traumatic brain injury
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Traumatic Brain Injuryfor
PHTCDr Nazhatul Muna Bt Ahmad Nasarudin
Emergency Physician & LecturerUKMMC
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◦Grading and classification of TBI◦Types of TBI◦Prehospital Care Management◦ED Management ◦Imaging of head injury◦Managing TBI patient ◦Monitoring◦Advice to patients/relative
Learning Outcome
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= defined as any trauma to the head, other than superficial injuries to the face. 1
acquired brain injury Traumatic brain injury Brain injury
1. National Institute For Health and Clinical Excellence (NICE) 2007. Head injury: Triage, assessment, investigation and early management of head injury in infants, children and adults.
Head Injury
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Cerebral Concussion = = Trauma-induced alteration in mental status with or without LOC. [American Academy of neurology]
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Injury Severity – GCS
Mechanism – Blunt - Penetrating
Pathoanatomic – Skull fractures - Intracranial lesions
2. ATLS 2010
Classification 1, 2
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Paediatric Verbal Score For children < 4 years old (Preverbal)
Verbal response V-Score
Appropriate words/Social smile/
Fix and follow
5
Cries, but consolable 4
Persistently irritable 3
Restless, agitated 2
None 1
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Mild: GCS 14-15. Awake and maybe oriented
Moderate: GCS 9-13. Confused or drowsy. But still follow simple commands
Severe: GCS 3-8. Unable to follow even simple commands. Or severely unconscious.
3. Saatman KE, Duhaime AC Workshop Scientific Team Advisory Panel Members et al (2008). "Classification of traumatic brain injury for targeted therapies". Journal of Neurotrauma 25 (7): 719–38.
CLASSIFICATION- GCS
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Primary head injury◦ Injury sustained by the
brain at the time of impact
◦ Eg; Brain laceration Brain contusion
Secondary head injury◦ Injury sustained by
the brain after the impact
◦ Causes Hypoxia Hypoperfusion Cerebral edema
causing ↑ ICP Infection
◦ Eg: EDH Cerebral edema
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Common cause of TBI MVA Fall Assaults Sporting or leisure Workplace injuries Others
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D - Danger R – Response A – Airway & C spine B - Breathing C - Circulation D – Disability. AVPU/GCS, Pupils E – Exposure/Extremity
Rapid Trauma Survey
Pre Hospital Care Management
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ABC AVPU/GCS Injuries suspected Mechanism of injuries
What information?
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Head injury management in ED
General aims◦ Stabilization◦ Prevention of secondary brain injury
Specific aims◦ Protect the airway & oxygenate adequaty◦ Ventilate to normocapnia ◦ Correct hypovolaemia and
hypotension ◦ CT Scan when appropriate ◦ Neurosurgery if indicated ◦ Intensive Care for further monitoring and
management
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Head injury management in ED
General aims◦ Stabilization◦ Prevention of secondary brain injury
Specific aims◦ Protect the airway & oxygenate adequaty◦ Ventilate to normocapnia ◦ Correct hypovolaemia and
hypotension ◦ CT Scan when appropriate ◦ Neurosurgery if indicated ◦ Intensive Care for further monitoring and
management
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Normoxia Normotension- MAP ~ 70mmHg Normocarbia Normotermia Normoglycemia
30º head elevation
To Maintain
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All moderate and severe head injuries
Mild = moderate, if: 1. GCS less than 15 > 2 hours 2. Sign of open skull # 3. Sign of basal skull # 4. Emesis more > once 5. Retrograde amnesia > 30 minutes
4. Canadian CT Head rules
CT Scan Indications (Adult) 4
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Signs of Skull Base Fracture
◦ Raccoon eyes
◦ Battle sign (after 8-12 h)
◦ CSF rhinorrhea or otorrhea
◦ Hemotympanum
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Pediatric Emergency Care Applied Research Network (PECARN) - Lancet. October 2009 5
Preverbal = less than 2 years Verbal = more than 2 years Aim: to identify children at very low risk of clinically-
important traumatic brain injuries (ciTBI) for whom CT might be unnecessary.
Negative predictive value for ciTBI in < 2y is 100% and sensitivity is 100%.
