TBI
What is our target ICP in TBI?
ICP < 22
What does PRVC stand for?
Pressure Regulated Volume Control
What three exam findings differentiate neurogenic shock from other types of shock?
1) neurologic deficit
2) bradycardia
3) pink/warm extremities
What length of line would you place in a L subclavian vein?
20cm
R central line: 16cm (subclav or IJ)
L central line: 20cm (subclav or IJ)
Fem central: typically 30cm
What is the most common side effect of Dexmedetomidine (Precedex)?
Bradycardia
If your TBI patient starts dumping urine, what are the two labs you should order immediately?
1) BMP
2) POC Urine Spec Grav
What tidal volume (cc/kg) do we target most commonly?
6-8cc/kg
When is atropine indicated in SCI? ____ AND ____
HR under 40 AND hypotension, chest pain, dizzy, nauseous (symptomatic)
An SVV greater than ___ on FloTrac suggests volume responsiveness?
10%
What is the maximum dose of levophed?
The limit does not exist!
(but typically 0.5-1mcg/kg/min)
What is your absolute last line medication to control refractory ICPs in TBI?
Pentobarbital
How far above the trachea should the end of the ETT be?
3-5 cm
What is target tidal volume in a pt with C1-C5 SCI?
8-12cc/kg
What diameter is a pigtail catheter?
14 Fr
What is levophed mixed in?
D5
A new forced downward gaze in a TBI patient is concerning for what?
Midbrain hemorrhage (or could be increased ICPs)
What is a RSBI, how do you calculate it, and why do we care?
Rapid Shallow Breathing Index: RR / Volume (L)
RSBI < 100, likely to wean
RSBI > 105, wean likely unsuccessful
ex: RR 30, Vt 250cc = RSBI 120
ex: RR 30 Vt 350cc = RSBI 85.7
What are common signs of autonomic dysreflexia?
Symptoms: hypertension, severe HA, bradycardia. Above level of injury: flushed, sweating. Below level of injury: pale, cool, dry
Pt w/ SCI at T6 or higher. Typically triggered by sustained stimulation BELOW the level of injury. Especially restrictive clothing, pressure injuries, full bladder, constipation.Where can you find a Cordis in the STICU?
Supply room near the IVF bags toward the bottom
Our TBI patients sometimes run into problems with hyperchloremia when we push their sodium so high. What IV fluid can you switch too that still has decent sodium content but less chloride content?
Plasmalyte (Electrolyte A in Epic)
What is triple flexion?
An involuntary, spinal-cord-mediated reflex: simultaneous flexion of the hip, flexion of the knee, and dorsiflexion of the ankle.
What value helps you differentiate poor lung compliance/stiffness from a problem with your sedation, ETT tube or vent circuit when peak pressures are high?
Plateau Pressure
What would an exam on an ASIA B T4 SCI look like?
No movement below chest. BUE movement intact. Sensation intact below level of injury.
https://asia-spinalinjury.org/wp-content/uploads/2019/04/ASIA-ISCOS-IntlWorksheet_2019.pdf
When do we check bladder pressures and what mmHg would be concerning?
Monitor for intra-abdominal compartment syndrome
Over 20mmHg accompanied by end organ dysfunction
When should you consider a bicarb drip?
pH under 7.2, HCO3 under 15,