.TRAUMATIC BRAIN INJURY.

Class - BPT 4th Year

Presented By - SHASHANK NAYER

#UNDER GUIDENCE – DR. AMIT SHUKLA

DEFINITION“An insult to the brain, not of degenerative or congenital nature caused by an external physical force that may produce a diminished or altered state of consciousness, which results in an impairment of cognitive abilities or physical functioning. It can also result in the disturbance of behavioral or emotional functioning.”

*An outside force impacts the head causing the brain to move

*A direct blow to the head

*A rapid acceleration and deceleration of the head

CAUSES

#Traumatic brain injury (TBI) is the leading cause of death for all age groups, contributing to over 60% of trauma-related deaths. The primary goals of management in TBI are to minimize cerebral edema, intracranial pressure (ICP), and to optimize cerebral perfusion pressure (CPP) thereby decreasing the incidence of secondary injury

Pathophysiology*TBI may be divided into primary injury and secondary injury.

*Primary injury is induced by mechanical force and occurs at the moment of injury. *Secondary injury is not mechanically induced. It may be delayed from the moment of impact, and it may superimpose injury on a brain already affected by a mechanical injury.

Primary injuryThe 2 main mechanisms that cause primary injury are:

Contact (as an object striking the head or the brain striking the inside of the skull)

Acceleration-deceleration.

Primary injury due to contact may result in; injury to the scalp, fracture to the skull and surface contusionsPrimary injury due to acceleration-deceleration results from unrestricted movement of the head and leads to shear, tensile, and compressive strains.These forces can cause intracranial haematoma or diffuse axonal injury (injury to cranial nerves and the pituitary stalk.

Secondary injury It may occur hours or even days after the

inciting traumatic event. Injury may result from impairment or local

declines in CBF after TBI as a result of local edema, haemorrhage or increased ICP.

As a result of inadequate perfusion, cellular ion pumps may fail, causing a cascade involving intracellular calcium and sodium which may contribute to cellular destruction.

To Summarize Causes Of Secondary Brain Injury

Hypotension Hypoxaemia Hypercarbia Hyperthermia Hyperglycaemia Hypoglycaemia Hyponatraemia Seizures Infection

Severity Head injuries can be classified into mild, moderate, and

severe. The Glascow Coma Scale (GCS),is the most commonly used

system for classifying TBI severity; TBI with a GCS of 13 or above is mild, 9–12 is moderate,

and 8 or below is severe. Other classification systems are also used to help

determine severity; duration of post-traumatic amnesia (PTA), and loss of consciousness (LOC).

GCS PTA LOC

Mild 13-15 Less than 1 day

0-30 min.

Moderate 9-12 1-7 days 30min.- 24hrs.

Severe 3-8 More than 7 days

More than 24hrs.

Severity of traumatic brain injury

Signs and symptomsSymptoms are dependent on the injury's severity:

• With mild TBI, the patient may remain conscious or may lose consciousness for a few seconds or minutes.

• Other symptoms of mild TBI include; headache, vomiting, nausea, lack of motor coordination, dizziness, difficulty balancing, lightheadedness, blurred vision or tired eyes, ringing in the ears, bad taste in the mouth, fatigue or lethargy, and changes in sleep patterns.

• Cognitive and emotional symptoms include; behavioral or mood changes, confusion, and trouble with memory, concentration, attention, or thinking.

When the pressure within the skull,ICP rises too high, it can be deadly.

Signs of increased ICP include decreasing level of consciousness, paralysis or weakness on one side of the body, and a blown pupil, one that fails to constrict in response to light .

Cushing's triad, a slow heart rate with high blood pressure and respiratory depression is a classic manifestation of significantly raised ICP.

Anisocoria, unequal pupil size, is another sign of serious TBI.

Abnormal posturing, a characteristic positioning of the limbs caused by severe diffuse injury or high ICP, is an ominous sign.

Small children with moderate to severe TBI may have some of these symptoms.

Other signs seen in young children include persistent crying, inability to be consoled, listlessness, refusal to nurse or eat and irritability.

