The Traumatic Brain Injury Survivor

This hot case typically has three major areas of interest:

  • Severity of injury, neurological deficits
  • Effectiveness of ICP control and neuroprotective measures
  • Complicatons (VAP, ventriculitis, slow ventilator wean etc)

Previous hot cases with this sort of theme to them can be found below.

Examination of the Traumatic Head Injury Patient

The standard introduction

  • The examiner will give you a history.

The prelude to the dance

  • Wash hands.
  • Gown and glove.
  • Ask, if relevant:
    • "Can I turn on all the lights?"
    • "Are there any movement restrictions? Can I sit them up, or roll them on their side?"
    • "Is there a language barrier?"
  • Introduce yourself: “Hi Mr or Mrs Bloggs, I’m Dr So-and-so. I’m going to examine you.”

The Monitors

  • Rhythm
  • Rate
  • Morphology: QRS width,
  • MAP and abnormal morphology of the arterial waveform
  • CVP and abnormal morphology of the CVP waveform
  • Ancillary waveforms eg. the PA catheter waveform
  • Oxygen saturation measurement, and the quality of the waveform
  • ICP and waveform
  • End-tidal CO2 waveform and level

The Ventilator

One can ask the examiners the following questions:

  • How are we oxygenating this patient?
  • How are we ventilating this patient?
 

One should ask about the following parameters:

  • FIO2
  • PEEP
  • Peak pressure
  • Plateau pressure
  • Tidal volume and minute volume

One should ask to look at the pressure-volume loops.

A decreased lung compliance might suggest pneumothorax, or pulmonary contusions.

Urine catheter

  • Unusual colour
  • Anuria
  • Haematuria
  • Tea-coloured urine of rhabdomyolysis
  • Polyuria of DI or CSW

Drains (surgical, intercostal, etc)

There may be surgical drains (what is in them? How much of it?). Asking how much has been coming out may be relevant in a hot case which focuses on the diagnosis of a shock state.

The pleural catheters are also interesting. One should make a mental note of whether the ICCs are on free drainage or on suction. The content of these drains could be informative, especially if one notices blood or chyle.

Infusions

This stage is critically important. The drug and fluid infusions which are currently in progress give a clue as to what problem is currently being addressed. One should not neglect the labelled bags; the choice of antibiotics gives one some idea of where the source of sepsis is thought to be.

Specifically, one should focus on blood products and evidence of rescue osmotherapy for raised ICP (eg. hypertonic saline or mannitol).

Thiopentone may be running.

EVD

One should observe the following features of an EVD:

  • Set height
  • Whether it is open or closed
  • The CSF colour - eg. is it full of blood?

The physical examination

Expose and observe

Ideally, one should get the patient sitting up to 30-45°. This may not be possible. However, one should still ask for it.

Ideally, the patient should be exposed from the waist up. The candidate can then stand back and look for anything externally obvious:

  • Skin colour, eg. jaundice or the discolouration of chronic renal failure
  • Muscle wasting, obesity
  • The evidence of trauma, wound dressings, etc
  • The pattern of breathing (eg. whether there is a characteristic chest flail)
  • All obvious injuries

GCS

Performing the GCS should be the first step, unless you notice that a neuromuscular junction blocker is among the infusions. The level of consciousness then determines how you go about examining the rest of the patient.

A traditionalist, who is examining Mr Bloggs, would approach the GCS in the following manner:

  • Grab hold of both of the patient's hands.
  • "Mr Bloggs!" One pauses to observe for eye opening.
  • "Can you squeeze my hands?"
  • If hand squeezing and eye opening is not observed, one administers a painful nail bed stimulus to both hands, to observe the response to pain.

Characteristic posturing may be observed.

Hands, nail signs, pulse and the arterial line.

One has just performed a GCS assessment; one is still holding the hands.

Now, time to look at them more closely.

First, one should spent a second assessing whether they are warm or cold.

