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Traumatic Brain InjuryGrand Rounds
Susan Kartiko MD PhD
10/30/13
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Traumatic brain injury
The most common cause of disability and death among youngpeople.
1.7 million people annually seek help to ED for TBI
52000 deaths and 80000 with permanent neurologcal disabilities.
In both more or less developed countries motor vehicles are themajor cause deaths and disabilities , particularly among youngpeople.
Falls are the major cause of death and disabilities for people age>65 yo.
Estimated 2% of US population is living with TBI related disabilities
Ghajar, Lancet 2000: 356: 923-29.
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Ghajar, Lancet 2000: 356: 923-29.
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Classifications of TBI
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Mild TBI
Defn: an acute alteration in brain function caused by ablunt external force and is characterized by
a GCS score of 13 to 15,
loss of consciousness for 30 minutes or less,duration of posttraumatic amnesia of 24 hours or less.
If a brain CT scan has been performed, its result must benormal.
The terms mild traumatic brain injuryand concussionmay be
used interchangeably.Estimated 1.1 million suffered from mild TBI, 75% fromtotal TBI
East Guideline, J Trauma. 73(5):S307-S314, November 2012
http://journals.lww.com/jtrauma/Fulltext/2012/11004/Evaluation_and_management_of_mild_traumatic_brain.6.aspxhttp://journals.lww.com/jtrauma/Fulltext/2012/11004/Evaluation_and_management_of_mild_traumatic_brain.6.aspxhttp://journals.lww.com/jtrauma/Fulltext/2012/11004/Evaluation_and_management_of_mild_traumatic_brain.6.aspxhttp://journals.lww.com/jtrauma/Fulltext/2012/11004/Evaluation_and_management_of_mild_traumatic_brain.6.aspx -
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Mild TBI: criteria for
dischargeHolmes et al 2011: children GCS 14-15 with negative CT scancan be safely discharged home
Livingstone 2000: CT scan have a 99.7% negative predictivevalue in GCS 14-15 patients
Kaen 2009: 1.4% patients with therapeutic INR and anegative CT scan have a positive CT scan in 24hr.
Cohen 2006: patient with GCS13-15, supratherapeutic INR,and negative CT scan should be admitted and have theirINR reversed at least to a therapeutic range.
East Guideline, J Trauma. 73(5):S307-S314, November 2012
http://journals.lww.com/jtrauma/Fulltext/2012/11004/Evaluation_and_management_of_mild_traumatic_brain.6.aspxhttp://journals.lww.com/jtrauma/Fulltext/2012/11004/Evaluation_and_management_of_mild_traumatic_brain.6.aspxhttp://journals.lww.com/jtrauma/Fulltext/2012/11004/Evaluation_and_management_of_mild_traumatic_brain.6.aspxhttp://journals.lww.com/jtrauma/Fulltext/2012/11004/Evaluation_and_management_of_mild_traumatic_brain.6.aspx -
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Moderate/Severe TBILong lasting effects: cognitive defects, psychiatric disorders (ie.Depressive and behavioral disorders, PTSD), social functional disorder
Cognitive: attention, memory, speed of processing, confusion,preseveration impulsiveness, language processing, executivefunctioning
Speech and language: reactive and expressive aphasia, slurred speech,problems writing/ reading
Vision/hearing/smell/taste
Seizures
Physical changes: chronic pain, control of bowel and urinary function,loss of stamina
Social/ emotion: aggression, depression, disinhibition, irritability, lack ofmotivation, denial/lack of awareness
Maas, et al Lancet Neurology vol7: 728-741
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Moderate/Severe TBI
Primary damage: brain damage result from external forceMacroscopic level: shearing of white matter tracts, focalcontusions, hematoma, diffuse swelling
Cellular level: microporation of membrane, leaky ion
channels, stearic conformation of protein, micro-hemorrhage from torn blood vessels
Secondary damageDevelop over hours and days, include neurotransmitterrelease, free radical generation, calcium-mediated damage,
gene activation, mitochondrial dysfunction and ,inflammatory responseInflammatory response causes brain swelling, and brain cellnecrosis
Maas, et al Lancet Neurology vol7: 728-741
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Management of Moderate/Severe TBI
Pre hospitalAim: reduce hypotension and hypoxia to prevent secondarybrain injury
Odds ratio 2.1 and 2.7 respectively to poor outcome
Keep SBP >90 mmHg
Keep PaO2 > 60, or O2 sat >90.
