? Does mannitol lower ICP in hypovolemia? - ANSWER>>No NO After administration of mannitol what should be monitored closely? - ANSWER>>ICP! mannitol has a substantial rebound effect on ICP What is the role of muscle relaxants (vecuronium or succinylcholine) in seizures with TBI?

• ANSWER>>NONE. these may mask tonic-clonic seizures and prevent anticonvulsant intervention (30-60 min of seizure = secondary brain injury) What meningeal tear would a CSF leakage of a head laceration indicate? - ANSWER>>dural tear What is the treatment of any intracranial mass lesion? - ANSWER>>Must be evacuated by neurosurgeon. transfer if not available. for a penetrating object such as an arrow or screw driver into the skull, test should be performed and what should be done with the object? - ANSWER>>need CT, Xray for

trajectory, and angiography. leave the object in place. Removing the object lead to fatal vascular injury. What clinical signs are the criteria for brain death? - ANSWER>>GCS of 3, nonreactive pupil, absent brainstem reflexes, no spontaneous ventilatory effort Which vertebrae is most susceptible to injury? - ANSWER>>Cervical. NOTE: in peds this accounts for only 1% of vertebral injury What nerve and cervical spine level would cause apnea and results in death in 1/3 of patient with upper cervical spine injury - ANSWER>>phrenic nerve C At what age do cervical spine differences begin to normalize? at what age does cervical spine look like that of an adult? - ANSWER>>marked differences in cervical spine occur until age 8 and steadily decline until age 12 when they are similar When a dislocation-fracture of the vertebrae occurs, almost always the result is _____. - ANSWER>>complete spinal cord injury T/F: the thoracolumbar junction is extremely strong and rarely incurs injury? - ANSWER>>FALSE: the flexible thoracic meeting the rigid lumbar make this area a common place for injury (15% of all spinal injuries) At what levels do the spinal cord begin and end? - ANSWER>>begins at foramen magnum at terminal end of the medulla oblongata and end at L What is sacral sparing? - ANSWER>>this is a sign of incomplete spinal cord injury where some sensation below an injury to spinal cord is preserved. In the case of sacral sparing, sensation and rectal sphincter tone is preserved.

What function does the dorsal column have? What tests can be done to assess function?

• ANSWER>>position, vibration, light touch, all from same side of body. TESTS: positioning of bent toes/fingers, vibration with tuning fork. What function does the spinothalamic tract have? what tests can be done to assess function? - ANSWER>>pain and temperature to opposite side of body TESTS: pinprick and light touch What function does the corticospinal tract have? what tests can be done to assess function? - ANSWER>>Motor power on same side of body TESTS: voluntary muscle contract or involuntary response to pain What type of gastric tube should be placed when cribiform plate fx or mid face fracture is present? - ANSWER>>orogastric. nasopharyngeal intrumentation is potentially dangerous When fluids must be administered what is the best route, and which type of catheter is best? - ANSWER>>-peripheral route it preferred with antecubital or forearm.
• if peripheral route is not accessable central vein access in any of the typical areas is acceptable. (in this case a short fat catheter should be used) What anatomical change is common in the third trimester of pregnancy? - ANSWER>>widening of the symphasis pubis What pulmonary complication is common with blunt trauma and PaCO2 <35? - ANSWER>>pulmonary contusion. Chest tube is indicated for which of the following?
• tension pneumo
• hemothorax

• ruptured bronchus
• pulmonary contusion
• mass hemothorax - ANSWER>>All EXCEPT pulmonary contusion What is the initial bolus for fluid resuscitation when a small child is in shock? - ANSWER>>20mL/kg ringers lactate What are the chest tube blood volume output parameters that would require a thoracotomy? - ANSWER>>>1500mL immediatley evacuated OR 200mL/hr for 2-4hrs NOTE: thoractomy is not indicated unless a surgeon qualified by training and experience is present How can one determine the appropriate tube depth for pediatric intubation? - ANSWER>>ETT tube size x 3 Ex: 4.0 ETT would be properly positioned at 12 cm from the gums In pediatrics: once past the glottic opening, the ETT should be positioned __ to ___ cm below the level of the vocal cords and then carefully secured. - ANSWER>>2-3 cm Fluid resuscitation of an infant begins with _______(amount and type). And then progresses to ______. (amount and type) - ANSWER>>20mL/kg Ringers lactate. (may give up to three of these boluses initially) For the third bolus consider PRBCs at 10mL/kg For a patient who is not breathing what intervention is indicated? - ANSWER>>orotracheal intubation

