Traumatic Brain Injury Management — MCQs

10 questions

A case of trauma comes to the emergency. On examination there is evidence of head injury, BP is 90/60 mmHg, and pulse is 150/min. Which of the following anesthetic agent should be used for induction?

In patient of head injuries with rapidly increasing intracranial tension without hematoma, the drug of choice for initial management would be :

A 25-year-old patient presents in coma with GCS of 5 and extensor posturing after a bike accident. Which of the following will be the best management of the patient?

The first and the most important measure in the management of a severely injured patient is to:

Which of the following drugs is contraindicated in a patient with raised intracranial pressure ?

All of the following causes decrease in CMRO2, CBF and ICP except:-

The earliest manifestation of increased intracranial pressure following head injury is

All are used in the management of head injury patient except?

Which of the following leads to development of SIADH?

Q10

Which of the following is false regarding cranial trauma?

Traumatic Brain Injury Management Indian Medical PG Practice Questions and MCQs

Question 1: A case of trauma comes to the emergency. On examination there is evidence of head injury, BP is 90/60 mmHg, and pulse is 150/min. Which of the following anesthetic agent should be used for induction?

A. Halothane
B. Succinylcholine
C. Thiopentone (Correct Answer)
D. Ketamine

Explanation: ***Thiopentone*** - It is a **short-acting barbiturate** that causes **rapid unconsciousness** and **reduces cerebral blood flow** and **intracranial pressure (ICP)**, which is beneficial in head injury. - It also has **cardiovascular-depressant effects** that can help manage hypertension, though in this hypotensive patient, careful titration is needed, but its **ICP-lowering effect** is crucial. *Halothane* - Halothane is a **volatile anesthetic** that can cause **dose-dependent myocardial depression** and a **decrease in blood pressure**, which would worsen the patient's existing hypotension. - It also tends to **increase cerebral blood flow**, which is counterproductive in a patient with a head injury and potential increased ICP. *Succinylcholine* - Succinylcholine is a **neuromuscular blocker** used for **rapid sequence intubation**, not as an anesthetic induction agent. - It can cause a **transient increase in ICP** and **hyperkalemia**, both of which can be detrimental in a trauma patient with head injury. *Ketamine* - Ketamine is a dissociative anesthetic that can **increase heart rate** and **blood pressure**, which could be beneficial in a hypotensive patient. - However, it also tends to **increase cerebral blood flow** and **intracranial pressure (ICP)**, making it less ideal for a patient with a head injury.

Question 2: In patient of head injuries with rapidly increasing intracranial tension without hematoma, the drug of choice for initial management would be :

A. 20% Mannitol (Correct Answer)
B. Lasix
C. Glycine
D. Steroids

Explanation: ***20% Mannitol*** - **Mannitol** is an osmotic diuretic that reduces **intracranial pressure (ICP)** by creating an osmotic gradient, drawing water from the brain parenchyma into the intravascular space [1]. - Its rapid onset of action and significant ICP-reducing effects make it the drug of choice for acute management of elevated ICP in head injuries without hematoma. *Lasix* - **Furosemide (Lasix)** is a loop diuretic that can reduce ICP by decreasing cerebrospinal fluid production and promoting diuresis. - However, its effects are generally slower and less potent than mannitol for acute, rapidly increasing ICP. *Glycine* - **Glycine** is an amino acid and neurotransmitter; it has no direct role in the acute management of increased ICP. - It is sometimes used as an irrigating solution in urological procedures but is not indicated for brain injury. *Steroids* - **Steroids**, particularly **dexamethasone**, are effective in reducing vasogenic edema associated with brain tumors or abscesses. - They are generally **not recommended** for acute traumatic brain injury due to lack of benefit and potential for increased mortality or complications.

Question 3: A 25-year-old patient presents in coma with GCS of 5 and extensor posturing after a bike accident. Which of the following will be the best management of the patient?

A. Hemi-craniectomy (Correct Answer)
B. Burr hole surgery
C. Hypertonic saline
D. Thrombolysis

Explanation: ***Correct: Hemi-craniectomy (Decompressive Craniectomy)*** - **GCS of 5** with **extensor posturing** indicates **severe traumatic brain injury (TBI)** with critically elevated **intracranial pressure (ICP)** and impending herniation - This clinical picture suggests **diffuse cerebral edema** or **massive intracranial pathology** requiring **urgent surgical decompression** - **Decompressive hemicraniectomy** removes a large skull bone flap to allow brain swelling, reducing life-threatening ICP and preventing herniation - This procedure is indicated for **refractory elevated ICP** despite maximal medical management, particularly in severe TBI with clinical deterioration - In the context of such severe presentation (GCS 5 with decerebrate posturing), surgical decompression is the definitive life-saving intervention *Incorrect: Burr hole surgery* - **Burr hole evacuation** is appropriate for **chronic subdural hematomas** or small, accessible lesions - It provides **inadequate decompression** for the diffuse cerebral swelling and massive pressure causing decerebrate posturing - Cannot address the extensive brain swelling and mass effect causing such severe neurological deterioration *Incorrect: Hypertonic saline* - **Hypertonic saline** is an important **medical adjunct** for temporizing elevated ICP by creating osmotic gradient - Used as part of **initial resuscitation** and bridging therapy to surgery - However, it is **not definitive management** for this severity of injury - with GCS 5 and extensor posturing, medical management alone has failed or is insufficient - Surgical decompression is required for survival in this critical presentation *Incorrect: Thrombolysis* - **Thrombolysis** is used for **acute ischemic stroke** to dissolve arterial clots - It is **absolutely contraindicated** in **traumatic brain injury** due to high risk of intracranial hemorrhage - Would cause catastrophic bleeding and certain death in this trauma patient

