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Chapter 33: Neurotrauma

A 19-year-old bicycle messenger is brought to the emergency department (ED) by bystanders after inadvertently running his bike into a sign. Unfortunately, he was not wearing a helmet. Upon arrival in the ED, the patient is somnolent and mumbling. He opens his eyes when his name is called and says occasional words, but he does not answer orientation questions appropriately. He does not follow commands, although he reaches up to grab the examiner’s hand when noxious stimulation is applied. What would this patient’s Glasgow Coma Scale (GCS) score be?

A. 2

B. 11

C. 15

D. 9

B. The patient described in the vignette would score a 3 for eye opening to voice and a 5 on the motor response subscale for localizing to pain. The description of his verbal response is consistent with a score of 3, for inappropriate words. Therefore, the total GCS score would be 11.

A 36-year-old woman is involved in a motor vehicle collision. She is intubated upon arrival in the emergency department due to her depressed neurologic status. Upon arrival in the intensive care unit, an external ventricular drain is placed; her intracranial pressure is found to be 19 mm Hg. Her mean arterial pressure is 58 mm Hg. What is her cerebral perfusion pressure (CPP)?

A. 39 mm Hg

B. 72 mm Hg

C. 58 mm Hg

D. Equivalent to her central venous pressure

A. The patient’s cerebral perfusion pressure is equal to her mean arterial pressure (58 mm Hg) minus her intracranial pressure (19 mm Hg), or 39 mm Hg.

For the patient in Question 2, what is the most appropriate next step in management?

A. Hyperventilate to induce cerebral vasodilation

B. Remove cerebrospinal fluid to achieve a CPP of 50 to 70 mm Hg

C. Support her blood pressure, with fluids and/or vasopressors, to maintain CPP of 50 to 70 mm Hg

D. Start steroids to treat cerebral edema

C. To maintain adequate cerebral blood flow, it is important to maintain a cerebral perfusion pressure (CPP) >50 mm Hg. However, there is no evidence that raising the CPP >70 mm Hg is beneficial, and there is some concern that doing so may predispose patients to intracranial hypertension and/or worsening cerebral edema. ...

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