Then, one can spend a moment on the nails. Nail signs are numerous and deserve their own page. This should not be a prolonged scrutiny.

Assess the pulse. While one still has both of the patient's hands, one ought to try to compare the radial pulses. An aortic dissection may result in a radioradial delay, or an asymmetrical pulse amplitude.

Arms

Tone of the upper limbs

Move up from the hands. While you are still holding the hands, you can perform a sort of gross examination of tone by pronating and supinating the wrists, and by flexing and extending the elbows.

Ask the examiners whether this is appropriate before going ahead- one does not want to be testing the tone of a multiply fractured limb.

Cubital fossa

Examine the cubital fossa for

  • Peripheral lines, rapid infuser sheaths
  • Evidence of multiple venepunctures
  • Lymph nodes
  • Brachial pulse
  • The presence of an obvious AV fistula

One should then palpate the axillary lymph nodes.

The Neck

  • Inspect any central lines
  • Look again at the CVP
  • The C-spine collar may still be present. One might ask to have it removed, so that one can inspect the neck (but they won't let you).

Palpate the neck:

  • Trachea: is it midline? Is there a new tracheostomy there?
  • Thyroid gland
  • Cervical lymph nodes
  • Carotid pulse - one side at a time!
  • Submandibular lymph nodes
  • Pre- and post-auricular lymph nodes

Pupils and the higher cranial nerves

One should take a moment to inspect the head for injuries.

If there are any head injuries, particularly features of a base of skull fracture, the candidate should examine the cranial nerves with as much detail as possible.

Thus, this section can be divided into three broad groups:

The paralysed patient The unconscious patient The awake patient

Visual acuity

A Snellen chart is ideal, but probably will not be available.

The extubated patient should be able to read the time on the clock in the room.

One performs this test with each eye individually.

This tests CN II.

Light reflex

Ask the examiners to dim the room lights.

Open both eyes. Each eye is exposed to light. The opposite pupil should constrict consensually.

This tests CN II (afferent) and CN III (efferent).

Corneal reflex

The cornea (not the sclera) is touched lightly with a moistened corner of a piece of gauze.

A normal reflex is to blink.

This tests CN V (afferent) and CN VII (efferent)

Eye movements

The conscious patient will be able to follow the tip of the candidate's finger.

The pattern of movements should be tracing the six cardinal points: superior left, inferior left, superior center, inferior center, superior right, inferior right.

This tests CNs III, IV and VI.

Facial pain sensation

Typically, this is performed by putting some pressure on the superior orbital notch.

The patient should either open their eyes or localise.

This tests CN V.

Facial movements

The conscious patient will be able to perform a series of grimaces to assess the bilateral motor control of facial muscles:

  • Raise eyebrows to wrinkle forehead
  • Squint eyes to assess periorbital muscles
  • Bare teeth to assess nasolabial muscles
  • Blow out cheeks

Oculocephalic reflex

In the comatose patient, as the head is moved from left to right, the eyes should move in the opposite direction. A fixed unchanging gaze is a negative test; the reflex is not working.

This tests CNs III, IV, VI, and most importantly VIII.

Cold caloric reflex

Cold water is funneled into the patient's ear. A positive reflex consists of the eyes turning towards the chilled ear. This is a more potent stimulus for CN VIII than the oculocephalic reflex.

Airway and the lower cranial nerves

Now that one has finished with the upper cranial nerves, one can move on to the mouth, airway, and swallowing apparatus.

Gag reflex

The Yankeur sucker is used to probe the posterior pharynx, on both sides. A gag reaction should result from this.

This collectively tests CN X and IX.

Cough reflex

While on the subject of CN X, one may test the cough reflex by suctioning the trachea.

This tests CN X.

This is also a convenient time to ask about the volume and character of the secretions.

Tongue movements

The conscious patient is asked to protrude their tongue, and move it from side to side.

This tests CN XII.

Uvula deviation

The uvula deviates away from the lesion.

This tests CN X and IX.

