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.