3- Traumatic Brain Injury

Question 1

What is GCS based on?

Answer 1

Eye, verbal, motor response

(more useful for mod to severe TBI)

Question 2

GCS score of 13-15 is classified as?

Answer 2

Mild TBI (concussion)- functional changes, but not structural damage

Question 3

GCS score of 9-12 is classified as?

Answer 3

Moderate TBI

Question 4

GCS score of 3-8 is classified as?

Answer 4

Severe

Question 5

A GCS should be obtained prior to intubation if possible. If a pt arrives intubated, what is the max score they can receive?

Answer 5

10T

Question 6

How do you assess GCS in an unresponsive pt?

Answer 6

Try to obtain pupillary response or motor function

Question 7

What score (other than GCS) is used for intubated pts?

Answer 7

FOUR score- no verbal response, assesses brainstem

Question 8

Pt presents with confusion and amnesia +/- LOC. What are you concerned for?

Answer 8

Acute mTBI

Question 9

Pt presents with HTN, bradycardia, and irregular breathing with hx of a head injury. What are you concerned for?

Answer 9

Cushing reflex/ triad; Late sign of increased ICP (concerning TBI presentation)

Question 10

Individual who incurs a head trauma during a football game is likely to be evaluated for TBI with which assessment tool?

Answer 10

SCAT 5 (sport concussion assessment tool)

Question 11

What is considered a (+) test for cognitive impairment if using the Westmead Post-Traumatic Amnesia Scale?

Answer 11

Any incorrect response

(9 A+O questions, 3 pictures)

Question 12

What is the preferred diagnostic study for acute/ initial imaging if suspicion of TBI?

Answer 12

Head CT w/o contrast

Question 13

Pt with hx of TBI presents with neurologic decline despite initial CT with normal findings. What follow up imaging should be ordered?

Answer 13

Brain MRI w/o contrast

(ex. possible PCS)

Question 14

What are the indications for a head CT in an adult with mTBI? (10)

Answer 14

• ≥ 60 yo
• GCS < 15
• ≥ 2 episodes of vomiting
• Amnesia > 30 min prior to event
• Dangerous mechanism
• Any sign of skull fracture (basilar, open, depressed)
• New neuro deficits
• Seizure
• Bleeding diathesis/ on anticoagulant

Question 15

Under what conditions should you always order imaging (CT) if suspicious for TBI? (5)

Answer 15

• Persistent amnesia (≥ 30 min anterograde/ retrograde)
• Intoxication
• HA
• Abn behavior
• Pt lives alone

Question 16

When would you order a CT for a pediatric patient with concern for TBI?

Answer 16

GCS = 14, AMS, signs of basilar skull fracture, palpable skull fracture

Question 17

What is 1st line in the management of TBI?

Answer 17

ATLS and obtain GCS

Question 18

What GCS score indicates need for intubation?

Answer 18

≤ 8

Question 19

What is included in the management of moderate and severe TBI? (4)

Answer 19

Maintain cerebral perfusion and oxygenation

Prevent secondary injury

Neurosurgical intervention

Tranexamic acid (GCS 8-13, w/i 3 hrs of injury)

Question 20

Management of mild TBI includes 24 hours of observation with admission or d/c home. When should a pt be admitted? (6)

Answer 20

• GCS < 15
• Abns on head CT
• Seizures
• Hx bleeding disorder/ on anticoagulant
• Recurrent vomiting
• Other neuro deficit

Question 21

What pt edu should be provided for mild TBI?

Answer 21

24-48 hrs cognitive rest if sxs, gradual return to work/ school/ sport, no return to sport until able to fully return to school

Question 22

Does severity of injury fully correlate with recovery/ risk of developing post-concussion syndrome (PCS)?

Answer 22

NO

Question 23

Pt presents with recent hx of head trauma and c/o HA and dizziness. What are you suspcious for and what is the management?

Answer 23

Post-concussion syndrome (PCS)

Management: Reassurance (worst @ 7-10 days post trauma), relative cognitive/ physical rest

Question 24

Pt with recent hx of head trauma and unresolved sxs presents with new head trauma. You note rapid, diffuse cerebral edema with increased ICP. What are you concerned for and what is the management?

Answer 24

Second impact syndrome

Management: reduce ICP (and prevention)

Question 25

Pt with hx of recurrent TBI presents with cognitive impairment, behavior abnormalties and mood disorders. What are you concerned for and what post-mortem patholgic/ histologic abns would be evident?

Answer 25

Traumatic encephalopathy

Extensive tau-protein accumulation

(no definitive dx study, manage sxs)