management of traumatic brain injury
TRANSCRIPT
Management of Traumatic Brain Injury
Nakornchai Phuenpathom M.D. Department of Surgery
Faculty of Medicine Prince of Songkla University
Definition
• A patient was classified as one with a head injury if he had one or more of the following features:
• Definite history of a blow to the head
• Laceration of the scalp or forehead
• Altered consciousness after a relevant injury, no matter how brief
Scottish Head Injury Management Study. Head injuries in Scottish Hospitals. Lancet 1977; 2: 696-698.
What is TBI?
A blow or jolt to the head that disrupts
-the function of the brain
- a person’s life
-the lives of their families/caregivers.
Traumatic Brain Injury (TBI)
• An alteration in brain function manifest as: – Confusion – Altered level of consciousness – Seizure – Coma – Focal sensory or motor neurological deficit
• Resulting from blunt or penetrating force to the head
Bruns J, Hauser WA. The epidemiology of traumatic brain injury: A review. Epilepsia 2003; 44(Suppl. 10): 2-10.
Primary Survey
• A: airway maintenance with cervical spine protection
• B: breathing and ventilation
• C: circulation with haemorrhage control
• D: disability or neurologic status
• E: exposure / environmental control
D: Disability
• Glasgow Coma Scale (GCS) score: Conscious level
• Pupillary size and reaction
• Lateralizing signs: motor weakness
• Spinal cord injury level
Glasgow Coma Scale
■ Input • Command or pain
■ Output • Best motor response • Best verbal response • Eye opening
■ Score range • 3-15
Decreased Conscious Level
• Decreased cerebral oxygenation and / or perfusion
• Direct cerebral injury
• Hypoglycemia
• Intoxications from alcohol, narcotics, and other drugs.
Definition of Severe Traumatic Brain Injury
■ The patient had a Glasgow coma scale (GCS) score of 8 or less following nonsurgical resuscitation or a GCS score deteriorating to 8 or less within 48 hours after head trauma.
■ Nonsurgical resuscitation means endotracheal intubation, mannitol administration, and volume support.
Secondary Insults & Injury• Secondary insults
• detrimental events
• Increased damage to the primary injury
• Hypoxia and hypotension
• Secondary injuries
• processes that develop in the hours to days after the unavoidable primary injury
• Result of the biochemical cascades initiated by trauma
Mild Traumatic Brain Injury
Definition ?
• An acute brain injury resulting from mechanical energy to the head from external physical forces. Criteria for identification include:* – One or more of the following
• Confusion or disorientation • Loss of consciousness for 30 minutes or less • Post-traumatic amnesia for less than 24 hours • And/ or other transient neurological abnormalities
– GCS score of 13-15 after 30 minutes post-injury. – Not be due to drugs, alcohol, medications, caused by
other injuries or treatment for other injuries, caused by other problems, or caused by penetrating injury.
*MTBI Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine1993.
Intracranial ComplicationsGCS score
Prevalence of CT abnormal
Prevalence of surgical intervention
Mortality rate
13 30 % 7.5 % 1.1 %
14 20 % 3.6 % 0.01 %
15 5 – 8 % 0.08 % 0.01 %
Borg J, et al. Diagnostic procedures in MTBI: Result of the WHO Collaborating Centre Task Force on MTBI. J Rehabil Med 2004; Suppl.43:61-75ใ
Diffuse Brain Injury
Cerebral concussion Physiological change/ dysfunction
Severe traumatic axonal Injury. Anatomical damage.
Injury severity
New Orleans Criteria (NOC)
• Headache
• Vomiting
• An age over 60 years
• Drug or alcohol intoxication
• Deficits in short-‐term memory
• Physical evidence of trauma above the clavicles
• Seizure
Haydel MJ, Preston CA, Mills TJ, et al. Indications for computed tomography in patients with Minor head injury. N Engl J Med 2000; 343: 100-‐5.
The Canadian CT Head Rule (CCHR)
• High risk (for neurological intervention)
– GCS score < 15 at 2 hour after inury
– Suspected open or depressed skull fracture
– Any sign of basal skull fracture (hemotympanum, racoon eyes, CSF otorrhea/rhinorrhea, Battle’s sign)
– Vomiting ≥ 2 episodes
– Age ≥ 65 years
• Medium risk (for brain injury on CT)
– Amnesia before impact > 30 min
– Dangerous mechanism
Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT head rule for patients with minor head injury. Lancet 2001; 357: 1391-‐96.