Stem: A 24-year-old young male brought to ED after RTA. On arrival, he had GCS 15, & then he vomited twice & after 20 minutes he become unconscious; now GCS decreased to 8. You have been called to see this patient. Considering this as critical care station, answer the following questions.

• How will you manage this patient?
  — I will follow the A, B, C, D protocol
• What will you expect in the CT scan?
  — biconvex, midline shift, & compression on the ventricle.
• What is the normal ICP?
  — Its 7-15 mm Hg( supine) &
• How will measure ICP? (Different methods?)
  —Invasive method:
  -Intraventricular catheter (EVD- external ventricular drain)
  -Extradural probe
  -Subarachnoid probe
  -Intraparenchymal probe
  -Lumbar CSF pressure
  —Non-invasive method:
  -Transcranial Doppler
  -Tympanic membrane displacement
  
• What body parts are injured?
  
• What is GCS & what are its constituents?
  
• Single test to confirm diagnosis? – CT head
  
• When will you consider CT brain for trauma?
  —High Risk Criteria:
  – GCS < 15 at 2 hours post-injury.
  – Suspected open or depressed skull fracture.
  – Any sign of basilar skull fracture:
  ->Hemotympanum.
  ->Racoon Eyes.
  ->Battle’s Sign.
  ->CSF oto-/rhinorrhea.
  – ≥ 2 episodes of vomiting.
  – Age ≥ 65.
  – Any head injury in anticoagulated patient.
  
  —Medium Risk Criteria:
  – Retrograde Amnesia to the event ≥ 30 minutes.
  – “Dangerous” Mechanism:
  -Pedestrian struck by motor vehicle.
  -Occupant ejected from motor vehicle.
  -Fall from > 3 feet or > 5 stairs.
• NICE guidelines: Criteria for performing a CT head scan. :
  —For adults who have sustained a head injury & have any of the following risk factors, perform a CT head scan within 1 hour of the risk factor being identified:
  –GCS < 13 on initial assessment in the emergency department.
  –GCS < 15 at 2 hours after the injury on assessment in the emergency department.
  –Suspected open/depressed skull fracture.
  –Any sign of basal skull fracture (hemotympanum, ‘panda’ eyes, CSF leakage from the ear or nose, Battle’s sign).
  –Post-traumatic seizure.
  –Focal neurological deficit.
  –More than 1 episode of vomiting.
  A provisional written radiology report should be made available within 1 hour of the scan being performed. 
  
• Describe CT head. – lenticular/ biconvex lesion—extradural haematoma.
• Management of raised ICP?
• GCS drops – management?
• Cause of secondary GCS drop?