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Category: Critical Care Medicine-Neurologic Disorders--->Neurotrauma
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Question 1#Print Question

A 15-year-old boy was struck by a car traveling 35 miles per hour and was thrown 15 feet. He was unresponsive and posturing upon arrival. He was intubated without use of paralytic or anesthetic agents. His examination prior to intubation was Glascow Coma Scale (GCS) 3 with reactive pupils at 4 mm. Following intubation and trauma screen, he was taken to CT scan, which demonstrated diffuse subarachnoid hemorrhage (SAH) and diffuse cerebral edema. He was admitted to the neurocritical care unit for ongoing management. Ten days into his hospital course, he was noted to have events of tachycardia, extensor posturing, and tachypnea in the setting of being bathed.

Which of the following is true regarding his likely diagnosis?

A. Start antiepileptic medications to better control seizure activities
B. The most common cause of this disease is traumatic brain injury (TBI).
C. The pathophysiology of this disease results from basal ganglia or thalamic synchronous neuronal firing
D. The patient’s age is not associated with this disease process


Question 2#Print Question

A 73-year-old female with hypertension, hyperlipedemia, and atrial fibrillation on oral anticoagulation with coumadin sustained a mechanical fall backwards and hit the right posterior aspect of her head. Following the fall, there was no loss of consciousness. On initial arrival to the emergency department (ED), she was interactive, but over the course of 30 minutes, she had neurologic deterioration with loss of spontaneous movement on the left side and multiple episodes of emesis and was intubated for airway protection. A head CT was completed at that time and is shown below. Her labs are remarkable for an elevated international normalized ratio (INR) of 2.1, Cr 1.4.

Vitals are remarkable for blood pressure (BP) 126/88 mm Hg, pulse 80 but irregular.

What is the age of the hemorrhage that is present on the noncontrast head CT?

A. There is only acute subdural hemorrhage.
B. There is mixed acute and subacute subdural hemorrhage
C. There is mixed acute and chronic subdural hemorrhage
D. There is only chronic subdural hemorrhage
E. There is only acute epidural hemorrhage


Question 3#Print Question

A 45-year-old female was riding her bicycle when she was struck by a car. She suffered a severe TBI requiring intracranial pressure (ICP) monitoring and treatment of elevated ICP with hyperosmolar therapy. Patient’s neurological status remained poor despite aggressive medical treatment, and she was eventually discharged to a skilled nursing facility following placement of a tracheostomy and gastrostomy tube. Six weeks following her initial injury, she was able to spontaneously open her eyes, track family, move all her extremities spontaneously, and reach for objects but not following commands. She had no verbal output or attempts at verbalization. Amantadine was considered by the primary team.

Which of the below comments is correct?

A. Amantadine can speed the rate of recovery
B. Amantadine can lower the seizure threshold and commonly results in seizures
C. Amantadine is the only studied pharmacologic agent in severe TBI that has shown improvement in functional outcomes
D. Amantadine can improve multiple behavioral domains, and the most commonly affected is vocalization
E. Although not fully elucidated, the mechanism by which amantadine works is through tubuloinfandibular pathway D2 receptor


Question 4#Print Question

A 21-year-old male with no past medical history is brought in via emergency medical services (EMS) for evaluation of a gunshot wound to the head. Police and EMS were called, and he was found at the scene awake, interactive but confused. There appeared to be a left frontotemporal entry site without an exit site. His initial vital signs were heart rate 136, BP 95/54, and SpO2 98% on 2 L nasal cannula (NC). His initial examination demonstrated an uncomfortable young man oriented to person only, following simple commands with antigravity movements throughout his extremities with some decreased movement on the right homebody. A head CT was completed (see figures below).

Which of these statements is most correct regarding penetrating head trauma?

A. Prognosis is better for penetrating head trauma than blunt head trauma
B. Extensive debridement of the scalp and bony wound should be undertaken, and accessible intraparenchymal bone and bullet fragments should be removed
C. Antibiotic prophylaxis with vancomycin should be started
D. Retained fragments in eloquent cortex increase the risk of epilepsy following penetrating head
E. The SAH demonstrated on the CT commonly leads to vasospasm and worse outcome


Question 5#Print Question

A 24-year-old male was a nonhelmeted motorcyclist hit by a car. EMS arrived to find him with labored breathing and intubated him. His GCS was 6 prior to intubation: eyes did not open, incomprehensible speech, and withdrawal of all extremities to painful stimulation. On presentation to the ED, he underwent a trauma evaluation and had nondisplaced parietal bone fracture, mastoid fracture, and multiple noncongruent rib fractures. His head CT demonstrated small bifrontal and temporal lobe intraparenchymal hemorrhages, a small amount of bilateral frontal SAH, and a 2 mm right frontal subdural hemorrhage. He was admitted to the neurologic intensive care unit (ICU) where a bolt was placed, which demonstrated a normal ICP. He continued in the same comatose state for 12 hours with a repeat head CT that was stable.

What is the next best test?

A. MRI of the brain with imaging including gradient echo sequence (GRE)
B. Long-term EEG monitoring (LTM)
C. Start hyperosmolar therapy to control pericontusional edema
D. Transcranial Doppler ultrasound for evaluation of possible vasospasm in the setting patient’s underlying SAH




Category: Critical Care Medicine-Neurologic Disorders--->Neurotrauma
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