Question 4: The first and the most important measure in the management of a severely injured patient is to:

A. Splinting fractures
B. Arrest bleeding
C. Start I.V. fluids
D. To maintain airway (Correct Answer)

Explanation: ***To maintain airway*** - Establishing a **patent airway** is the absolute first step in managing any severely injured patient, as **airway compromise** can rapidly lead to hypoxia and death. - The ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach to trauma prioritizes **airway management** immediately to ensure oxygenation. *Splinting fractures* - While important for pain control and preventing further injury, **splinting fractures** is not the immediate priority over securing an airway. - This intervention falls under the 'D' (disability) or 'E' (exposure) in the primary survey of trauma care. *Arrest bleeding* - **Controlling severe external bleeding** is critical, but only after an **airway has been secured** and any immediate life-threatening breathing problems addressed. - Uncontrolled hemorrhage is a major cause of preventable death in trauma, but **airway patency** precedes it as per trauma protocols. *Start I.V. fluids* - Initiating **intravenous fluids** is crucial for resuscitating patients in shock due to blood loss. - However, it comes after ensuring a **patent airway** and adequate breathing, as per the ATLS guidelines for trauma management.

Question 5: Which of the following drugs is contraindicated in a patient with raised intracranial pressure ?

A. Ketamine (Correct Answer)
B. Midazolam
C. Propofol
D. Thiopentone

Explanation: ***Ketamine*** - **Ketamine** typically causes an increase in **cerebral blood flow** and **intracranial pressure (ICP)**, making it contraindicated in patients with raised ICP. - This effect is due to its action as a **dissociative anesthetic** which can lead to cerebral vasodilation. *Midazolam* - **Midazolam**, a benzodiazepine, can decrease **cerebral metabolic rate** and **cerebral blood flow**, thereby reducing ICP, making it a suitable option for sedation in patients with raised ICP. - It provides **sedation** and **anxiolysis** without significantly increasing ICP. *Propofol* - **Propofol** is a common choice for sedation in patients with raised ICP because it significantly reduces **cerebral blood flow**, **cerebral metabolic rate**, and thus **intracranial pressure**. - Its rapid onset and offset allow for precise control of depth of sedation and neurological assessment. *Thiopentone* - **Thiopentone**, a barbiturate, effectively reduces **cerebral blood flow** and **cerebral metabolic rate**, leading to a decrease in **intracranial pressure**. - It is often used for inducing anesthesia and as a neuroprotective agent in situations with acute brain injury.

Question 6: All of the following causes decrease in CMRO2, CBF and ICP except:-

A. Etomidate
B. Propofol
C. Thiopentone
D. Ketamine (Correct Answer)

Explanation: ***Ketamine*** - Ketamine is a dissociative anesthetic that typically causes an **increase in cerebral blood flow (CBF)** and **intracranial pressure (ICP)**, while its effect on cerebral metabolic rate of oxygen (CMRO2) can be variable but often does not decrease significantly. - It works by antagonizing **NMDA receptors**, inducing a state of dissociation rather than global cerebral depression. *Etomidate* - Etomidate is an anesthetic agent that effectively **decreases CMRO2, CBF, and ICP**, making it suitable for neurosurgical procedures. - Its mechanism involves enhancing **GABA-A receptor activity**, leading to global central nervous system depression. *Propofol* - Propofol is a commonly used intravenous anesthetic that significantly **reduces CMRO2, CBF, and ICP**. - It primarily acts on **GABA-A receptors** to induce sedation and anesthesia, making it a good choice for patients with elevated ICP. *Thiopentone* - Thiopentone, a barbiturate, is known to produce a dose-dependent decrease in **CMRO2, CBF, and ICP**. - It also enhances **GABA-A receptor-mediated inhibition**, resulting in cerebral vasoconstriction and metabolic suppression.