Shoulder shrug

The conscious patient is asked to shrug their shoulders against resistance.

This tests CN XI.

Thus, the whole process should look like this:

  • Ask the patient to read the time in the room (or similar)
  • Ask the examiners to dim the room lights. Open both eyes and test the light reflex and consensual pupillary constriction.
  • Test the corneal reflex with a moistened gauze piece.
  • Test eye movements by asking the patient to follow your fingertip with their eyes.
  • Test for facial pain sensation
  • Ask the patient to grimace: raise eyebrows, squint eyes, bare teeth, blow out cheeks.
  • Test the oculocephalic and/or cold caloric reflex in the comatose patient.
  • Test the gag reflex with the sucker.
  • Test the cough reflex by suctioning the trachea.
  • Open the patient's mouth, and look for a deviated uvula.
  • Ask the patient to stick out their tongue and move it from side to side.
  • Ask the patient to shrug their shoulders.

During the cranial nerve examination, one will inevitably end up tripping over the endotracheal tube. One should note whether there is anything unusual there; for instance, is there a dual-lumen tube, or a bronchial blocker?

Chest palpation, percussion and auscultation

Palpation:

One puts both their hands on the chest to assess the symmetry of chest expansion.

The whole chest must be palpated.The crepitus of subcutaneous emphysema cannot be missed. Plus, one needs to find the flail segment, if there is one.

Percussion:

One might wish to percuss the chest.

Changes in percussion resonance may be worth commenting on.

Auscultation:

One may begin by auscultating the apices anteriorly. Then, one should auscultate as posteriorly as possible. The money is in the bases.

Palpation and auscultation of the praecordium

Palpation:

The clever candidate will make a big show of palpating both the apex and the right sternal edge.

Auscultation:

One should auscultate in the following sequence:

  • Apex
  • Left sternal edge, lower
  • Left sternal edge, upper
  • Right sternal edge, lower
  • Left sternal edge, upper
  • Both carotids

The various clicks and murmurs one encounters are discussed elsewhere.

Abdominal palpation, percussion and auscultation

For this, one should ask to lay the patient flat.

Abdominal observation

  • Take a moment to behold the abdomen. One may ask the examiners to look under any surgical dressings; one is likely to be denied this part of the examination (they will tell you the wound looks clean and dry).

Abdominal palpation

  • All quadrants should be palpated.
  • Then, feel for the liver edge; observe respiratory excursion
  • Then, feel for the spleen.
  • Then, try to ballot the kidneys. Enquire about renal tenderness.

Abdominal percussion

  • This can double as a test for peritonism.
  • If there is some suspicion of ascites, one may ask to roll the patient, so shifting dullness can be better appreciated. The examiners may not permit this test.

Abdominal auscultation

  • One should spend a good length of time on this, if one suspects bowel obstruction or ileus.

Examination of the pelvis and groins

The pelvic content would have been palpated during the abdominal examination.

The more important part of this examination is the groin.

At this stage, the patient should be re-draped - cover them from the waist up, and uncover their legs.

Observation and palpation of the pelvis:

  • There may be a rash of thrush, or a groin haematoma, or an external fixation device.
  • The posterior pelvis and sacrum should ideally be palpated for pitting oedema.

Examination of the lines

  • One should take notice of anything going into or coming out of the femoral vessels.
  • There may be a vascath, a PiCCO catheter or some sort of angiography sheath. These are important clues. Why did this patient get an angiogram? Was there pelvic haemorrhage?

Examination of the genitals and rectum

  • A complete examination would call for the palpation of the testes, and a comment on their size. However, this may not be practical.One should at least comment on any sort of scrotal haematoma.
  • One should take note of any sort of waste management devices, eg. rectal tube, SPC or IDC.
  • One should definitely ask about performing a PR.
  • If one is forbidden from performing the PR, one should ask about the following features:
    • Anal sphincter tone
    • Size and quality of the prostate
    • Presence of melaena or hard stool

Once one is finished with the pelvis, one should cover it again, so that only the legs are sticking out.

