TBI Flashcards
leading cause of TBI
Falls (elderly) vs MVA (children)
TBI demographic
single, white, undereducated, teen to 25 yo, male
cerebral profusion pressure equation
What value keep CPP?
CPP = MAP - ICP
CPP>60mmhg
Keep ICP <20mmhg
Managing ICP
nl range 2-5, keep under 20
- force hyperventilation (decrease PaCO2-> vasoconstriction-> less flow)
- hypothermia
- Meds: IV mannitol or acetazolamide
- emergency- burr hole, craniotomy
Primary injury
Contusion
Diaschisis
DAI
immediate concussive force
brain bruises at “horns” of brain. usually at inf frontal lobe and ant temp lobe
“split across”- damage area damages remote region connected
“Diffuse Axon Injury”
DAI- causes, most common locations
diffuse axonal injury
axon injury 2.2 concussive blat to head and shears axon leading to central white matter damage. white on diffusion weighted MRI. Usually seen at central white matter, brain stem, corpus callosum
DAI grading
Using MRI criteria
1- no focal change
2- focal change
3- brain stem involvement
Secondary injury
biochemical cascade after primary injry
- excitatory toxicity (glutamate): massive neurotransmitte r surge and burn out
- Brain swelling- CT shows decrease ventricle size
- Brain edema - longstanding, blood vessel damage, fluid leak out of brain tissue
Posturing
decorticate
decerebrate
deCORticate: arms flexed, legs extended. lesion at brainstem
Decerebrate: arms extended, leg extended. lesion at midbrain. (worse due to brainstem involvement)
Epidural hematoma
Lens
middle meningeal artery
no midline shift
lucid then downhill
Subdural hematoma
Crescent
bridging vein
bleed between dura and arachnoid
subarachnoid hemorrhage
bleeding in subarachnoid space
rupture AVM or berry aneurysm (usually Acomm or Pcomm)
give nimodipine x 21days for cerebral vasospasm
C1 injury
smell, most common injury
C2
visual field
C7
deficit at ant 2/3 tongue, facial expression, salivation, tears
C8
hearing loss and balance
most dizziness is BPPV
what should pts be on after brain radiation tx?
steroids
Coma
eyes closed
no wake/sleep cycle on EEG
no purposeful behavior or comprehension
Vegetative state
eyes open \+ wake/sleep on EEG no localization of objections \+ reflexive behavior w/o crossing midline Persistent = >1month Permanent= >1 year, 3months on nontraumatic (anoxia)
Minimally conscious state
+eyes open
+wake/sleep
+environmental awareness, purposeful behavior crossing midline but not consistent
Treating disorders of consciousness (DOC)
supportive
meds increasing dopamine: amantadine, methylphenidate, modafinil
Posttraumatic Amnesia -PTA
Test and score
cant make memories of daily events
GOAT- Galveston Orientation and Amnesia Test
>75 points for 2 straight days
Orientation log
>25 points for 2 straight days
Glasgow Outcome Scale (GOS)
1- dead 2- VS 3- conscious with disability 4-independent with disability 5- independent
Rancho Los Amigos
1- no response 2- generalized response 3- localized response 4- confused agitated 5- confused inappropriate 6- confused appropriate 7- automatic appropriate 8- purposeful appropriate
“4 is on the floor” confused agitated pt
Posttraumatic seizure
timing
simple partial after TBI immediate in first day early 1-7days late after 7 days Check prolactin levels, EEG tx leve or phenytoin
Posttraumatic epilepsy
recurrent seizures in first week
R/o other causes
caused by foreign body, blood, or bone
Tx AED x1 week for ppx. continue 2 year if late seizure. okay to stop if no seizure for 2 years
Levetiracetam, Carbamazepine, valproate, phenytoin, phenobarbital
Posttraumatic hydrocephalus
increase pressure
dilated ventricles, N/V/HA/ confusion
tx with VP shunt
Dysautonomic/ sympathetic storm
sympathetic output
HTN, fever, tachy, sweat intermittently
tx with propanolol, scheduled pain control (tylenol) and dopamine agonist (bromocriptine, amantadine)
-ID work up if SIRS
Tx agitation
decrease stimuli let pt burn off energy
lesion usually at frontal and temporal lobes
meds: antispychotics/ D2 blockers, haloperidol (slows motor recovery), quetiapine, olanzapine, ziprasidone, rispirodone , watch for metabolic issues and prolonged QT
ABS agitation behavior scale
<21 normal
SIADH
too much ADH, holding on to too much water
Euvolemic hyponatremia
tx with water restriction
CSW- central salt wasting
hypovolumic hyponatremia
tachy, low bp, appropriate elevated ADH
tx with iv fluids
Diabetes insipitus
no ADH, peeing out water, thirsty
Hypernatremia, dilute urine
give ADH
Concussion
mild tbi: GCS 12-15
Sx: HA, sensory issues, psych, memory, sleep, tired
Brain trauma with LOC < 30mins or PTA < 1 day of AMS or focal neuro deficit
recovers in 1-3 months
Return to play protocol
Stages can only proceed if asymptomatic to start 1- do nothing 2- light cardio 3- directional cardio 4- drills: sports specific cardio 5- full practice 6- cleared to play
