Herniation.Syndrom.

[eightyonegs11]

I am testing this weekend ACP and of course second guessing myself on a few things could I ask if a patient has TBI in order for me to hyperventilate at 20 breaths/min would the patient have to exhibit all symptoms of herniation syndrome. Cushings reflex, blown pupils and extensor posturing or just 2 of the 3 cushings reflex and blown pupils for example.

Second question, suspected head injury with or without icp I can give 12.5 g D50W slow iv push and if needed I can give other half my question how long should I wait before giving second dose if needed?

Sorry for the silly questions up until today I felt comfortable guess it's just pretesting jitters!

Thank you,

Andy.

Edited June 9, 2011 by eightyonegs11

[mobey]

I am testing this weekend ACP and of course second guessing myself on a few things could I ask if a patient has TBI in order for me to hyperventilate at 20 breaths/min would the patient have to exhibit all symptoms of herniation syndrome. Cushings reflex, blown pupils and extensor posturing or just 2 of the 3 cushings reflex and blown pupils for example.

If ACP wants you to hyperventilate, they will make it obvious... dont sweat the little trivial shit like this at ACP.

BTW: The ore direct answer is YES.

Second question, suspected head injury with or without icp I can give 12.5 g D50W slow iv push and if needed I can give other half my question how long should I wait before giving second dose if needed?

You only need to wait as long as it takes for 12.5g of Dextrose to be metabolized.

[tniuqs]

Ok I believe I am having pre-stroke S/S, if "on ACoP the website" it is stated Evidence Based Medicine are the new "targets to perfection" in patient care ? Just WHY is an ACP examiner asking you to Hyperventilate a head injury as they misinformed:

Firstly they do not understand that a respiratory rate of 20 has NOTHING to do with Hyperventilation !!! .. PaC02 > 30 defines hyperventilation !(see Shapiro)That would be effective minute volume not rate, the use of ETC02 is highly advised although these days I am hard pressed to believe most understand its many applications or complications of values. GGB.

Secondly: evidence based medicine is mostly conclusive that hyperventilation and even if their are signs of severe traumatic brain injury (ICP can not be assumed it is a measure value) .. is HARMFUL and this modality in "therapy" just gives the provider something to do while watching the patient die.

Here is the simple math, ICP + MAP = CCP ... Mean Arterial Pressure (being a fixed value in this case say > than 20 mmhg ) if one by theoretically constricting blood flow in circle of Willis, with lower PaC02 hence magically lowering the ICP (ps these mechanism is transient) ... but ask yourself a question: Why are you attempting to lower Cerebral Perfusion Pressure to cause a decrease in blood flow to the brain and produce more ischemic brain cells ?

Frankly ACP (very old school) level S/S of herniation or "coneing" hyperventilation the patient is just giving you something to do while watching the patient die, and if you manage to get the patient alive to an ICU the attending MD will be doing some bedside "teaching" upon admission.

http://scholar.google.ca/scholar?q=hyperventilation+head+injury+patients&hl=en&as_sdt=0&as_vis=1&oi=scholart

Dear mobey is this the expected ACoP examination response ?

Ok another query in this patient with or without increased ICP (as for increased ICP) D50W is ill advised in fact outcome studies are suggestive that hyperglycaemia is associate's with poor outcomes, and then why is one giving D50W in the first place a TBI post hypoglycaemic event ?

http://journals.lww.com/neurosurgery/Abstract/2000/02000/The_Influence_of_Hyperglycemia_on_Neurological.15.aspx

Yes, I know mannitol can be considered a "sugar alcohol", yet another topic for a another on line date (see cerebral oedema) I believe AHS pulled it off Air Ambulances ?

I believe my answer would include monitoring or serial BGL with any hypoglycemic presented patient, treating to maintain "normal" blood glucose values. ie prn.

cheers

GGB = Good Grief Batman

Edited June 11, 2011 by tniuqs

[DartmouthDave]

Hello,

Is the D50W give to to drop ICP?

Interesting post so far.

Cheers

[tniuqs]

Correction(s) <insert lame excuses> some days I should actually read what I write before hitting ADD REPLY ! my bad ? When I see "old wives tales" perpetuated by a body that regulates, examines and believes they are "world leaders" .. simply stated I loose my fricken mind !

PaC02 < 30 defines hyperventilation (see Shapiro)

CCP = ICP minus MAP

Mean Arterial Pressure ICP (being a fixed value in this case say > than 20 mmhg )

ps I can't believe Dave didn't bust my balls with these glaring errors.

cheers

[DartmouthDave]

Hello,

I knew what you ment.

LOL

Cheers