Traumatic Brain
Injury
Almario G. Jabson MD
Section Of Neurosurgery
Asian Hospital And Medical Center
Brain Injury Incidence: 200/100,000
Prehospital Brain Injury Mortality Incidence:
20/100,000
Hospital Admissions by Severity:
Mild: 80%
Moderate: 10%
Severe: 10%
RACE AND GENDER
Peak Incidence:
15 - 24 years old
Secondary Peak Incidence:
Infants and children
Elderly
M:F = 2-3:1
DIAGNOSIS
HISTORY
DOI: DATE OF INJURY
TOI: TIME OF INJURY
POI: PLACE OF INJURY
MOI: MECHANISM OF INJURY
MECHANISM OF INJURY
MVA/TRANSPORT RELATED
FALLS
INTERPERSONAL VIOLENCE
SPORTS RELATED
WORK RELATED
HISTORY
HEADACHE
LOSS OF CONSCIOUSNESS
AMNESIA
NAUSEA/VOMITTING
SEIZURES
ALCOHOL INTAKE
DIAGNOSIS
PHYSICAL/NEUROLOGIC EXAM
RAPID INITIAL ASSESSMENT
SYSTEMIC
NEUROLOGIC (GCS, LATERALIZING SIGNS, INC.
INTRACRANIAL PRESSURE)
COMPREHENSIVE PHYSICAL AND NEUROLOGIC
EXAM
GLASGOW COMA SCALE
POINTS BEST EYE BEST VERBAL BEST MOTOR
6
OBEYS
ORIENTED
LOCALIZES PAIN
SPONTANEOUS
CONFUSED
WITHDRAWS TO PAIN
TO SPEECH
INAPPROPRIATE
DECORTICATE
TO PAIN
INCOMPREHENSIBLE
NONE
NONE
NONE
DECEREBRATE
INITIAL NEUROLOGIC EXAM
LATERALIZING SIGNS
PUPIL SIZE AND REACTIVITY
WEAKNESS
INCREASED ICP
CUSHINGS TRIAD
INCREASING BP
DECREASING HR
DECREASING RR
DIAGNOSIS
DIAGNOSTIC WORK-UP
LABORATORY WORK-UP
RADIOGRAPHIC EVALUATION
X-RAYS
CT-SCAN
X-RAYS
SKULL AP-LATERAL
CERVICAL FILMS
CERVICAL AP-LATERAL
OPEN MOUTH VIEW
CT SCAN
EMERGENT CONDITIONS DETECTED
ON PLAIN CT SCAN
BLOOD
HYDROCEPHALUS
CEREBRAL SWELLING
CEREBRAL ANOXIA
SKULL FRACTURES
ISCHEMIC INFARCTION
PNEUMOCEPHALUS
MIDLINE SHIFT
PATHOLOGIES IN HEAD INJURY
CLOSED HEAD INJURY
PRIMARY INJURY
SECONDARY INJURY
PENETRATING HEAD INJURY
GUNSHOT WOUND
NONGUNSHOT WOUND INJURY
PRIMARY INJURY/IMPACT DAMAGE
FOCAL INJURIES
CONTUSIONS
LACERATIONS
FRACTURES
HEMATOMAS
DIFFUSE INJURIES
DIFFUSE AXONAL INJURY
CONCUSSION
SECONDARY INJURY
EVENTS WHICH OCCUR AFTER ONSET OF
PRIMARY INJURY
AGGRAVATING CONDITIONS
ISCHEMIA
HYPOXEMIA
EDEMA
COMPRESSION FROM MASS LESIONS
SPECIFIC PATHOLOGIES
SCALP INJURIES
LACERATION
CONTUSION
HEMATOMA
AVULSION
SPECIFIC PATHOLOGIES
SKULL FRACTURES
LINEAR
PINGPONG
DEPRESSED
OPEN
CLOSED
COMMINUTED
BASAL SKULL
DIASTATIC
SPECIFIC PATHOLOGIES
INTRACRANIAL LESIONS
HEMATOMAS
EPIDURAL
SUBDURAL
INTRACEREBRAL
INTRAVENTRICULAR
SUBARACHNOID HEMORRHAGE
CONTUSIONS
HEMORRHAGIC CONTUSION
CONTUSION HEMATOMA
Epidural Hematoma
Acute Subdural
Hematoma
Chronic Subdural
Hematoma
Contusion Hematoma
Penetrating Injury
MANAGEMENT
RESUSCITATION/CABs
IMMOBILIZATION AS NEEDED
MEDICATIONS
SURGERY