What should be used when vocal chords cannot be visualized on direct laryngoscopy? - ANSWER>>gum elastic bougie. in place when you feel clicks. can be inserted blindly beyond epiglottis What is the acronym BURP? - ANSWER>>backward, upward and rightward pressure used in external laryngeal manipulation with orotracheal intubation what is the most common life threatening injury in children? - ANSWER>>tension pneumothorax What is the most common acid-base disturbance in the injury child and what is it caused by? - ANSWER>>Respiratory acidosis caused by hypoventilation. What are the options to establish an airway when bag-mask ventilation and attempts at orotracheal intubation fail for a child? - ANSWER>>LMA, or intubating LMA, or needle cricothyroidotomy.

• needle-jet insufflation is an appropriate temporizing technique for oxygenation but does not provide adequate ventilation. NOTE: surgical cric is RARELY indicated for infants an small children. usually it is an adoption when the cricothyroid membrane is easily palpable around the age of 12. A local area of frost bite should be rewarmed with what temperature and in what waY? - ANSWER>>40C (104F) should be done in whirlpool. not dry heat. What is the main utility of ECG during resuscitation? - ANSWER>>detecting rhythm abnormalities What does PaCO2 of 35-40 mmHg indicate in late pregnancy? - ANSWER>>impending respiratory failure. hypocapnia (around 30) is typical in late pregnancy due to inc tidal volume.

Other than maternal death, what is the leading cause of fetal death? Symptoms? - ANSWER>>abruptio placentae (70%) suggested by vaginal bleeding, uterine tenderness, uterine contractions, uterine tetany, and irritability of uterus (contracts when touched) What type of monitoring should be initiated in fetus of gestation age >20 wks - ANSWER>>continuous monitoring with tocodynamometer. monitor should be done for 6 hours with no symptoms, and 24 with abruptio symptoms. What are the two extra precautions during primary survey of pregnant woman? - ANSWER>>1. uterus should be displaced manually to the left to relive pressure not he inferior vena cava.

2. early initiation of crystalloid fluids due to moms compensatory mechanisms masking fetal distress associated with hypovolemia T/F? Diaphragmatic breathing in a patient who is unconscious is not a sign of C-Spine injury - ANSWER>>FALSE. diaphragmatic breathing=c-spine injury What is used to evaluate a suspected urethral injury? What is used to evaluate a bladder rupture? - ANSWER>>retrograde urethrogram cystogram What are the abdominal structures that may not be detected on DPL? - ANSWER>>duodenum, ascending/descending colon, rectum, biliary tract, and pancreas In a severe trauma where facial anatomy is distorted and an ETT cannot be placed, what is the next step to provide ventilation? - ANSWER>>Next would be a transchricothyroid needle-jet insufflation. this is attached to high pressure oxygen, but can only be provided for around 30-45min due to CO2 accumulation.

• the definitive after this would be a surgical chricothyroidotomy or an emergent tracheotomy. (emergent tracheotomy is not preferred because complication and time consuming)

What hold urine output be maintained at after a crush injury to prevent kidney injury? - ANSWER>>100 mL/hr Is operation ever indicated in first hour after injury of multiple injured patient? - ANSWER>>yes. especially if class 3 or 4 hemorrhagic shock is present What class of shock are there NO clinical signs of inadequate organ perfusion? - ANSWER>>Class I. <14% blood volume loss. (<750mL) What is suggested if chest tube placement for suspected pneumothorax results in incomplete lung expansion and air leak with bubbling? What imaging confirms? - ANSWER>>This suggests tracheobronchial injury such as ruptured bronchus.

• a second chest tube may need to be placed
• this is confirmed with broncoscopy Why do chest injuries have a high priority in the multiply injured person? - ANSWER>>they often result in hypoxia What is the physiology behind neurogenic shock? - ANSWER>>loss of vascular tone What is another name for Central Venous Pressure? When is it elevated? - ANSWER>>Basically the same as Right atrial pressure.
• Elevated in cardiac failure, tamponade, tension pneumo, disrupted thoracic aorta. What would be expected on ABG abnormalities for pulmonary contusion? - ANSWER>>PaO2 <65 mm Hg (sat <90) would suggest need for intubation and in the presence of flail chest is more suggestive

t/f vomitus in the posterior oropharynx suggests esophageal intubation. - ANSWER>>false. signs include: epigastric fullness, absent end title CO2, absent breath sounds, audible borborygmi sounds over abdomen t/f: major head injury rarely causes shock by itself - ANSWER>>true What are the vital signs to be expected when ICP increases? - ANSWER>>decreased respirations and HR, increased systolic and pulse pressure Urethral injury should be suspected in the presence of what three things? - ANSWER>>1. blood at the meatus

