traumatic brain injury final 2013.5.29

7/25/2019 Traumatic Brain Injury Final 2013.5.29

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The Gordon Center for Research in Medical Education

Division of Prehospital and Emergency Healthcare

Continuing Medical Education Trauma

Head Traumatic Brain Injury


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Learning Objectives

Explain the pathophysiology of CNS trauma

Identify the different types of brain injuries

Describe the assessment and managementof patients with traumatic brain injuries

Determine the Glasgow Coma Scale whenpresented with several trauma case studies.


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Head & Brain Trauma

Worldwide, approximately: 200 to 300 cases of TBI per 100,000 population

25 cases of severe TBI per 100,000 population

In the United States, approximately: 4 million head injuries per year

1.4 million treated in hospitals 300,000 admitted per year

Approximately 90,000 have residual neurologicaldeficit.


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Pathophysiology of CNS Injury

Primary injury Damage that occurs at the moment of impact

Secondary injury Damage that occurs subsequent to the initialimpact

Systemic causes

Intrinsic causes


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Primary Brain Injury

Diffuse brain injury Concussion

Diffuse axonal injury

Focal brain injury Contusion

Intracranial hemorrhage Epidural or extraduralSubdural

Subarachnoid Intracerebral


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Range from mild concussion to severe ischemic insult

Normal T Diffuse Injury

Diffuse Brain Injury


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Classification of TBI byMorphology

From Saatman et al., J Neurotrauma, July2008, 25(7): 719-738.


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Secondary Brain Injury

Can occur from minutes to days followinginitial injury

Hypotension SBP < 90 mm Hg (Adults), Children: age-dependent

ICP, MAP, CPP

Hypoxia SpO2< 90%


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Pathophysiology of CNS Injury

Systemic causes Hypoxia

Hypotension

Increased or decreasedCO2

Anemia (blood loss)

Increased or decreasedblood glucose

Intrinsic causes Seizures

Edema

Hematomas

Increased intracranialpressure (ICP)

Secondary Injury


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Blood Pressure and TBI

Intracranial Pressure (ICP)must be lower thansystemic BP) CPP = MAP ICP

Mean arterial pressure =(2x diastolic + systolic)/3

As ICP rises, CPP willdecrease if BP does notrise


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Hypoxia

SpO2< 90% have significant negativeoutcomes

Continuous monitoring

Correct difficulty breathing early

Keep intubation times short to hypoxic

time


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Assessment

Accurate blood pressure readings Use the most accurate method available

Repetitive neurologic exams

GCS is designed to allow providers to repeatthe exam through continuum of care

Pupillary responses

Continuous SpO2

& EtCO2

measurements

Frequent reassessments

**Change in LOC is the earliest and best indicator of patients ICP


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Pupil Response

Assess eyes for traumato the eye orbits

Oculomotor nerve

provides function topupils

Assess pupils afterresuscitation andstabilization

Both eyes must beassessed and compared


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Pupil Assessment

Pupil asymmetryis > 1 mm < 1 mm is a

normal finding Unilateral or

bilateral dilatedpupils

Fixed and dilatedpupils < 1 mm responseto bright light


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Intracranial Pressure

An increase in the volume of any of thesethree contents may cause increased ICP: Swelling of brain tissue

Bleeding

CSF accumulation


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Intracranial Pressure

As ICP increases, everything in the skull iscompressed Blood vessels

CSF

Brain

You can displace a small amount of blood.

You can displace a small amount of CSF. But


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Increasing ICP

Early signs Vomiting (with orwithout nausea)

Headache Dizziness

Amnesia

Visual disturbances

Altered LOC Seizures

Late signs Cushings Triad

Hypertension (with

widening pulsepressure)

Bradycardia

Irregular respirations

Pupil changes Coma

Posturing


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The Brain Death Cycle

In the case of EDH or SDH, we can also add

the effect of the expanding hematoma.Copyright 2012 by Mosby, Inc., an affiliate of Elsevier Inc. 18


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Clinical Effects of ICP

19


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Respiratory Patterns

Altered respiratorypatterns Cheyne-Stokes

Central neurogenichyperventilation

Biots


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Management of Oxygenation

Oxygen to maintain normoxia (>94% SaO2)

Begin ventilations at signs of ineffective

breathing 10 to 12/min for adults

15 to 20/min for infants and children

Intubation or airways may increase ICP


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Management of Fluids

Assess patient for bleeding

TBI patients are often hypertensive Restrict fluids to prevent edema

Hypotension must be treated with fluid

Blood pressure should be kept above90 mm Hg systolic Crystalloid fluids for bolus


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Volume-Pressure Curve


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Cerebral Herniation Signs of herniation