Examination of the lower limbs

One should ask to remove TEDs and compression stockings.

  • One should observe whether the lower limbs are mottled, and whether they are of the same size (assymetrical swelling leads one to suspect lymphoedema or DVT)
  • One should palpate the larger muscles. Muscle swelling is an important feature of compartment syndrome. Additionally, one gets to appreciate the temperature difference between the limbs, which could be important in the assessment of peripheral vascular injury.
  • Pitting oedema should be palpated.

Leg muscle tone

The best way to test muscle tone is by holding the knee. Roll the knee gently to distract the patient; then try to lift it off the bed. In the presence of increased tone, the leg will remain straight and the whole thing will lift up; with normal or decreased tone, only the knee will bend

Calf tenderness

In the conscious patient, one might be able to assess whether a gentle calf squeeze produces the characteristic pain which suggests a DVT may be present.

This brings one to the feet, and to the beginning of the neurological examination.

Feet and the Babinsky reflex

The feet would have already been palpated to assess their temperature, and to look for pitting oedema.

Observation of the feet

One should look specifically for changes suggestive of chronic diabetic foot disease, or chronically poor vascular supply.

Palpation of the feet

This should consist of palpating the dorsalis pedis and posterior tibial pulse.

Babinsky reflex

One should test the Babinsky bilaterally.

Clonus

One should attempt to assess clonus in both feet.

Power in the lower limbs

Now is the time to properly start the neurological examination of this patient.

Power of the muscle groups may be tested in the following sequence:

  • Ankle dorsi and plantarflexion
  • Knee flexion and extension
  • Hip flexion, extension, adduction and abduction.

Power in the upper limbs

The patient has spent most of this time flat and supine. Time to sit them back up again.

Power of the upper muscle groups may be tested in the following sequence:

  • Hand grip
  • Wrist dorsiflexion/palmarflexion
  • Elbow flexion/extension
  • Shoulder adduction / abduction

Reflex testing

Now that one is back to the upper limb, one may as well start their reflex tests there.

The reflexes may be tested in the following order:

  • Brachioradialis
  • Biceps
  • Triceps
  • Knee jerk
  • Ankle jerk

Sensory testing

After testing the ankle jerk reflex, one is again back to the feet.

At this stage, with a conscious patient, one may wish to test light touch sensation.

The following order (with corresponding dermatomes) is suggested:

  • Sole of the foot (S1)
  • Lateral lower leg (L5)
  • Medial lower leg (L4)
  • Medial knee (L3)
  • Anterior upper quads (L2)
  • Umbilicus (T10)
  • Nipple level (T5)
  • Medial forearm (T1)
  • Pinky finger (C8)
  • Middle finger (C7)
  • Thumb (C6)
  • Lateral forearm (C5)
  • Posterior shoulder (C4)

The cerebellar examination of the critically ill patient

Now, usually, the cerebellum requires all sorts of dynamic manoeuvres- one should assess the gait, balance, speech, and so forth. The intubated ICU patient does not permit the majority of these. They are so entangled in tubes they may not be able to perform dysdiadochokinesis.

The following is a list of cerebellar tests one may be able to perform with an intubated ICU patient.

Many of these findings would have been discovered during earlier stages of the examination.

Nystagmus

This would have become apparent during the testing of the eye movements.

Resting tremor

This would have become apparent during the test for nystagmus

The finger-nose test

This is an assessment of coordination. The patient is asked to alternate between touching their nose and touching the finger of the candidate, who keeps changing its position.

The heel-shin test

The patient is asked to run the heel of one foot along the shin of the opposite leg.

The measured observations

Ask to see the obs chart. If it is not allowed, ask for the following:

  • Trends of blood pressure and heart rate
  • Temperature
  • Drain output - very important for chest drains!
  • Urine output
  • CSF volume

One may also wish do demonstrate an interest in the trends of any sort of advanced haemodynamic monitoring, eg. cardiac index as measured by PAC or PiCCO.

