E3: TBI

Question 1

What is the pathophysiology of a TBI?

Answer 1

• Direct contact or acceleration/deceleration trauma
• cortical contusions, axonal swelling/damage and release of excitatory neurotransmitters, causes brain function impairment

Question 2

What classifies as a mild TBI?

Answer 2

• “concussion”
• Functionl changes, but no structural damage
• GCS 13-15

Question 3

What is the GCS of a moderate TBI?

Answer 3

9-12

Question 4

What is the GCS of a severe TBI?

Answer 4

3-8

Question 5

What is GCS based on?

Answer 5

• eye response
• verbal response
• motor response

Question 6

What is the max GCS if a patient is intubated?

Answer 6

10

Question 7

What is the presentation of a mild TBI (mTBI)?

Answer 7

• Confusion and anemia, with or without LOC

- HA, dizziness, N/V, slowed speech, decreased focus, and sleep disturbance

Question 8

What are the concerning features of a TBI?

Answer 8

• Clinical deterioration over time with mental status, vitals, seizures, etc
• Precipitating symptoms such as chest pain, syncope, HA
• Cushing reflex

Question 9

What is the triad of Cushing reflex?

Answer 9

• HTN, bradycardia, and irregular breathing

- Late sign of ICP and sign of impending brain herniation

Question 10

What are the 3 PE findings consistent with basilar skull fracture?

Answer 10

Hemotympanum, battle signs, and raccoon eyes

Question 11

What is the SCAT5?

Answer 11

• Sport concussion assessment tool

- used frequently as a sideline evaluation tool, initial office, and follow up assessment

Question 12

What imaging should be ordered for a TBI?

Answer 12

• Head CT without contrast is test of choice
• possible cervical spine CT
• Subacute or follow up imaging includes MRI

Question 13

When should you order a head CT for mTBI?

Answer 13

• GCS <15
• Any signs of basilar skull fracture
• suspected open or depressed skull fracture
• > 2 episodes of vomiting
• New neurological deficits
• presence of bleeding diathesis or on anticoagulant
• > 60 yo
• seizure
• dangerous mechanism
• amnesia >30 min prior to event

Question 14

What is the first thing you should do in the management of a TBI?

Answer 14

-ATLS and GCS: treat any condition that may compromise ventilation

Question 15

What are the two main goals of the treatment of TBI?

Answer 15

• Maintain cerebral perfusion and oxygenation (No hyperventilation to decrease ICP)
• Prevent secondary injury (correct hypoxia, hypercapnia, hyperglycemia, hyperthermia, etc)

Question 16

What are the admission criteria for mild TBI?

Answer 16

• GCS <15
• abnormalities on head CT
• seizures
• hx of underlying bleeding diathesis
• recurrent vomiting
• other neuro deficit

Question 17

What is the managment of a mild TBI?

Answer 17

• Relative cognitive rest if symptomatic

- gradual return to work, school, or sports (no return to sports until able to fully return to school)

Question 18

What are the common symptoms of post-concussive syndrome?

Answer 18

• HA and dizziness

- fatigue, irritability, anxiety, sleep disturbance

Question 19

What is the management of post concussive syndrome?

Answer 19

• reassurance
• relative cognitive and physical rest
• imaging if worsening or concerning symptoms

Question 20

What is second impact syndrome?

Answer 20

• When a second trauma occurs prior to the resoluation of TBI symptoms
• rapid diffuse cerebral edema with increased ICP may occur which is rare, but potentially fatal

Question 21

What is traumatic encephelopathy?

Answer 21

-Recurrent TBI leading to progressive neurodegenerative disease

Question 22

If extensive tau protein accumulation is seen on post-mortem exam, what should be suspected?

Answer 22

Traumatic encephelopathy