TRAUMATIC BRAIN INJURY

: Emergency Aspects

Handoyo Pramusinto
ED Sardjito Hospital
 Head Injury
 Common problem
 High morbidity and mortality
 Secondary insults
• Worsen outcome
• Often preventable
 Early neurosurgical consult and transfer
 Why Is It Important?
• Traumatic Brain Injury (TBI)
– Accounts for 51.6% of mortality amongst trauma
patients
Dutton. J Trauma. 2010.

• Progression of Intracranial Hemorrhagic Injury (IHI)

– Longer hospitalizations (14.4 d vs. 9.7 d, p <0.01)
– Increased mortality (24% vs. 3%, p <0.01)
Thomas. J Am Coll Surg. 2010.
Who’s Involved?
Demographics
• Traumatic brain injury effects all levels of society
• TBI affects all ages
• Majority (75 to 90%) recover quickly
– “Mild” = 90%
• 10 to 25% have long-term deficit
• 2% of Americans living with TBI-related disabilities
– (313.9 Million x .02 =6.3 Million) 2012 census

• The ‘Hidden’ TBI patient

– Emotional distress/cognitive issues
“At Risk” Groups

• Males are more likely to incur TBI compared to

females. (3.4:1)
– GSW 6:1
– MVC 2.4:1
• Highest rate of injury: 15-24 years old.
• Also at higher risk:
– Children <5 years old
– Elderly > 75 years old
How Much Does it Cost?
Financial Impact
• Costs:
– Acute care: $8000/day
– Rehabilitation: $2500/day
• Employment:
– Approx 60% at time of injury
– 28% post-injury
• 34% are unable to return to work rapidly
– Majority require up to 3-6 months
– 25% over one year

Rimel Neurosurgery 1981, Boake Neurosurgery 2005, Max JHTR 1991

Normal Anatomy
• Scalp
• Skull
– Epidural Space
• Dura
– Subdural Space
• Arachnoid
– Subarachnoid Space
• CSF
• Brain
 Important Information

 Age And History

 Vital signs
 GCS score and pupils
 Alcohol/drug(s) intake
 Associated injuries
 Brain CT
Glasgow Coma Scale

Motor Verbal Eyes

6- Follows 5- Oriented/Conversant
4- Opens Spontaneously
commands 4- Confused 3- Opens to voice
5- Localizes to pain 3- Inappropriate 2- Opens to pain
4- Withdraws to pain 2- Incomprehensible 1- None
3- Flexion 1- None
2- Extension
1- No movement

Teasdale, Lancet, 1976

M
 Intracranial Pressure (ICP)

 10mm Hg = Normal
 >20 mm Hg = Abnormal
 >40 mm Hg = Severe
 Many pathologic processes affect outcome
 ↑ICP →↓Brain function,↓outcome
 Classifications
Blunt High velocity
By Low velocity
Mechanism
GSW
Penetrating Other

GCS = 14-15
Mild

GCS = 9-13
By Moderate
Severity
Severe GCS = 3- 8
 Classification
By Morphology
Linear vs stellate
Vault Depressed/ non depressed
Skull Open/ closed
Fracture
Basilar With / without CSF leak
With / without cranial palsy
Fraktur Depresi
 CT scan
Fraktur Depresi
 Classifications
By Morphology • Epidural
• Subdural
Focal Injury • Intracerebral

• Mild concussion
Diffuse Injury • Classic
concussion
• Diffuse axonal
injury
 Epidural Hematoma
 Associate with skull fracture
 Classic : Middle meningeal artery

tear
 Lenticular/biconvex due to dural

adherence to skull
 Lucid interval
 EPIDURAL
HEMATOM

Epidural
 Epidural Hematoma
 Can be rafidly fatal
 Early evacuation better prognosis
 Subdural Hematoma

 Venous tear /brain laceration

 Covers entire cerebral surface
 Morbidity /mortality due to underlying
brain injury
 Rapid surgical evacuation recommended,
especially if > 5 mm shift of midline
Subdural hematom
What Do We Do?
Management

• Immediate
– “Time is brain”
• Short-term: Intensive care / Acute Care
– Monitors
– Surveillance
– Management
• Long-term: Post-discharge
Immediate
• Trauma Team: Manage Resuscitation
• Protection
– Anoxia
– Hypotension
• 25% Increased Mortality
– Individually
• 75% Increased Mortality
– Combined
Acute Care Management

• CT scans?
• Head up
• Sedation
• ICP/CPP management
– Osmolar therapy
– Hypertonic saline
• Decompressive craniotomy
• Induced coma
• Hypothermia
ICP Monitoring – when?
• Intracranial Pressure Monitoring
– All ‘salvageable’ severe TBI patients
• GCS <8
• CT scan with pathology
– ICH
– Swelling
– Herniation
– Normal CT scan
• Age >40
• Posturing
• Sys BP <90mmHG
Medical Management
 Intravenous fluids
• Euvolemia
• Isotonic
 Hyperventilation, if necessary
• Goal : PaCO₂ at 25-35 mm Hg
Medical Management
 Mannitol
• Use with signs of tentorial herniation
• Dose : 0.5 –1.0 g/kg IV bolus
 Other
• Anticonvulsants
• Sedation
• Paralytics
Surgical Management
Scalp injuries
 Possible site of major blood loss

 Direct pressure to control bleeding

 Occasional temporary closure

Surgical Management
Intracranial Mass Lesion
 May be life threatening if expanding rapidly

 Immediate neurosurgical consult

 Hyperventilation / Mannitol

 ? Emergency burr holes ?

What do we see?
Presentation (Mild, Moderate, Severe)
• Physical

• Cognitive

• Behavioral
• Acute in-patient treatment
‘standardized’
– ICU care by guideline
• Post-discharge treatment personalized:
– TBI severity
– Injury Severity
– Age
– Cost

Chestnut, JHTR 1999

Physical Impairments
•   Speech, vision, hearing, other sensory impairments
•  Headaches
•  Lack of coordination
•  Muscle spasticity
•  Paralysis
•  Seizure disorders
•  Problems with sleep
•  Dysphagia
•  Dysarthria (articulation and muscular/motor control of
speech)
Who Can Help ?
Interdisciplinary Approach

• Neurosurgery Team
• Rehabilitation Team
– Inpatient Treatment
– Rehabilitation Evaluation
– Cognitive evaluation / RLA Scoring
– Swallow Evaluation / Education
• Case Management
• Social Work
Summary : Prescription (Do)
 Maintain mean BP > 90 mm Hg
 Maintain PaCO₂ between 25 - 35 mm Hg
 Use isotonic solution for euvolemia
 Frequent neurologic exams
 Liberal use of CT scans
 Early neurosurgical consult
Summary : Proscription (Don,t)
 Allow patient to become hypotensive
 Over-aggressively hyperventilate
 Use hypotonic IV fluids
 Use long acting paralytics
 Paralyze before performing complete
exam
 Depend on clinical exam alone