PREVENTION
MANAGEMENT
PRIMARY INJURY
SURGICAL VS. NONSURGICAL
SECONDARY INJURY
MINIMIZE/PREVENT DELETERIOUS
EFFECTS OF FACTORS CAUSING
SECONDARY INJURY
MANAGEMENT ISSUES
MANAGEMENT OF INTRACRANIAL
PRESSURE ( ICP )
CEREBRAL BLOOD FLOW ( CBF )
INDIRECTLY MEASURED BY CEREBRAL
PERFUSION PRESSURE ( CPP )
CPP = MEAN ARTERIAL PRESSURE ( MAP ) INTRACRANIAL PRESSURE ( ICP )
ROUTINE MEASURES
POSITIONING
ELEVATE HOB TO 30-45 DEGREES
KEEP HEAD MIDLINE
LIGHT SEDATION
AVOID HYPOTENSION
CONTROL HYPERTENSION
PREVENT HYPERGLYCEMIA
INTUBATE IF GCS < 8 OR WITH RESPIRATORY DISTRESS
AVOID EXCESSIVE HYPERVENTILATION
DVT Prophylaxis if possible
SPECIFIC MEASURES
HEAVY SEDATION AND/OR PARALYSIS
CSF DRAINAGE
OSMOTIC THERAPY
MANNITOL
FUROSEMIDE
SERUM OSMOLARITY
HYPERVENTILATION
STEROIDS NOT RECOMMENDED
MANAGEMENT ISSUES
INTRACRANIAL PRESSURE MONITOR
Although ICP monitor is widely used,
the overall outcome of severe HI hasnt been
improved by its use.
MANAGEMENT ISSUES
HYPERVENTILATION
Chronic use (>24 hours) of hyperventilation
correlates with poor outcome in sever HI
Recommended for acute ICP increase
Class I Evidence
AACNS/Brain Trauma Foundation
MANNITOL
MECHANISM OF ACTION
INCREASE CBF AND O2 DELIVERY BY IMMED. PLASMA
EXPANSION, REDUCED HCT AND VISCOSITY
DOSE
0.25g/kg to 1gm/kg/dose
ONSET OF ACTION
1 -5 MINUTES
DURATION OF ACTION
PEAKS IN 20 - 60 MINUTES
FUROSEMIDE
MECHANISM OF ACTION
INCREASE SERUM TONICITY
MAY SLOW PRODUCTION OF CSF
ACTS SYNERGISTICALLY WITH MANNITOL
DOSE
ADULTS: 10-20 MG IV
PEDS: 1MG/KG
PRECAUTIONS
SERUM OSMOLARITY
DEHYDRATION
HYPERVENTILATION
MECHANISM OF ACTION
INDICATIONS
TO TIDE PATIENT OVER
IF UNRESPONSIVE TO OTHER MEASURES
HYPEREMIA
ONSET OF ACTON
< 30 SECONDS
DURATION OF ACTION
PEAKS IN 8 MINUTES, EFFECT LESSENED BY 1 HOUR
PRECAUTIONS
MANAGEMENT ISSUES
CORTICOSTEROIDS
The use of corticosteroids does not cause a
decrease in ICP nor does it improve outcome
of HI.
Class I Evidence
AANS/Brain Trauma
Foundation
MANAGEMENT:
Concussion
Special Circumstances in
Concussive Injuries
Impact Seizure
12% (more common than in adults)
not predictive of early or late epilepsy
anticonvulsant treatment is not needed
MANAGEMENT ISSUES
ANTICONVULSANT
Lewis et al , 1993
Pedia HI
Post-traum Sz
GCS 3 - 8
38.7 %
GCS>8 3.8%
Pxs with low GCS, prophylactic treatment reduces posttraumatic seizures
When Does Surgery Come In?
Basic Principle
To lessen the Impact of Primary Injury and
Prevent Secondary Injury
MANAGEMENT:
Discharge Criteria
Normal level of alertness
Tolerates oral intake
Usual gait