Dilated and unreactive pupils

Asymmetric pupils

Extensor posturing

Drop in GCS of 2 or more with initial GCS < 9


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Management of Cerebral

Herniation In patients who are already well ventilated,

hyperventilation may be indicated

Adults 20 breaths/min Child 25 breaths/min

Infant (< 1 year) 30 breaths/min

Temporizing until signs of herniation resolve

Goal: Ventilate to ETCO2of 30 to 35 mm Hg


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Mechanics of Hyperventilation

CO2is a vasodilator

CO2makes blood vessels in the head

expand, taking up more space CO2makes them constrict, thereby taking

up less space

Caveat: when vessels are small, they have aharder time carrying oxygenated blood


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Pharmacologic Therapy

Diuretics Mannitol may take 15 to 30 min

Furosemide may not reduce fluid in brain

Seizures Benzodiazepines

Antiepileptic medications

Steroids should not be used


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Transport

Minimize on-scene time

Supine position (unless patient is at risk foraspiration- then elevate HOB 30)

Appropriate receiving facility

Frequent reassessment


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The Bottom Line

Most of the bad TBI stuff presents about thesame way: Headache

Vomiting

Altered mentation

Neurological deficits


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Optimal Management

Priorities: ABCDE

Minimize secondary brain injury

Administer oxygen Maintain adequate ventilation

Maintain blood pressure (systolic > 90 mm Hg)


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Summary

Primary survey: identify and treat life-threatening conditions first.

Shock is a late finding in patients withtraumatic brain injury; consider thepossibility of internal hemorrhage.


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Summary The primary goal of treatment for patients

with suspected TBI is to prevent secondarybrain injury.

The most important sign of traumatic braininjury is a change in mental status.

Key aspect is to determine whether baselineassessment findings are changing and inwhich direction (better or worse). Frequent Reassessments


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Summary

Treatment keysminimize secondary injuryof the brain. Correct or prevent hypoxemia (Goal SpO2 >

94%). Correct or prevent hypotension (Goal: SBP >90mmHg).

Avoid hyperventilation.

Transport to an appropriate facility.


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Practice Session:

Glasgow Coma Scale


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35

0

Developed to assess level of consciousness aftertrauma

Scored from 3-15 (no 0)

Initially developed in 1974 - University of Glasgow

Assesses a patients best Eye Response, Verbal Response, & Motor Response

Brain Injury based on severity: Severe: GCS 3-8

Moderate: GCS 9-12 (controversial)

Minor: GCS 13

Incorporated into several ICU scoring systems(APACHE, SAPS, SOFA)

Glasgow Coma Scale


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35

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Glasgow Coma Scale:

Eye Opening

Eye opening

Score Response

4 Opens eyes spontaneously

3 Verbal: Opens eyes in response to verbal stimuli

2 Pain: Opens eyes in response to painful stimuli1 None: Patient does not open eyes

GCS for Adults


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35

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Glasgow Coma Scale :

Verbal Response

Best Verbal Response

Score Response

5 Oriented: To person, place, and time, conversesnormally

4 Disoriented: Patient is conversant but confused

3 Nonsensical Conversation: Inappropriate use of words

2 Patient makes incomprehensible sounds (e.g. moans)

1 No response: Patient does not respond verbally

* If the pt. is intubated or has a tracheostomy aTshould be added to the comments


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35

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Glasgow Coma Scale Score:

Motor ResponseBest Motor Response

Score Response

6 Follows commands: Obeys simple commands

5 Localizes pain: Purposeful movement toward painful stimuli

4 Withdraws from pain: Patient withdraws from pain

3 Decorticate: Patient flexes arms inward towards the chest

2 Decerebrate extension: Patient extends arms outward from

the body1 No response: Patient does not move

*If the pt. is sedated or chemically paralyzed a Por Sshould be added to the comments


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0

CASE 1 57 y/o M fall from bicycle. On exam, eyes are

open, he is holding the Rt. side of his head, andanswering questions inappropriately.

Obvious laceration from his Rt. eyebrow to hisear

GCSEye Opening 1-4

Verbal Response 1-5Motor Response 1-6


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What is the patients GCS?

A. GCS 14

B. GCS 12

C. GCS 10D. GCS 9

E. GCS 5

GCSEyes are open =4

Response inappropriate =3Localizes pain =5

GCS = 12

i i di l d i


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CASE 2

24 y/o F found on the ground after being struck by acar. Her eyes are closed, and she is moaningincomprehensible sounds. She does not open her

eyes to verbal or painful stimuli.

Arms are down and hands are extended outwardwith increased tone.

