head injury (tbi) m k alam, ms; frcsed. head injury (tbi) the most common cranial condition. decline...
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Head Injury (TBI)
M K Alam, MS; FRCSEd
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Head Injury (TBI)• The most common cranial condition.
• Decline in mortality:
• 50% 1970s to 36% 1980s to 27% 1990s to 15% 2000s
• EMS, Critical Care, CTs
• USA: brain injury occurs every 7s, result in death every 5
min
• TBI: 1/3 of all trauma related deaths
• Motor vehicle accidents: 50%
• Incidence: M:F 2:1
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Outcome of TBI
• Death : 30 -36%
• Severe Disability : 15%
• Moderate Disability : 14 – 20%
• Persistent vegetative state : < 5%
• Good Outcome : 25%
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Causes of trauma
• RTA or MVA• Pedestrian trauma• Fall from height• Assault• Industrial accidents• Natural disasters• Explosions• Firearm injuries• Knife
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Pre-hospital care• Delivery to the hospital for definitive care as rapidly
as possible- scoop and run
• Only critical interventions at the scene
• Airway established, hard collar, spine board, control any external hemorrhage
• Infusion on way to the hospital
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Hospital care
• ATLS approach
• A well defined order
• Primary survey- initial assessment and management
• Treat the greatest threat to life
• Immediate intervention as the threat to life is identified
• Detailed history not essential
• Re-evaluation of initial management
• Secondary survey- a head to toe evaluation
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Primary survey
• A B C D E• Airway & cervical spine protection
• Breathing
• Circulation
• Disability (neurologic assessment)
• Exposure and Environmental control
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Disability Neurologic evaluation
• Level of consciousness measured by the Glasgow
Coma Scale (GCS)
• If the GCS is used in intubated and paralyzed
patients, record should be made
• Pupillary response can still be assessed in a
paralyzed patient
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CLASSIFICATION OF TBI
Primary vs. SecondarySeverity - mild, moderate, severeMechanism
Closed (blunt) vs. PenetratingMorphology
Skull #sIntracranial lesion
Focal vs. Diffuse
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Glasgow Coma Scale (GCS), Total = 15 Eye response Vocal response Motor responseSpontaneous 4 Oriented 5 Obeys commands 6
To voice 3 Confused 4 Purposeful movement to pain 5
To pain 2 Inappropriate words 3
Withdraw from pain 4
None 1 Incomprehensible words 2
Flexion to pain 3
*** None 1 Extension to pain 2
*** *** None 1
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PUPILSUnilateral Dilated:
CN III compression secondary to tentorial herniationTraumatic Mydriasis
Bilateral Dilated:Inadequate brain perfusion, bilateral CN III compression
Bilateral Miotic: Drugs, metabolic encephalopathy, Pontine lesion
Unilateral Miotic:Injured sympathetic pathway (e.g. carotid sheath injury)
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Head injury severity
• Mild GCS ≥ 13
• Moderate GCS 9- ≤ 12
• Severe GCS ≤ 8
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Secondary Survey
• Only after completion of primary survey
• All life threatening injuries dealt, normalization of vital signs
Secondary Survey:
• A head to toe evaluation
• Detailed history and examination
• Continuous reassessment of vital signs
• Additional laboratory/ radiological tests.
• Additional tubes, lines and monitoring devices
• Priorities and plan definitive management of all injuries
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Head injury
• Traumatic brain injury (TBI)- the leading cause of death in trauma
patients. Upto 50% of all traumatic deaths.
• Primary injury- the anatomic and physiologic disruption that occurs
as a direct result of trauma
• Secondary injury- extension of the primary injury, result from local
swelling, increased ICP, hypoperfusion, hypoxemia, or other
factors.