The laboratory investigations

One needs to show an interest in the following labs:

  • ABG
  • Routine bloods - particularly, coags and FBC
  • Urinalysis
  • Culture results
  • CK, troponin, LFTs, pancreatic enzymes, inflammatory markers...

Imaging and other investigations

One should always ask for the following:

  • ECG
  • CXR
  • CSF analysis
  • CT or MRI results

 

Case presentation and discussion

"Mr Bloggs is suffering from [severe, moderate, mild] head injury."

"This is complicated by [raised ICP, ventriculitis, VAP, aspiration, C-spine trauma, other injuries]"

"I base this assertion on the following findings: [insert clinical findings here]"

"In my survey, I have also found the following injuries: [insert clinical findings here]"

"I would like to confirm my diagnosis with the following investigations: [insert appropriate investigations]"

"My management of his intracranial pressure would consist of the following strategies: [a brief list of management priorities]"

"The other management issues are as follows: [a brief list of management priorities]"

"I would approach the management of these issues in the following manner: [list of management strategies; it helps to organise this into an A,B,C,D,E approach if one has a complex multisystem problem to manage]"

Number of previous hot cases in this topic: 20

2015, Paper 1

Unspecified hospital in Melbourne

26 - year - old male day 4 ICU following fall from roof. He had sustained a severe head injury with extradural haematoma, contrecoup inju ry, SAH and temporal bone fracture extending to carotid canal. On examination there was a craniotomy scar and a pack in his left ear and he was waking up, localising with both upper limbs.
Candidates were asked to examine him with a view to assessing the severity of his head injury, and any other associated injuries likely to affect his recovery.

Unspecified hospital in Melbourne

69-year-old male, day 2 ICU following a fall from a standing height. Background history included hypercholesterolaemia, C-spine fusion and insulin dependent T2DM. His injuries included intracranial haemorrhage and base of skull fracture with blood in the right external auditory meatus. Candidates were asked to examine him with a view to identifying his main injuries and any ongoing issues

Unspecified hospital in Melbourne

A 23 - year - old man with a severe traumatic brain injury following a motor vehicle accident. Patient h a d poor conscious level with non - reactive pupils and a CSF leak. Candidates were told the family wished to meet to discuss prognosis, and to exami ne the patient and present their findings.

Unspecified hospital in Melbourne

A 77 - year - old male admitted two days ago, having fallen down the s tairs. Found unconscious by his wife and intubated at the scene by paramedics. Underwent an emergency craniotomy. Candidates were asked to examine him with an emphasis on neurology and injuries, and to present their plan of management for the day.

2014, paper 2

Unspecified hospital in Sydney

  • 67-year-old female, day 7 post elective left common carotid stent placement , heparinised for visual disturbance day 1 post stent, complicated by large subdural and intra-parenchymal bleeds and refractory intracranial hypertension despite bilateral craniectomies. Clinical findings included sedation to control ICP, the presence of a femoral arterial puncture site, bifrontotemporal craniectomies and bilateral subdural drains, dilated unreactive pupils with absent corneal and oculo-cephalic reflexes and generalised hyporeflexia.
  • Candidates were directed to assess her neurological status and discuss what they would say to the next-of-kin.

Unspecified hospital in Sydney

  • 39-year-old male, day 6 in the ICU, who presented following a head injury while intoxicated. He was slow to recover neurological function post-operatively. Clinical findings included invasive ventilatory suport, temperature of 38 degrees, right hemiplegia, brisk reflexes in left leg, bilateral upgoing plantars, normal brainstem reflexes, signs of left sided pneumonia. His CT showed an acute extradural haematoma.
  • Candidates were asked to assess the patient with regards to potentially reversible factors that may be contributing to his slow neurological recovery.

