A patient is intubated in the ICU, but can follow commands with his right arm, extends with his lower extremities, and does not move his left arm. His eyes open to command. What is his GCS?
This patient would get 1 point out of 5 for verbal (the lowest that you can get in a single category is 1), but would get the designation T to indicate that he is intubated. He would get all 6 points for verbal because this follows the best result (the right arm). He would get 3 out of 4 points for eyes.
A patient comes into the trauma bay with a large laceration of his scalp with a skull deformity after a motor vehicle collision. He seems to be moving all 4 extremities spontaneously, and he is tachycardic. He has a large pool of blood on the stretcher. He also has a large flail segment of his right chest. What should your first move be?
A. Attempt to stop the bleeding with pressure or with suture repair of his scalp
B. Transfer the patient to CT scan to rule out intracranial trauma
C. Assess the patient’s airway
D. Transfuse 2 units of uncross-matched blood
When in a trauma resuscitation, the first priority is to secure the patient’s airway. All other choices may be necessary, but the airway is of prime importance.
You are seeing a patient in the ICU who has suffered a head injury. He has a ventricular monitor placed for measuring intracranial pressure, as well as an arterial catheter placed. His blood pressure is 120/80 with a mean of 90 and his ICP is 20. What is his cerebral perfusion pressure?
Cerebral perfusion pressure is defined as MAP – ICP. In this case, 90 – 20 = 70.
Which intracranial component can be affected most rapidly to decrease intracranial pressure in an acute situation?
D. An extra-axial hematoma
The intravascular blood volume can be decreased rapidly, but transiently by methods such as hyperventilation and mannitol dieresis. This can provide the necessary time to affect a more permanent solution.
Which of the following patients is most likely to require emergent surgical decompression?
A. An 85-year-old female with advanced dementia who has a 1-cm left subdural hematoma following a fall at her nursing home
B. An 8-month-old baby with an intraparenchymal hemorrhage after a fall from her sister’s arms
C. A 17-year-old male with a 2-cm frontal epidural hematoma with a GCS of 15
D. A 56-year-old male with bilateral subdural hematomas found after a CT scan for headache
E. An 18-year-old female with a small fracture of her skull following a gunshot wound, with no appreciable underlying hematoma.
An epidural hematoma is caused by a disruption of the middle meningeal artery and thus is exposed to higher pressures than a subdural hematoma, which is caused by tearing of bridging veins. In addition, younger patients have more brain tissue that increases pressure by mass lesions proportionately more than in an older individual with significant atrophy. An epidural hematoma classically has a “lucid interval” in which the patient’s GCS may be normal. This should not delay decompression, as the epidural hematoma can rapidly expand causing herniation.
A patient presents with weakness of his upper extremities, but four-fifth strength of his lower extremities. Which syndrome is most likely to be the cause of his findings?
Central cord syndrome results in weakness of the upper extremities with relative sparing of the lower extremities. Brown-Sequard is a hemitransaction that would cause ipsilateral paralysis and contralateral sensory deficit. Anterior cord leaves proprioception and deep sensation intact. Total cord disruption results in paralysis of both the upper and lower extremities distal to the lesion. Monro-Kelly is a doctrine that describes the contents of the calvarium.
Which of the following therapies is useful in the majority of prolactinomas?
Bromocriptine is a dopamine agonist that inhibits prolactin secretion from the anterior pituitary. The other options are not helpful in this condition.