Question 7: The earliest manifestation of increased intracranial pressure following head injury is

A. Hemiparesis
B. Altered mental status (Correct Answer)
C. Contralateral pupillary dilatation
D. Ipsilateral pupillary dilatation

Explanation: ***Altered mental status*** - As intracranial pressure (ICP) rises, brain perfusion is compromised, leading to **cerebral ischemia** and dysfunction of the reticular activating system, causing subtle changes in **awareness, orientation, and level of consciousness**. [1], [3] - This is an early and sensitive indicator because the brain's overall function is affected before focal neurological deficits become apparent. *Hemiparesis* - **Hemiparesis** is a **focal neurological deficit** suggesting damage to specific motor pathways. [1], [2] - While it can occur with increased ICP due to herniation or focal masses, it is typically a later sign or directly related to the injury's location rather than the earliest manifestation of *generalized* ICP rise. *Contralateral pupillary dilatation* - **Contralateral pupillary dilatation** is a **late or atypical sign** of increased ICP, often associated with specific patterns of herniation (e.g., transtentorial herniation causing compression of the contralateral oculomotor nerve). [2] - Most commonly, pupillary changes due to increased ICP are ipsilateral to the lesion compressing the oculomotor nerve. *Ipsilateral pupillary dilatation* - **Ipsilateral pupillary dilatation** (usually due to **compression of the oculomotor nerve**) is a significant and serious sign of increased ICP, indicating **uncal or transtentorial herniation**. [1], [2] - However, this is typically a **later finding** (herniation syndrome) that occurs after more generalized signs like altered mental status.

Question 8: All are used in the management of head injury patient except?

A. Neuromuscular paralysis
B. Norepinephrine
C. Glucocorticoids (Correct Answer)
D. Sedation

Explanation: ***Glucocorticoids*** - **Glucocorticoids** are generally **not recommended** for the routine management of head injury patients due to a lack of proven benefit and potential for harm. - Studies have shown that their use in **traumatic brain injury (TBI)** can be associated with increased mortality and other adverse outcomes. *Neuromuscular paralysis* - **Neuromuscular paralysis** (e.g., with vecuronium or cisatracurium) is often used in severe head injury to facilitate **endotracheal intubation**, control intractable intracranial pressure (ICP), or prevent self-extubation. - It helps in reducing metabolic demands and ensuring proper ventilation and oxygenation in critically ill patients. *Norepinephrine* - **Norepinephrine** is a potent **vasopressor** frequently used to maintain adequate cerebral perfusion pressure (CPP) by increasing mean arterial pressure (MAP) in head injury patients. - Maintaining **CPP** is crucial to prevent secondary brain injury from ischemia. *Sedation* - **Sedation** (e.g., with propofol or midazolam) is essential in head injury management to reduce **agitation**, prevent increases in ICP, and facilitate mechanical ventilation. - It helps in patient comfort and ensures stability of vital signs and neurological parameters.

Question 9: Which of the following leads to development of SIADH?

A. Lung cancer
B. Pituitary adenoma
C. CNS disorders (Correct Answer)
D. All of the options

Explanation: ***CNS disorders*** - Neurological conditions such as **stroke**, hemorrhage, infection, and trauma can cause inappropriate **ADH release** due to damage or irritation of the hypothalamus or posterior pituitary [2]. - This leads to increased water reabsorption and subsequent **hyponatremia** characteristic of SIADH [1]. *Lung cancer* - Certain types of **lung cancer**, particularly **small cell lung carcinoma (SCLC)**, are known to produce ADH ectopically, leading to SIADH. - This represents a **paraneoplastic syndrome**, where the tumor cells independently synthesize and secrete ADH. *Pituitary adenoma* - While pituitary adenomas can cause various endocrine dysfunctions, they are generally **not a direct cause of SIADH**. - **SIADH** typically results from unregulated ADH secretion rather than a primary pituitary tumor's overproduction of ADH itself. *All of the options* - Although **lung cancer** and **CNS disorders** are well-established causes of SIADH, **pituitary adenomas** are not a common or direct cause. - Therefore, choosing "all of the options" would be incorrect due to the inclusion of pituitary adenoma as a direct cause.

Question 10: Which of the following is false regarding cranial trauma?

A. Depressed skull is associated with brain injury at the immediate area of impact
B. Raccoon eyes seen in subgaleal hemorrhage (Correct Answer)
C. Carotid-cavernous fistula occur in base skull
D. Post traumatic epilepsy seen in 15%

Explanation: ***Raccoon eyes seen in subgaleal hemorrhage*** - **Raccoon eyes** (periorbital ecchymosis) are typically seen with **anterior cranial fossa fractures**, not subgaleal hemorrhage. - Subgaleal hemorrhage is a collection of blood between the galea aponeurotica and the periosteum, usually causing diffuse **scalp swelling**. *Depressed skull is associated with brain injury at the immediate area of impact* - A depressed skull fracture means a portion of the skull is pushed inward, directly impacting the underlying **brain tissue**. - This can lead to localized **contusions**, **lacerations**, or **hematomas** at the site of impact. *Carotid-cavernous fistula occur in base skull* - **Carotid-cavernous fistulas** (CCF) commonly result from **traumatic rupture** of the internal carotid artery within the **cavernous sinus**. - This type of injury is often associated with **severe skull base fractures**, particularly those involving the sphenoid bone. *Post traumatic epilepsy seen in 15%* - The incidence of **post-traumatic epilepsy** (PTE) after severe head injury ranges from 5% to 15%, making 15% a plausible, though upper-end, estimate. - Risk factors for PTE include **depressed skull fractures**, **intracranial hematomas**, and **early seizures**.

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