Diagnosis Neurological examination and assigning a GCS Score. Neuroimaging helps in determining the diagnosis and prognosis and

proposed treatment. The preferred radiologic test in the emergency setting is computed

tomography (CT): it is quick, accurate, and widely available. Followup CT scans may be performed later to determine whether the

injury has progressed. Magnetic resonance imaging (MRI) can show more details than

CTas detecting injury characteristics such as diffuse axonal injury. However, MRI is not used in the emergency setting.

X-rays are still used for head injuries that are so mild that they do not need imaging or severe enough to merit the more accurate CT.

Angiography may be used to detect blood vessel pathology. Electroencephalography and transcranial doppler may also be

used.

Complications Posttraumatic seizures; frequently occur after moderate or severe TBI, they are usually general or partial. Immediate seizures occur in the first 24 hours. Early seizures occur in the first 2-7 days. Late seizures occur after 7 days. *Temkin showed that prophylactic use of phenytoin is effective

during the first week after TBI. *He recommended discontinuation after 1 week if no seizures

develop because of its lack of effect in preventing late seizures.

Hydrocephalus-Hydrocephalus is characterized as communicating or noncommunicating; Noncommunicating Communicating hydrocephalus is the most common form after TBI and occurs when the obstruction is in the subarachnoid space.

Deep vein thrombosis-DVT is common in persons with TBI, with an incidence as high as 54%. -Risk factors for DVT include; immobility, lower extremity fracture, paralysis, and disruption in coagulation and fibrinolysis. -DVT may cause pulmonary embolism, postthrombotic syndrome or recurrence. -DVT best detected by venous Doppler ultrasonography and contrast-enhanced venography. -Prophylaxis for DVT should be started as soon as possible.

GIT and urinary tract complications remain among the most common sequelae in patients with TBI.

-Most frequent GIT complications are; stress ulcers, dysphagia, bowel incontinence, and elevated levels of liver function tests. -Urinary tract complications include; urethral strictures, infections, and urinary incontinencePosttraumatic agitation is common after TBI. Furthermore, aggression was consistently associated with depression.Insomia is common in TBI patients. They may have nighttime awakenings and longer sleep-onset latency.Posttraumatic headache in 38%.Posttraumatic depression in 40% after TBI, it is further associated with cognitive decline, anxiety disorders, substance abuse, dysregulation of emotional expression, and aggressive outbursts.

What tests will be done?

Glascow Coma Scale A point system to monitor level of

consciousness CT Scan or MRI Intracranial Pressure Monitor

A monitor placed in the skull to detect swelling and pressure on the brain

How is TBI treated!Initial treatment focuses on keeping the swelling in the brain from causing further damageMedications:Diuretics to reduce the amount of fluid in tissueAnti-seizure medicationComa-inducing medication to decrease oxygen needs to the brain

Surgery:Remove blood clotsRepair broken skull bonesRemove skull bone to allow the brain to swell

Treatment Therapy;

Patients with moderate to severe traumatic brain injury will need to have intense rehabilitation

Therapy begins in the hospitalTypes of therapy include:

Physical therapy: walking, strength, regaining balance Occupational therapy: self care activities, career

assistance Speech therapy: talking, reading, comprehension Therapy may continue for months or years

Prevention Always wear a seat belt!

Use proper restraints for children (car seats)

Never drive under the influence or alcohol or drugs

Wear a helmet when riding a bicycle, skateboard, motorcycle or ATV.

Avoid falls by maintaining a safe environment

Family Stressors TBI affects not only the patient, but the total family

system Family provides most of the care for the injured, often

without adequate professional support and intervention

Family caregivers often experience: Anxiety Shock Disbelief Denial Frustration

Family Stressors Challenges that caregivers often encounter:

Monitoring medications Managing challenging behaviors Adjusting to different emotions Grief or sense of loss

Caregiver Resources: Support groups through Brain Injury Association Supportive counseling Family therapy Respite care

Coping and support A brain injury often

erases memory of events that occurred just before injury.

It may be difficult to remember new information and learn new tasks

Some problems may get better over time, and some may be permanent

Coping strategies:Slow downStop and thinkBreak it down, step by stepAsk questionsDo not assumePay attention to detailsTake frequent breaksCarry a calendar

Thank You