Question 1

Intracranial pressure (ICP)monitoring has been initiated for a patient with brain injury.The child's ICP is 10 mm Hg,and mean blood pressure is 80 mm Hg.What is this child's CPP?

Accepted Answer

Compression of the brain tissue inhibits blood flow by reducing cerebral perfusion pressure (CPP)and causes cerebral tissue hypoxia,ischemia,and coma.CPP = mean BP - ICP and averages 85 ± 15 mm Hg.

Question 2

What is the mechanism of action of the osmotic diuretic mannitol in the setting of increased ICP?

Accepted Answer

Mannitol is given intravenously as a 20% solution.It does not cross the blood-brain barrier and remains in the plasma,creating an osmotic gradient that draws water from the brain into the capillaries,reducing cerebral fluid volume and therefore ICP.The effect is short term,and infusions must be given 3 to 6 times each day.

Question 3

Which of the following anatomic considerations in children are important to better understand trauma in this age group?
I.Children have less body fat.
II.Children have a small surface area relative to volume.
III.Children's skeletons are more pliable.
IV.Children have a greater distribution of force per unit body area of smaller body mass.

Accepted Answer

Children are not just small adults.It is important to understand the fundamental differences between adults and children.Notable are the size and shape differences.There is a greater distribution of force per unit body area because of smaller body mass resulting in greater acceleration.The child's body has less fat,elastic connective tissue,and close proximity of multiple organs.This can place the child with a penetrating injury at risk of multiple organ involvement.Children also have a large surface area relative to volume,predisposing them to thermal evaporative loss resulting in hypothermia.A child's skeleton is more pliable due to incomplete calcification.Trauma can result in serious organ injury without overlying skeletal fracture.

Question 4

Which of the following respiratory procedures must be avoided in a patient suspected of having direct cranial trauma?
I.Oral airway insertion
II.Nasotracheal suctioning
III.Nasotracheal intubation
IV.Nasogastric tube insertion

Accepted Answer

In patients with direct cranial trauma,avoid nasotracheal intubation,nasotracheal suctioning,or inserting nasogastric tubes because inadvertent cranial intubation may result through open fractures of the cranial vault,especially in patients who may have basilar skull injuries or paranasal fractures.In addition,irritating procedures such as nasopharyngeal or nasotracheal suctioning,insertion of a nasogastric tube,or intubation may result in an exacerbation of an already increased intracranial pressure.

Question 5

What is the meaning of the word plasticity when used to describe brain damage in infants?

Accepted Answer

The brains of infants and children apparently have a large degree of plasticity (i.e. ,adaptability)in redistributing function from a damaged area to an undamaged area.In adults the ability of brain segments to adapt to new functions seems to be rarely,if ever,present.

Question 6

The therapist is instituting hyperventilation to a child with intracranial hypertension.What should be the lowest PaCO₂ before brain ischemia can occur?

Accepted Answer

ICP declines within seconds of beginning hyperventilation.The mechanism is vasoconstriction resulting from hypocarbia.The goal is to lower the partial pressure of arterial carbon dioxide (PaCO₂)from 40 to 25 mm Hg.Further reduction can result in cerebral ischemia and is contraindicated.

Question 7

What should be always assumed in the case of traumatic injury regardless of the mechanism?

Accepted Answer

The initial assessment is the same for all pediatric patients who have sustained a traumatic injury regardless of mechanism.Always assume cervical spine injury and take necessary precautions during the assessment.The head and neck should be held in line with the body by placing a cervical collar or by assigning an individual to hold the patient in C-spine precautions.

Question 8

Why are infants and children highly vulnerable to head injury?
I.Their head is large and heavy compared with the rest of the body.
II.They lack mature judgment.
III.They are uncoordinated.
IV.They tend to move too fast.

Accepted Answer

A child's head is large and heavy in relation to the body.Therefore,the center of gravity shifts toward the head.In addition,a child's balance,coordination,gait,and judgment are immature,which results in children being especially vulnerable to falls with head injury.

Question 9

A respiratory therapist working in the emergency department has received report of a patient who suffered a traumatic brain injury and whose Glasgow Coma Scale score is 8.What should the therapist anticipate doing when the patient arrives?

Accepted Answer

If the GCS is less than or equal to 8,the patient likely does not have the ability to protect his/her airway and a more definitive airway should be established.Intubation is the most common option for a definitive airway,with cricothyroidotomy being a secondary option.

Question 10

A respiratory therapist is asked to rapidly assess adequacy of peripheral circulation while an intravenous line is placed.Which of the following methods should the therapist use?

Accepted Answer

Assessing capillary refill is a quick and specific method of checking the adequacy of peripheral circulation.One method of determining capillary refill is to depress the patient's thumb nail with moderate force.This will cause the underlying tissue to blanch (turn white or pale pink)by forcing blood from the tissue.Releasing the pressure allows blood to refill the tissue's capillaries.Normal capillary refill time is less than 2 seconds.Inadequate capillary refill on initial assessment may be caused by regional perfusion problems.To rule out this possibility,repeat the capillary refill test on the opposite hand.