Unspecified hospital in Sydney

  • 27-year-old man, day 5 ICU. Post op evacuation of left parietal extradural haematoma. Clinical findings included a craniotomy scar, fever, decreased air entry at the left base and bronchial breath sounds at the right.
  • Candidates were informed the patient had been found wandering the streets in an agitated state, and on arrival at the hospital had dropped his GCS from 13 to 7. They were asked to begin by examining the patient’s neurology.

Unspecified hospital in Sydney

  • 84-year-old man, Day 2 ICU. Background of traumatic brain injury following a fall. Currently agitated, requiring restraints. Clinical signs included a GCS score of 6, left hemiparesis, left facial haematoma, left basal bronchial breathing and a soft systolic murmur.
  • Candidates were informed the patient had been admitted to ICU 2 days previously having been found at the bottom of his stairs with a GCS of 3. They were asked to examine his neurological system as well as any other systems they thought appropriate and give an overview of his present condition.
2013, Paper 1

Royal Adelaide Hospital

  • 25-year-old woman, day 10 in ICU, with a severe traumatic brain injury post MVA (GCS 3 at the scene) and a new fever. Candidates were asked to examine her with a view to assessing her prognosis.
2012, Paper 1

Princess Alexandra Hospital

  • 53-year-old man who fell from a balcony 5 days earlier, sustaining a traumatic brain injury, chest trauma and unstable fracture T12. Candidates were asked to assess him paying particular attention to his neurological state, interpret his CXR and CT chest and discuss which investigations would be helpful in evaluating his neurological state
2011, Paper 2

St George Hospital

  • 23-year-old male with multi-trauma including traumatic brain injury with refractory intracranial hypertension despite decompressive craniotomy, sedation, paralysis and hypothermia. Candidates were asked to assess the patient and discuss management of intracranial hypertension

Royal North Shore Hospital

  • 20-year-old male with severe traumatic brain injury secondary to fall from skateboard, decompressive craniotomy, intracranial hypertension, aspiration pneumonitis with lower zone collapse/consolidation, ventilated with NO
2010, Paper 1

Alfred Hospital

  • A young man involved in a MVA, had severe TBI and had ongoing issues of sepsis, MODS with slow neurological recovery. Candidates asked to examine patients and formulate a plan.
2009, Paper 2

Royal Prince Alfred Hospital

  • A 64 year old man with previous Parkinsonian features following a traumatic brain injury admitted to ICU with decreased conscious level. Discussion topics: Parkinsonian features, septic encephalopathy, prognostication, management of wean.

Royal North Shore Hospital

  • A young man 11 days post severe TBI making poort neurological progress. His family want a meeting to discuss withdrawal of care. Candidates asked to examine him and discuss how they would approach this case.
2009, paper 1

Royal Brisbane Hospital

  • 17 year old pedestrian admitted 48 hrs ago following an MVA. Deeply unconscious at the scene, difficulty in securing the airway due to blood in the airway. Candidates were asked to assess neurological state and outline plan of management.
    Other issues – comment on CT head, management of ICP, family discussions
    Areas of weakness identified by examiners:
    • Poor systematic examination of the relevant neurology.
    • Application of pain to a paralysed fully sedated patient.
    • CT scans: difficulty with simple diagnosis including distinguishing between an extradural and subdural
    • Inability to summarise the neurology and formulate a management plan including a realistic view of the prognosis for discussion with the family.
2008, Paper 2

Unspecified hospital

  • A 32 yr old lady admitted with isolated head injury and candidates asked to assess neurology.
2007, Paper 2

Unspecified hospital

  • A young man with traumatic head injury, facial fractures, traumatic mydriasis, Discussion: on ICP management, interpretation of CT scans, pupillary signs

Unspecified hospital

  • 22 yr old male with severe head injury after a fall from a horse. Had bifrontal craniectomies. Discussion: on ICP management, neurological prognosis

Unspecified hospital

  • Male in his 60's with traumatic brain injury who had a craniectomy and ICP monitor in situ and was generally hypertonic and hyperreflexic. Discussion: Candidates asked to determine his prognosis