2. perineal ecchymosis
3. high riding or non-palpable prostate What test is used to confirm the integrity of the urethra before a catheter is inserted? - ANSWER>>retrograde urethrogram What physical exam is essential before passing a urethral catheter - ANSWER>>examine the rectum and perineum What is the best guide for adequate fluid resuscitation in a burn patient? - ANSWER>>urine output adults: 0.5mL/kg/hr

30kg: 1mL/kg/hr NOTE: parkland is only for estimating and should be adjusted in accordance with urinary output. fluids should not be slowed at 8 hours if urine output is not adequate The LEAST likely cause of a depressed level of consciousness in the multisystem injured patient is

a. shock. b. head injury. c. hyperglycemia. d. impaired oxygenation. e. alcohol and other drugs. - ANSWER>>c hyperglycemia. For a patient bleed profusely from a wound not he medial thigh where should pressure be applied? - ANSWER>>pressure should b applied directly to the wound. Do not apply pressure to the proximal femoral artery at the groin What is one characteristic shared by all SURVIVORS of traumatic aortic disruption? - ANSWER>>contained hematoma What does x ray showing widened mediastinum and obliteration of the aortic knob suggest? - ANSWER>>traumatic aortic disruption What is the sensitivity and specificity of CT in aortic disruption? - ANSWER>>around 100%. NOTE: CT angiography should only be used to further identify site of disruption (not an initial test) What three X-ray views are most important for a person with multiple trauma? - ANSWER>>c-spine, chest, pelvis Pulse oximetry provides information about _____ and ____ but does not provide information about ____ - ANSWER>>1. O2 sat

2. peripheral perfusion
3. adequacy of ventilation Carboxyhemoglobin levels greater than ___% in burn patient indicate inhalation injury and require transport and/or intubation if transport is prolonged. - ANSWER>>10%

An 18-year-old man is brought to the hospital after smashing his motorcycle into a tree. He is conscious us and alert, but paralyzed in both arms and legs. His skin is pale and cold. He complains of thirst and difficulty in breathing. His airway is clear. His blood pressure is 60/40 and his pulse rate is 140 beats per minute. Breath sounds are full and equal bilaterally. He should be treated for what first? - ANSWER>>hypovolemic shock with fluids. NOTE: airway is OK because he is talking even though he complains of trouble breathing. What is the most important principle in the early management of someone with TBI and increasing ICP? - ANSWER>>prevent hypotension For a trauma patient that requires a chest tube, the tube is placed and 1600mL of blood returns. What is the next step in management? - ANSWER>>prepare for exploratory thoracotomy What are the symptoms with anterior crod syndrome? - ANSWER>>paraplegia and loss of temperature and pain sensation, with preservation of position and vibratory senses and deep pressure sense. WORSE PROGNOSIS What are the symptoms of central cord syndrome? - ANSWER>>disproportionate motor strength loss greater in upper extremities than lower with varying degree of sensory loss.(the arms and hands are most severely affected) What are the symptoms of Brown-Sequard syndrome? - ANSWER>>Think of a cut from anterior to posterior of the cord.

• ipsilateral motor loss, and loss of position of and vibratory sense
• contralateral loss of pain/temperature sense beginning 1-2 levels down from lesion. What is the primary concern in flail chest? - ANSWER>>pulmonary contusion resulting in hypoxia

prevention of hypo perfusion and hypoxia are most important for optimal outcome in _____. - ANSWER>>TBI What imaging is required for a patient displaying basilar skull fracture: hemotympanum, raccoon eyes, CSF otorrhea, battle sign? - ANSWER>>CT! also age >65, GCS<15 2hours post injury, suspected depressed skull frac, committing more than two episodes, LOC >5 min, amnesia before impact (more than 30 min), dangerous mechanism. T/F: bony injury in pediatrics is more common than in adults? - ANSWER>>FALSE: because bones are more pliable you will often find internal organ damage without overlying bone damage. Compare the specificity and sensitivity of DPL and CT in blunt abdominal trauma. - ANSWER>>DPL- high sens (98), low spec CT - high sens (92-98), high spec (95)