Chapter 22 Traumatic Brain Injury (Direct Text) Flashcards
INTRODUCTION AND EPIDEMIOLOGY:
TBI is a serious public health problem in the United States.
Each year, an estimated 1.7 million people sustain a TBI. Of them 52,000 die, 275,000 are hospitalized, and 1.365 million, nearly 80%, are treated and released from an emergency department.
TBI is responsible for a third (30.5%) of _________ injury-related deaths in the United States.
TBI is more common in children aged 0 to 4 years, adolescents aged 15 to 19 years, and adults aged 65 years and older. Adults aged _________ years and older have the highest rates of TBI-related hospitalization and death. TBI rates are higher for males than for females.
INTRODUCTION AND EPIDEMIOLOGY:
TBI is a serious public health problem in the United States.
Each year, an estimated 1.7 million people sustain a TBI. Of them 52,000 die, 275,000 are hospitalized, and 1.365 million, nearly 80%, are treated and released from an emergency department.
TBI is responsible for a third (30.5%) of all injury-related deaths in the United States.
TBI is more common in children aged 0 to 4 years, adolescents aged 15 to 19 years, and adults aged 65 years and older. Adults aged 75 years and older have the highest rates of TBI-related hospitalization and death. TBI rates are higher for males than for females.
The leading causes of TBI are \_\_\_\_\_\_\_\_\_ (35.2%); \_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_ – traffic (17.3%); struck by/against events (16.5%); and \_\_\_\_\_\_\_\_\_ (10%). Blasts are a leading cause of TBI for military personnel in war zones.
The leading causes of TBI are falls (35.2%); motor vehicle – traffic (17.3%); struck by/against events (16.5%); and assaults (10%). Blasts are a leading cause of TBI for military personnel in war zones.
Direct medical costs and indirect costs such as lost productivity because of TBI totaled an estimated $_________ billion in the United States in 2000.
Direct medical costs and indirect costs such as lost productivity because of TBI totaled an estimated $60 billion in the United States in 2000.
Primary injury occurs at the time of impact and results from the _________ forces of the impact (Fig. 22-1).
Secondary injury follows primary injury and is the effect of cerebral and extracerebral insults. It occurs at both a macroscopic level and a cellular level.
Primary injury occurs at the time of impact and results from the shear forces of the impact (Fig. 22-1).
Secondary injury follows primary injury and is the effect of cerebral and extracerebral insults. It occurs at both a macroscopic level and a cellular level.
The mechanisms of secondary injury are classified under four categories (Table 22-1):
_________, _________, energy failure, and cell death.
_________ swelling.
_________ injury.
_________ and regeneration.
The mechanisms of secondary injury are classified under four categories (Table 22-1):
Ischemia, excitotoxicity, energy failure, and cell death.
Cerebral swelling.
Axonal injury.
Inflammation and regeneration.
Theories of Recovery:
At least three different theories have been proposed to explain the recovery that follows a brain injury and include a reversal of _________, _________, and adaptive _________.
Theories of Recovery:
At least three different theories have been proposed to explain the recovery that follows a brain injury and include a reversal of diaschisis, compensation, and adaptive plasticity.
Diaschisis is a temporary reduction in function of structures interconnected with an injured brain. Functional recovery is likely to be related to a gradual _________ in diaschisis.
Compensation is the use of _________ strategies as an individual attempts to supplement lost function.
A third theory is that functional recovery is largely dependent upon neuroplasticity of intact remaining brain structure. Underlying mechanisms include _________ of existing connections, long-term _________, long-term _________, _________ sprouting, dendritic sprouting, synaptogenesis, and angiogenesis (Table 22-2).
Diaschisis is a temporary reduction in function of structures interconnected with an injured brain. Functional recovery is likely to be related to a gradual reduction in diaschisis.
Compensation is the use of alternative strategies as an individual attempts to supplement lost function.
A third theory is that functional recovery is largely dependent upon neuroplasticity of intact remaining brain structure. Underlying mechanisms include unmasking of existing connections, long-term potentiation, long-term depression, axonal sprouting, dendritic sprouting, synaptogenesis, and angiogenesis (Table 22-2).
Glasgow Outcome Scale: The Glasgow Outcome Scale (GOS) is a five-level score:
- _________.
- _________ state.
- _________ disabled.
- _________ disabled.
- Good recovery.
Glasgow Outcome Scale: The Glasgow Outcome Scale (GOS) is a five-level score:
- Dead.
- Vegetative state.
- Severely disabled.
- Moderately disabled.
- Good recovery.