• Aim- detection and treatment of primary injury and prevention of
secondary injury
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MILD TBI
• 80% of all TBI (GCS ≥ 13)• 3% of pts with mild TBI deteriorate• How could I know if my patient is in the
3%?• Classification of mild TBI:– Admission GCS– Duration of LOC– Post traumatic amnesia– Focal neurological deficits
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MODERATE TBI
• 10% of all TBI pts seen in ER (GCS 9- ≤
12)
• 10% will deteriorate
• CT head in all
• Admission
• F/U CT16
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SEVERE TBI
• GCS ≤ 8
• Will typically be evident by CT
• ICU required
• The worse the GCS the worse the
prognosis
• In this regard the motor component of
GCS is more important than the other 217
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SKULL FRACTURES
• Fracture patterns depend on:– Thickness–Morphology– Composite nature of the bone
• Types– Linear– Depressed (open or closed)– Basilar or Basal
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LINEAR FRACTURES
• Most common
• Direct impact to the cranium
• From a broad surface
• Separation of the # edges (diastasis)
• Thinnest areas of the skull
• Squamous portion of temporal bone & damage
of middle meningeal artery - epidural
hematoma19
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DEPRESSED FRACTURES
• Small surface area of the object
• Punched inwards• CSF leakage• Open (laceration of
scalp)• Infection• Seizures
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DEPRESSED FRACTURES
• Surgical intervention when:– > 8-10 mm depression (or > than the thickness of skull)– Deficit related to underlying brain– CSF leak– Compound fractures– Cosmetic region
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BASAL FRACTURES Direct trauma to
Mastoid (Battle’s sign)OccipitalSupraorbital (Raccoon
eyes)
Indirectly to
Cribriform plate
CSF leak
RhinorrheaOtorrhea
Cranial nerves Carotid artery
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Subdural hematomaMore common than EDH
Acute form is associated with other significant brain injuriesCerebral contusion (67%)
Highest Mortality rate: 60-70%. (acute SDH)
Can be subdivided into Acute - less than 3 daysSubacute - 3 days to 3 weeksChronic - after 3 weeks 23
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Subdural hematoma
• Surgical intervention when …– Symptomatic– SDH thickness > 1cm (5mm in Peds)– Midline shift > 5mm
• Positive Displacement Factor or shift out of proportion– Midline shift > SDH thickness
• Timing of Surgery:– Early : 0 – 4 Hrs from injury– Late : > 4 Hrs
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Epidural hematoma
• An acute lesion• Commonly seen in frontal or
temporal region • 75-90% of patients with
epidural hematomas will have fractures.
• Middle meningeal artery (85%)
• “Lucid interval”• Surgery: > 5mm midline
shift, symptomatic, detoriation of GCS
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Epidural SubduralHematoma Hematoma
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TRAUMATIC SAH• Most common lesion from
closed head injury.
• Significant SAH always associated with cortical contusions.
• Block arachnoid villus causing hydrocephalus.
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DAI (Diffuse axonal injury)
• Rotational injury forces (angular acceleration) can disrupt axons. DAI shows minimal gross alteration.
• SEVERITY: – Mild: coma 6 – 24 Hrs – Moderate: coma >24 Hrs without decerebrate posturing– Severe: coma > 24 Hrs + decerbrate posturing & flaccidity
– CLINICAL HALLMARK – prolonged loss of consciousness. – occurs immediately after the injury. – no correlation with external trauma or skull fractures.
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Intracranial hypertension
• Surgical intervention when:
– Progressive neurological deterioration
– Refractory high ICP
– GCS 6 – 8
– Frontal or temporal contusions >20 cm3
– Midline shift > 5mm
– Any lesion >50 cm3
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Late complications of TBI
• Posttraumatic seizures
• Communicating Hydrocephalus
• Post-concussive syndrome
– Cluster of Symptoms (organic / psychological)
• Dizziness, visual disturbance, anosmia, hearing difficulty
• Difficulty concentrating
• Emotional difficulties, insomnia
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Head injury- management summary
• Maintain BP >90 mmHg, PaO2 >60 mmHg
• Assess GCS and lateralizing signs- pupil and motor function
• Pupillary asymmetry >1 mm suggests intracranial injury
• Larger pupil is on the side of the mass lesion
• Extremity weakness- detected by testing motor power
• CT scan head- accurate localization of the lesion
• Epidural or subdural hematoma: evacuated• Intracerebral hematoma & contusion• Diffuse axonal injury: maintain brain perfusion & prevent rise in ICP.