Negative predictive value in > 2y is 99·95% and sensitivity is 96·8%.
Paediatrics
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Mild head injury Home Care
◦ No serious symptoms◦ Carefully observed for 24-72 hours following the injury.◦ Responsible adult to stay with patient◦ First 24 hours
Observe for WARNING SIGNS (72 hours) Maintain the following observation
schedule: ◦ allow to rest or sleep◦ awaken every 2 hours for the first 12 hours. Children (0-
17 years) awaken every 2 hours from time of the injury, through the first night
◦ Set an alarm to maintain schedule
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If CT normal, do we admit patient ? Yes, if…
◦ Possible drug or alcohol use ◦ Epilepsy ◦ Attempted suicide ◦ Preexisting neurological conditions (eg, Parkinson
disease, Alzheimer disease) ◦ Patient treated with warfarin or who has
coagulation disorder ◦ Lack of responsible adult to supervise ◦ Any uncertainty in diagnosis
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Moderate Head Injury (GCS 9-12)
CT scan Admit Observed, examine every 2
hours (If CT normal) they should
improve If not – repeat CT scan NBM + IVD Mild analgesia / anti-emetics
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What To Advise
Difficulty breathing or loss of consciousness Altered mental state, behavior, slurred speech or
motor deficit (loss of coordination, dizziness or staggering gait)
Decreased level of consciousness, extreme weakness, lethargy or irritability
Extreme, unusual drowsiness or difficulty arousing
Vomiting more than twice Development of bilateral black eyes (resembling
‘raccoon looking eyes’) or black and blue behind the ears
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Visual disturbances or unequal pupils Bloody or clear watery drainage from ears
or nose Rapid pulse (0-17 years) Severe neck pain or headache Bulging fontanel (soft spot) in child under
2 years of age who is not crying Slowing of pulse (18 years and older) Inconsolable crying Severe, increasing, persistent or
intermittent symptoms
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Make it simple ….. Headache Vomiting Drowsiness
Urgent◦ prolonged unconsciousness◦ unsteadiness (difficulty
standing or walking)◦ unequal pupils
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May up to months but rarely beyond 3 months. Symptomatic n supportive tx.
Post Concussion Syndrome
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CT Findings
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Skull Fracture Types
◦ Depressed / non-depressed
Importance◦ Non-depressed per se:
minimal◦ Depressed◦ A/w low GCS◦ Compound fractures◦ Foreign body
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Acute ExtraDural Hemorrhage Young patient Between skull & dura No direct injury to brain Blood clot – from torn blood
vessel of dura (artery)
Trauma – okay – slowly deteriorating – coma – death
EDH patient should NOT die If patient die … we better
die too
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Acute SubDural Hemorrhage Young patient Clot – between dura & brain
surface From damaged brain surface
◦ Brain laceration◦ Burst lobe◦ DIRECT brain injury
Hematoma – usually thin Major problem – damaged
brain Outcome – worse than EDH
Usually need surgery, to remove◦ Hematoma◦ Skull bone (open the box)
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SDH vs EDH
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Brain contusion Young Direct brain injury Size: small large If multiple – means severe diffuse brain injury
Surgery if◦ Large◦ Easily accessible
Prognosis: moderate
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Diffuse Axonal Injury Young CT scan ‘normal’ Very small ‘white dots’ Acceleration – decerelation Shearing force “Poor GCS with ‘normal’ CT
scan” Treatment – based on GCS,
ICP & CPP Important to repeat CT
after 24-48 hours◦ Edema◦ Delayed hematoma
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1. National Institute For Health and Clinical Excellence (NICE) 2007. Head injury: Triage, assessment, investigation and early management of head injury in infants, children and adults.
2. Advance Trauma Life Support. 8th Edition
3. Saatman KE, Duhaime AC. Workshop Scientific Team Advisory Panel Members et al (2008). Classification of traumatic brain injury for targeted therapies. Journal of Neurotrauma 25 (7): 719–38.
4. IG Stiell , GA Wells, K Vandemheen et al. The Canadian Ct Head Rule For Patients With Minor Head Injury (2001). Lancet 357(9266):1391-96
5. Kuppermann et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 2009;374(9696):1160-1170.
References