Admission
To neurosurgical facilities (2-15 odds of death if treated in
non-neurosurgical facilities)Aim: early detection and intervention if needed (ie. STAT CT)
In penetrating injury: dural closure with debridement orsimple wound closure and antibiotic treatment
Maas, et al Lancet Neurology vol7: 728-741
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Management of Moderate/Severe TBI
ICP monitoringCerebral hypertension occur in 77% of patients
Raised ICP is correlated to poorer outcome
0.5% risk of hemorrhage, 2 % risk of infection
Intraventricular catheter is prefered because can be
therapeutic vs intraparenchymalMaintenance of CPP> 70 with vaso-pressors and fluid bolusesincreased the risk of ARDS
Chestnut et al , NEJM 2012 (367): 2471-81; Maas, et al Lancet Neurology vol7: 728-741
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Management of Moderate/Severe TBI
NeuroICUNO steroids!!!
Increased mortality
Osmotherapy
Mannitol and hypertonic saline
Sedation and artificial ventilation to prevent high ICP
Propofol, barbiturates, paralytic
Decompressive creniectomy
Controversial on what is the indication.Needs to be large enough (ie. 15x15 cm)
DECRA, RescueICP
Maas, et al Lancet Neurology vol7: 728-741
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DECRA
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Prognosis of moderate to severe TBI
Outcome is usually assessed at 6 mo85% of recovery occur during this time period
Medical complication after TBI prevents early rehab
UTI, pulmonary complications, electrolytesderangement, liver function derangement,hydrocephalus, seizure
Happen to 60-70% of TBI patients.
Maas, et al Lancet Neurology vol7: 728-741
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Rehabilitation in TBI
WHO International classifications:
Impairment: any loss or impairment of psychological,physiological or anatomical structure or function
Disability: any restriction or lack of activity resultingfrom an impairment to perform an activity in themanner or in the range considered normal for thepeople of similar age, sex, or culture.
Handicap: a disadvantage of a given individual
resulting from an impairment or disability that limitsor prevents the fulfillment of a role that wouldotherwise be normal for that individual
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Components of
rehabilitationGoal settingShort and long term goals
Attainable goals to build confidence
Outcome measurements
Ie. timed 10 m tests, nine hole peg test
Setting of rehab
Recovery curve is steepest in the 3-4 months posttrauma- needs to be capitalized
Inpatient vs day-center rehab
Barnes, British Medical Bulletin 1995. 55 (4): 927-943
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Rehabilitation in TBI
McKay 1992: rehab vs no rehab on matched groups ofsevere TBI showed coma length, rehab stay andlengths of stay is better in rehab
Rehab: PT, OT, speech therapy94% rehab group went home vs 57% no rehab group
Blackerby 1990: increased intensity of rehab (5-8h/day) decreases length of stay in the hospital andrehab setting
Barnes, British Medical Bulletin 1995. 55 (4): 927-943
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From: Cognitive Rehabilitation for Traumatic Brain Injury: A Randomized Trial
JAMA. 2000;283(23):3075-3081. doi:10.1001/jama.283.23.3075
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Rehabilitation in TBI
Ghua et al Annal Acad of Sin a ore 200 6: 1- 2
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Rehabilitation in TBI
Ghua et al Annal Acad of Sin a ore 200 6: 1- 2
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Issues during rehab
periodPressure soresSpasticity
Nutrition
Cognitive problem
Behavioral issues
Barnes, British Medical Bulletin 1995. 55 (4): 927-943
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Return to work/ society
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GCS and classifications