Question 11

A child is admitted to the emergency department displaying an abnormal breathing pattern consisting of random,ineffective,haphazard breaths and pauses.What is the name of this breathing pattern?

Accepted Answer

Hypothalamic and midbrain damage results in rapid,sustained,deep hyperventilation (central neurogenic hyperventilation).Injury to the medulla and the pons affects the respiratory centers and produces several different patterns: apneustic breathing,with a prolonged pause at full inspiration;ataxic breathing,which consists of random,ineffective,haphazard breaths and pauses without a predictable pattern;and primary alveolar hypoventilation (Ondine's curse),a failure to breathe while sleeping,which is the failure of automatic breathing centers when asleep.

Question 12

Which of the following conditions results from the fracture of adjacent ribs in at least two places along the same ribs?

Accepted Answer

When several adjacent ribs are fractured in two areas,a flail segment of the chest wall may be produced.This segment of the chest moves in paradoxical fashion with respiratory effort,collapsing with inspiratory effort and expanding with expiration.This paradoxical motion interferes with tidal ventilation of the ipsilateral lung and,in conjunction with pulmonary parenchymal contusion,may cause serious respiratory embarrassment.

Question 13

A respiratory therapist arrives at the scene of an accident to assist a victim of a motor vehicle accident.What would the best method to open the airway until a full assessment is completed?

Accepted Answer

A patent airway can be initiated by means of a jaw thrust maneuver to open the airway.Maintain the airway with orotracheal intubation,nasotracheal intubation,cricothyrotomy,or tracheostomy.In order to maintain cervical spine stabilizations,do not use the head tilt,sniff position,or chin lift maneuvers because these procedures change the orientation of the spinal column and increase the risk of additional spinal injury.The jaw thrust technique may be used in these children unless otherwise contraindicated.

Question 14

A 3-month-old baby suspected of having a life-threatening encephalopathy is being transported from a rural area.Which of the following signs may assist in the confirmation of intracranial hypertension?

Accepted Answer

Increased ICP can be a life-threatening feature of an encephalopathy.CSF and blood acting on the brain and bony structures of the skull generate ICP.In the newborn and infant,measuring the head circumference and palpating the anterior fontanel allow rapid assessment of ICP.Bulging of the fontanels may be a key sign of increased ICP that requires a response by caregivers.

Question 15

Which of the following areas is evaluated on the Glasgow Coma Scale,used for the neurologic assessment of adults,older children,and adolescents?

Accepted Answer

Immediate assessment of neurologic status is beneficial in acute trauma management.The most common way to perform this assessment is with the Glasgow Coma Score (GCS).Patients are scored in three areas: eye opening,verbal response,and motor response.Although the standard GCS is accurate for use in adults,older children,and adolescents,the age-specific GCS combines adult and child forms so it is applicable to all ages.The age-specific GCS is particularly useful in nonverbal children.

Question 16

Which of the following factors provide infants and young children protection against head trauma by allowing a degree of expansion of the cranial volume?
I.Reduced cranial weight
II.Less cranial ossification
III.Presence of fontanels
IV.Presence of flat bones

Accepted Answer

Infants and young children also have malleable skulls because of the large fontanels ("soft spots")and the flat bones of the skull,which have not yet fused and still may be cartilaginous before ossification.These factors allow for elasticity of the cranial vault and lessen or prevent both fractures and pressure-related brain injuries during passage through the birth canal.Skull malleability also protects against damage from other sources,such as trauma or illness,causing increased pressures in the cranial vault.This protection occurs by allowing a degree of expansion of the cranial volume.

Question 17

The respiratory therapist has intubated a patient with a traumatic brain injury whose respiration has deteriorated.Which of the following ventilatory strategies should the therapist try to minimize the effects on intracranial pressures?

Accepted Answer

Minimizing peak inspiratory pressure can help reduce the risk of increased intracranial pressure, which is crucial in managing patients with traumatic brain injury.

Question 18

A patient with status epilepticus has been treated with benzodiazepines and phenobarbital without success.Now a pentobarbital coma is indicated.What should the therapist do at this time?

Accepted Answer

If none of the medications administered are effective in stopping the seizure,a pentobarbital coma may be necessary.For this,the patient should be intubated and mechanically ventilated,and vital signs need to be monitored closely.

Question 19

A child with a head injury displays bruising discolorations around the orbits,or "raccoon eyes." What does this indicate?

Accepted Answer

Some classic "signs" are associated with certain head injuries.These signs indicate fractures of the basilar skull.Traumatic head injury may be highlighted by the presence of Battle's sign or "raccoon eyes." Battle's sign represents ecchymosis,or bruised areas behind the ear that indicate basilar skull fractures.The self-explanatory term raccoon eyes represents bruising discolorations around the orbits.Both Battle's sign and raccoon eyes are the body's attempts to show internal injury with as simple a sign as a small bruise.

Question 20

What is the normal value for intracranial pressure?

Accepted Answer

Normal intracranial pressure is 130 mm H₂O (10 mm Hg).

Quiz 31: Pediatric Trauma

Intracranial pressure (ICP) monitoring has been initiated for a patient with brain injury.The child's ICP is 10 mm Hg,and mean blood pressure is 80 mm Hg.What is this child's CPP?