GCSEye Opening 1-4Verbal Response 1-5Motor Response 1-6

C i i M di l Ed i T


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A. GCS 12

B. GCS 10

C. GCS 9D. GCS 7

E. GCS 5

GCSEyes no response =1

Incomprehensible sounds =2Extensor posturing =2

GCS = 5

C ti i M di l Ed ti T


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0

CASE 3 37 y/o M driver of vehicle involved in a

roadside IED explosion. Vehicle turned on toside with extensive damage.

Patient opens eyes to painful stimuli, pullshands away as you pinch his fingernails, andmoans without making coherent words.

GCSEyes Opening 1-4Verbal Response 1-5Motor Response 1-6



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A. GCS 8

B. GCS 5

C. GCS 4D. GCS 3

E. GCS 0

GCS

Eyes open to pain =2Response incoherent =2Withdraws from pain =4

GCS = 8



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0

CASE 4 19 y/o M is unconscious with eyes closed

following an assault. Patient has multiple gunshot wounds to upper torso area.

Patient does not respond or open eyes to anyverbal or painful stimuli and there is nomovement from the patient.

GCS

Eyes Opening 1-4Verbal Response 1-5Motor Response 1-6



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A. GCS 8

B. GCS 5

C. GCS 4

D. GCS 3

E. GCS 1

GCSEyes none =1Response none =1No movement =1

GCS = 3

Contin ing Medical Ed cation Tra ma


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0

CASE 5 39 y/o M lying on the ground following a fall

from height of 10 feet.

Patient is lying on ground with eyes open, he is

disoriented, and brings his hands to his chestwhen palpated.

GCSEye Opening 1-4

Verbal Response 1-5Motor Response 1-6



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A. GCS 15

B. GCS 14

C. GCS 13

D. GCS 9

E. GCS 7

GCS

Eyes are open =4Response disoriented =4Localizes pain =5

GCS =13



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0

CASE 6 33 y/o F lying on the ground following an

ejection from a motor vehicle 30 feet away.

Paramedic is attending to the patient who is

conscious with eyes open, disoriented, strongsmell of ETOH, holding obvious deformity to Rt.femur.




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A. GCS 14

B. GCS 13C. GCS 10

D. GCS 8

E. GCS 5

GCSEyes are open =4

Disoriented =4Localizes pain =5

GCS =13



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Pediatric Glasgow Coma Scale

(3-15)

> 1 year < 1 year

Score Response Response

4 Spontaneously Spontaneously

3 To verbal command To verbal command

2 Requires painful stimuli to

open eyes

Requires painful stimuli to

open eyes1 No response No response

Eye opening



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Pediatric Glasgow Coma Scale:

Verbal Response> 5 years 2-5 years 0-23 months

Score Response Response Response

5 Oriented: To person,place, and time

Appropriate words &phrases

Smiles, coos, orients tosounds, follows objects,

interacts4 Disoriented: Patient

is conversant butconfused

Inappropriate words Cries but consolable

3 NonsensicalConversation:

Inappropriate use ofwords

Cries and/or screams Inappropriate cryingand/or screaming

2 Incomprehensiblesounds (e.g. moans)

Inconsolable, agitated Grunts

1 No response No response No response



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Pediatric Glasgow Coma Scale:

Motor Response> 1 year < 1 year

Score Response Response

6 Follows simple commands Normal spontaneous movement

5 Localizes pain: Patient

indicates location of pain

Withdraws from touch

4 Withdraws from pain: Patientwithdraws from pain

Withdraws from pain: Patientwithdraws from pain

3 Decorticate: Patient flexesarms inward towards thechest

Decorticate: Patient flexes armsinward towards the chest

2 Decerebrate extension:Patient extends arms outwardfrom the body

Decerebrate extension: Patientextends arms outward from thebody

1 No motor response No motor response



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0

CASE 7 10 y/o F conscious, eyes open and lying on a gym

mat, following a fall from the exercise bars. Thecoach tells you that she was unconscious prior toyour arrival.

She has an abrasion on her forehead, and no otherobvious injuries, she knows were she is but doesnot remember what happened. Pt. squeezes yourhands when asked.




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A. GCS 15

B. GCS 14

C. GCS 13

D. GCS 10

E. GCS 8

GCS

Eyes are open =4Inappropriate response =4Follows Commands =6

GCS=14



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0

CASE 8 2 y/o M sitting in a car seat after an MVC. Patient

is restrained with minor bleeding from theforehead. The child appears very calm.

Child stares into space, when you try to talk to himhe begins to cry inconsolably and becomesagitated. He withdraws his hand when you pinchhim.




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1. GCS 14

2. GCS 10

3. GCS 9

4. GCS 8

5. GCS 6

GCS

Eyes are open =4Response inappropriate =2Withdraws from pain =4

GCS=10



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ANY QUESTIONS



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Thank You!

Michael S. Gordon Center for Research in Medical Education

University of Miami Miller School of Medicine

traumatic brain injury final 2013.5.29

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