Traumatic Brain Injuryfor

PHTCDr Nazhatul Muna Bt Ahmad Nasarudin

Emergency Physician & LecturerUKMMC

◦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

= 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

Cerebral Concussion = = Trauma-induced alteration in mental status with or without LOC. [American Academy of neurology]

Injury Severity – GCS

Mechanism – Blunt - Penetrating

Pathoanatomic – Skull fractures - Intracranial lesions

2. ATLS 2010

Classification 1, 2

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

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

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

Common cause of TBI MVA Fall Assaults Sporting or leisure Workplace injuries Others

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

ABC AVPU/GCS Injuries suspected Mechanism of injuries

What information?

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

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

Normoxia Normotension- MAP ~ 70mmHg Normocarbia Normotermia Normoglycemia

30º head elevation

To Maintain

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

Signs of Skull Base Fracture

◦ Raccoon eyes

◦ Battle sign (after 8-12 h)

◦ CSF rhinorrhea or otorrhea

◦ Hemotympanum

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

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

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

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

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

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

Make it simple ….. Headache Vomiting Drowsiness

Urgent◦ prolonged unconsciousness◦ unsteadiness (difficulty

standing or walking)◦ unequal pupils

May up to months but rarely beyond 3 months. Symptomatic n supportive tx.

Post Concussion Syndrome

CT Findings

Skull Fracture Types

◦ Depressed / non-depressed

Importance◦ Non-depressed per se:

minimal◦ Depressed◦ A/w low GCS◦ Compound fractures◦ Foreign body

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

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)

SDH vs EDH

Brain contusion Young Direct brain injury Size: small large If multiple – means severe diffuse brain injury

Surgery if◦ Large◦ Easily accessible

Prognosis: moderate

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

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