Posttraumatic Amnesia (PTA): the duration during which patients neither encode nor retain any new information and experience and can be assessed by _________ _________ _________ Test (_________). The end of PTA is marked by a score of > _________ on _________ on _________ _________ days (Table 22-3). In the future, a combination of clinical, laboratory (serum biomarkers and genetic markers), evoked potentials, and radiological techniques (functional MRI and MR spectroscopy) may need to be used for prognostication (Table 22-4).
Posttraumatic Amnesia (PTA): the duration during which patients neither encode nor retain any new information and experience and can be assessed by Galveston Orientation Amnesia Test (GOAT). The end of PTA is marked by a score of >75 on GOAT on two consecutive days (Table 22-3). In the future, a combination of clinical, laboratory (serum biomarkers and genetic markers), evoked potentials, and radiological techniques (functional MRI and MR spectroscopy) may need to be used for prognostication (Table 22-4).
ACUTE TREATMENT
The “ABCs,” _________ maintenance, _________, and _________, are addressed first. The spine is immobilized due to a risk of associated cervical spine injury.
ACUTE TREATMENT
The “ABCs,” airway maintenance, breathing, and circulation, are addressed first. The spine is immobilized due to a risk of associated cervical spine injury.
Intracranial Pressure (ICP) Monitoring in Severe TBI: ICP monitoring is appropriate in:
- Patients with Glasgow Coma Scale scores postresuscitation ≤ _________.
- Head CT showing _________, _________, _________, or compressed basilar cisterns.
- ICP monitoring may also be appropriate in patients with postresuscitation scores ≤ _________ with a normal head CT and two of the following: age > _________ years, motor posturing, or a systolic pressure of
Intracranial Pressure (ICP) Monitoring in Severe TBI: ICP monitoring is appropriate in:
- Patients with Glasgow Coma Scale scores postresuscitation ≤8.
- Head CT showing contusions, hemorrhages, edema, or compressed basilar cisterns.
- ICP monitoring may also be appropriate in patients with postresuscitation scores ≤8 with a normal head CT and two of the following: age >40 years, motor posturing, or a systolic pressure of
ICP is monitored by external _________ drain that can both monitor and drain CSF if necessary. Increased ICPs can be managed by elevating the head end of the bed, preventing _________, and using diuretics like _________. Additional modalities may include use of hyperventilation, barbiturates, and decompressive hemicraniectomy. _________ have not been shown to reduce ICP and are not recommended for use in TBI.
ICP is monitored by external ventricular drain that can both monitor and drain CSF if necessary. Increased ICPs can be managed by elevating the head end of the bed, preventing hyperthermia, and using diuretics like mannitol. Additional modalities may include use of hyperventilation, barbiturates, and decompressive hemicraniectomy. Steroids have not been shown to reduce ICP and are not recommended for use in TBI.
Use of hypothermia has _________ shown to reduce all-cause mortality. Brain Trauma Foundation recommendations (Guidelines for the management of severe TBI, 3rd edition, 2007) do not show any level 1 or level 2 evidence for use of hypothermia. However, patients treated with hypothermia were more likely to have a neurological favorable outcome of GOS 4 or 5.
Use of hypothermia has not shown to reduce all-cause mortality. Brain Trauma Foundation recommendations (Guidelines for the management of severe TBI, 3rd edition, 2007) do not show any level 1 or level 2 evidence for use of hypothermia. However, patients treated with hypothermia were more likely to have a neurological favorable outcome of GOS 4 or 5.
Issues Unique to TBI
Sleep Disturbances – Sleep disturbances occur commonly in patients who have suffered a TBI and may occur during all stages of recovery. Establishing an adequate _________–_________ cycle plays a vital role. Nonpharmacological and pharmacological techniques may need to be utilized. Medications for sleep initiation and for sleep maintenance may need to be considered.
Issues Unique to TBI
Sleep Disturbances – Sleep disturbances occur commonly in patients who have suffered a TBI and may occur during all stages of recovery. Establishing an adequate sleep–wake cycle plays a vital role. Nonpharmacological and pharmacological techniques may need to be utilized. Medications for sleep initiation and for sleep maintenance may need to be considered.
Pharmacotherapy of Arousal and Alertness Dopaminergic agents (\_\_\_\_\_\_\_\_\_ and \_\_\_\_\_\_\_\_\_) and adrenergic agents like methylphenidate are considered in issues related to impaired arousal and alertness.
Pharmacotherapy of Arousal and Alertness Dopaminergic agents (amantadine and bromocriptine) and adrenergic agents like methylphenidate are considered in issues related to impaired arousal and alertness.