Brain injuries Flashcards by Austin Su

Acquired brain injury definition

Damage to the brain at least 7 days after birth

Not related to congenital disorder

Ex: trauma, anoxia, CVA, tumor, infection

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Theories on brain injury recovery and adaptation (2)

Recovery occurs when depressed areas anatomically and functionally related to damaged areas regain function

Originally dmg area recovers or non-dmg related areas adapt to take over function

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Shaken baby syndrome

Acute subdural hematoma

Subarachnoid hemorrhage

Evidence suggests most have evidence of blunt trauma to the head

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TBI outcomes for children

Better than an adult if its severe

Outcomes are worse in very young children

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Critical pediatric GCS score

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Long term effects of moderate/severe TBI

Generalized whole brain volume loss

Diffuse cerebral atrophy
Loss of more white matter than grey matter

Some specific areas of grey matter affected

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Primary TBI injuries (types)

Acceleration dependent; translational coup-countercoup

Rotational; diffuse axonal injury, contusions, lacerations

Acceleration independent; skull depression

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Secondary TBI injuries

Intracranial; hemorrhage and brain swelling, laceration of blood vessels

Extracranial; hypoxemia and hypotension

Primary determinant of outcome in severe TBI

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Secondary brain damage

Intracranial; mass lesions, cerebral edema, cells sludging, endothelial cell swelling

Extracranial factors; hypoxemia, hypotension

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T/F Diffuse brain swelling is lower in infants and children than adults

False, higher

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TBI - secondary injuries

Intracerebral hemorrhage

Epidural hematoma

Acute subdural hematoma

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What artery is commonly involved in epidural hematoma?

Middle meningeal artery

Arterial bleed, require rapid attention

More common in age 9 and up

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Subdural hematoma

More common in age 3 or younger

Due to physical abuse

Tearing of bridging veins

Slow bleed

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What can increased ICP lead to?

Brain herniation

Multiple cerebral infarctions

Permanent brainstem necrosis

Irreversible coma

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When is it appropriate to monitor ICP?

Infants/children with severe TBI - GCS ≤ 8

Treatment begins when ICP ≥ 20

Pts can herniate at ICP < 20-25 mm Hg

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Complications of TBI

Infection

Hydrocephalus

Hygroma - localized CSF collection or hematoma resolution

Seizures

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Medical complications associated with TBI

Suppressed immune response

Endocrine dysfunction

Skin disorders

GI disorders

Orthopedic injuries

Heterotropic ossification

Osteoinductive factors stimulate soft tissue mesenchymal cells to differentiate into osteoblasts to form mature bone

Bone formation around pericapsular space around joint

Unexplained fever, inflammation, pain, less ROM, and swelling

Baclofen and botox to decrease tone

Assessment scales for TBI

GCS

Rancho pediatric levels of consciousness

Pediatric evaluation of disability (PEDI)

Functional independence measure for children

GCS adjustment for 0-6 months old

Best verbal reponse: cry

Best motor respone: flexion

Max GCS expected: 9

GCS adjustment for 6-12 months old

Normal infant makes noises

Infant will usually locate pain but not obey commands

Max GCS expected: 11

GCS adjustment for 12 months - 2 years old

Recognizable words are expected

Toddler will locate pain but not obey commands

Max GCS expected: 12

GCS adjustment for 2-5 years old

Recognizable words are expected

Toddler usually obeys commands

Max GCS expected: 13

GCS adjustment for 5 years old and up

Orientation is defined as awareness of being in hospital

Max GCS expected: 15

GCS values

13-15 mild 9-12 moderate 3-8 severe (under 5 for children)

Coma duration prognostics

Mild = less than 20 minutes Moderate = 20 minutes - 6 hrs Severe = 6-24 hrs

Post traumatic amnesia (PTA)

Period after trauma of confusion, disorientation Less than 2 months = better Greater than 3 months = severe

RLA scale

Level I - No Response: Total Assistance Level II - Generalized Response: Total Assistance Level III - Localized Response: Total Assistance Level IV - Confused/Agitated: Max Assistance Level V - Confused, Inappropriate Non-Agitated: Max Assistance Level VI - Confused, Appropriate: Mod Assistance Level VII - Automatic, Appropriate: Minimal Assistance for Daily Living Skills Level VIII - Purposeful, Appropriate: Stand-By Assistance Level IX - Purposeful, Appropriate: Stand-By Assistance on Request Level X - Purposeful, Appropriate: Modified Independent

Physical and functional impairments from TBI

Atypical and asymmetric stresses imposed by muscles on developing bones

Common causes of anoxia/hypoxia

Drowning/near drowning Inhalation of foreign body Hanging and strangulation Suffocation and asphyxia Apnea

Mechanism of near drowning

Apnea Water aspiration (wet drowning) Laryngospasm (dry drowning) - contraction in the larynx closes it Hypoxemia

T/F Ischemia of the brain longer than 5 minutes results in permanent neuronal injury

True

T/F ICP is important for TBI patients from drowning

False, not correlated with outcome

Presenting symptoms of pediatric CVA

headache focal deficits altered mental status seizure

Most frequent cause of pediatric CVA

Vascular malformations Younger onset is associated with poorer neurocognitive outcomes

Surgical treatments for pediatric CVA

Hematoma evacuation Embolization Lesion excision/repair

Most common pediatric solid tumor

Brain tumor Most common 1-10 y/o

What part of the brain are where pediatric brain tumors most common?

Cerebellum or brainstum 80% are malignant Astrocytomas and medulloblastomas

Types of pediatric brain tumors

Astrocytomas and medulloblastomas Ependymomas Craniopharyngiomas - benign but cause visual disturbances, vomiting, endocrine disturbances Brainstem gliomas - gait disturbance and CN dysfunction

Interventions for pediatric brain cancer

Surgical resection - debulking Radiation Chemotherapy Shunts - CSF flow can be blocked

Prognosis of pediatric brain cancer

5 year survival rate is 70% Typically better prognosis with older age at onset Astrocytomas (slow) have better prognosis than medulloblastomas (fast)