Severe: GCS <9
Moderate: GCS 9-12
Mild: GCS 13-15
Used to classify what?
Traumatic Brain Injuries
Almost 2 million TBI US/yearly
75-95% fall into ____ category
Highest mortality for severe in young (15-24) and old (over 65)
- Young people
- Low income
- Athletes (contact sports)
- Members of ethnic minorities
- Residents of inner cities
- Men (3:1)
- Hx of substance abuse
- Suffered previous
At greatest risk for what?
MVC/MVA (leading cause in general population)
ALOCHOL (increases all the above)
Common causes of _____?
15 point scale used to rate mental status and function—used to rate severity of brain injury and predict outcome
Based on eye opening, verbal responses and motor control
15 is the highest score
3 is the lowest score
Should be performed at triage and repeatedly during evaluation
Any decrease in score is a danger sign
Glasgow Coma Scale (GCS)
Best eye response for TBI
How many grades are there?
- No eye opening
- Eye opening in response to pain (Patient responds to pressure on the patient’s fingernail bed; if this does not elicit a response, supraorbital pressure and/or sternal rub may be used—with caution)
- Eye opening to speech. 1.. (Not to be confused with an awaking of a sleeping person; such patients receive a score of 4, not 3.)
- Eyes opening spontaneously
Best eye response for TBI
1.No verbal response
2.Incomprehensible sounds. (Moaning but no words.)
3.Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange)
4.Confused. (The patient responds to questions coherently but there is some disorientation and confusion.)
5.Oriented. (Patient responds coherently and appropriately to questions such as the patient’s name and age, where they are and why, the year, month, etc.)
Best verbal response for TBI
best verbal response for TBI
How many grades?
Best motor response for TBI
How many grades?
1.No motor response
2.Extension to pain (decerebrate response)
3.Abnormal flexion to pain (decorticate response)
4.Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied; pulls part of body away when nailbed pinched)
5.Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital pressure applied.)
6.Obeys commands. (The patient does simple things as asked.)
Best motor response
3 types of tissue deformation: Compression, Tensile, Shear
Mechanical injury to neurons & axons
Direct & indirect
Coup & Countercoup
Acceleration & deceleration
Seen in what?
Primary injury with TBI
Tissue distortion when tissue slides over tissue
Occurs in minutes, hours, days AFTER the inital insult
Microscopic/cellular: intracellular swelling, electrolyte imbalances (Na, K, Cl, Ca, Mg), inflammatory response (increased cytokines), Cytoxic edema, disruption of axonal neurofilament organization
More severe: cerebral arterial dilation, intracranial hemorrhage, cerebral edema, ischemia/hypoxia. increased intracranial pressure
What type of TBI injury?
Can be obtained in seconds on nursing not/triage form:
MOI (mech. of injury)
Focused on head/neuro, but don't forget C-spine!
PE of patient evaluation
Can patient have skull fractures, scalp lacerations, scalp hematomas WITHOUT brain injury?
but be highly suspicious for underlying brain injury (serial exams, maybe admit for observation)
CSF rhinorrhea or otorrhea
Classic signs for what?
Basilar skull fracture
Age under 60
No deficits in STM
No physical evidence of trauma about clavicles
likely or not likely to hve signficant intracranial injury?
Complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces
What does everyone with possible TBI get?
non-contast head CT
May be caused by direct blow to the head, face, neck, or elsewhere on body with 'impulse' force transmitted to head
Results in graded set of clinical syndromes that may or may not involve loss of consciousness
Typically associated with grossly normal structural neuroimaging studies
Rapid onset of short-lived impairment of neurologic function that resolves spontaneously
May result in neuropathological changes , but actue clinical sx largely reflect functional disturbance rather than structural injury
Vacant stare (befuddled facial expression)
Delayed verbal expression (slower to answer or follow instructions)
Inability to focus attention (easily distracted and unable to follow through w/ normal activites)
Disorientation (wallking in wrong direction, unaware of time, date, place)
Slurred/incoherent speech (making disjointed or incomprehensive statements)
Gross observable incoordination (stumbling, inability to walk tandem/straight line)
Emotionality out of proportion to circumstances (appearing distraught, crying for no apparent reason)
Memory deficits (exhibited by patient repeatedly asking the same question that has already been answered or inability to memorize and return three of three words and three of three objects for five minutes)
Any period of loss of consciousness (coma, unresponsiveness to stimuli)
Signs of someone with what?
Some surverys have found that more than ___% of individuals with past concussion did not recognize it as such
Diffuse cerebral swelling --> ICP
Rare but fatal
Hypothesis: disordered cerebral autoregulation
Second impact syndrome
No loss of consciousness
Post-traumatic amnesia or other signs lasting less than 30 mins
Management: Athlete may return to play is asymptomatic for 1 week
What grade of cantu guidelines for concussion?
Loss of consciousness for less than 1 min
Post-traumatic amnesia or other sx for more than 30 mins, less than 24 hours
Management: Athlete may return to play in 2 weeks if asx at rest and on exertion for 7 days
What cantu guidelines grade for concussion?
Loss of consciousness for longer than 1 min
Post-traumatic amnesia or other sx for longer than 24 hours
Management: Athlete may return to play in one month if asx at rest and on exertion for 7 days
What canti guideline grade for concussion?
No activity and rest until asx
Light aerobic exercise
Stepwise return to play
Observation in ED
Most discharged home
If GCS<15, abnormal head CT, seizures, abnormal bleeding --> may need to admit
Sleeping - no clear recommendations. One recommendation: awaken pt every 2 hours the first night and avoid strenuous activity for 24 hours and return with ANY concerning sx
Tx for what?
Within first week after injury
Occurs in less than 5%
1/4 occur in 1st hour, 1/2 occur in 24 hours
Increases risk of post-traumatic epilepsy to 25%
Early post-traumatic seizures
Within 5 years of traumatic event
50% within first year
80% within first 2 years
May be caused by multiple factors:
Rupture of perilymphatic fluid
Displacement of otiliths
Direct injury to cochlear/vestibular structures
More resistant to tx but usually resolves
Anosmia and hyposmia
Other complications of what?
May occur even with most mild TBI (30-80%)
Occurs within days to weeks after inital concussion
Sx: HA, dizziness, vertigo, memory problems, difficulty with concentrating, sleeping problems, restlessness, irritability, apathy, depression, or anxiety
May last for weeks
More common in patients with pre-existing psychiatric dx (depression/anxiety) and in women
Tailored to patient
Try to avoid narcotic pain medications
Counseling/Cognitive behavioral therapy
Most get better in 3 mon-year
Tx for what?
Chronic traumatic encephalopathy
plaques, neurofibrillary tangles, tau proteins (similar to Alzheimers)
Cognitive deficits from repeated TBI