TBI Lecture Flashcards by Cassidy Ruocco

Young people
Low income
Unmarried
Ethnic minorities
Residents of inner city
Men
Hx of substance abuse
Previous TBI

greatest risk for TBI

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Max score on the glascow coma scale?

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3 categories in the glascow coma scale?

Eye opening (4 possible pts)
Verbal response (5 possible pts)
Motor response (6 possible pts)

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What are the options for eye response on the glascow coma scale?

1 pt= no eye opening

2 pts= eyes open to pain

3= eyes open to speech

4= eyes open spontaneously

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What are the options for verbal response on the glascow coma score?

1 pt= no verbal response

2= incomprehensible sounds (moaning)

3= inappropriate words

4= disorientation/confusion

5= oriented, clear speech

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What are the options for motor response on the glascow coma scale?

1 pt= no motor response

2= decerebrate

3= decorticate

4= flexion/withdrawal from pain

5= localizes pain

6= obeys commands

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A minor TBI has a GSC score of…

13-15

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A moderate TBI has a GCS score of…

9-12

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A severe TBI has a GCS score of…

under 8

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Compression
Tensile (stretching)
Shear (tissue slides over tissue)

..all examples of what type of injury?

primary injury

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What type of injury occurs minutes, hours, days after the initial injury

Secondary injury

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Intracellular swelling
Electrolyte imbalances (Na, Cl, Ca, Mg)
Inflammatory response (increase in cytokines)
Cerebral arterial dilation
Intracranial hemorrhage
Cerebral edema
Ischemia/hypoxia
Increased ICP

Secondary injury

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What does ABCDE stand for?

Airway
Breathing
Circulation
Disability
Expose

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must maintain a MAP above…

90 mmHg!

MAP= [dbp + (sbp-dbp)/3]

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Battle’s sign
Racoon eyes
CSF rhinorrhea or otorrhea
Hemotympanum

Signs of a basilar skull fracture

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External exam of the head
Level of alertness
Pupils- size, reactivity, equal
Ear canals- hemotympanum
Cranial nerves
Reflexes
Posturing
Strength
Sensation

what to look at with a TBI patient

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No vomiting
No HA
Under 60
Not intoxicated
No deficits in short term memory
No evidence of trauma above clavicles
No seizures

…NOT likely to have significant intracranial injury

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Rapid onset of short lived impairment of neurologic function that resolves spontaneously

Concussion

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With a concussion, acute clinical symptoms largely reflect a functional disturbance rather than…

structural injury

No LOC
Post traumatic amnesia or other signs lasting less than 30 mins

*athletes can return if asymptomatic for 1 week

Concussion grade 1

LOC under 1 min

Post traumatic amnesia or other sxs >30 mins (but under 24 hrs)

*athletes can return to play in 2 weeks if asymptomatic at rest

Concussion grade 2

LOC >1 minute

Post traumatic amnesia or other sxs >24 hrs

*athletes can return to play in 1 mo if asymp at rest

Concussion grade 3

a “bruise”, commonly in:

orbitofrontal cortex
anterior temporal lobe
posterior portion of superior temporal gyrus area

can present with confusion to coma
MAY* be seen on CT

Brain contusion with intracerebral hemorrhage

Acceleration/deceleration MOI (ie shaken baby syndrome)

*widespread damage
*shear forces injuring axons (white matter)

*axonal tearing- secondary injury degradation of cytoskeleton, ion imbalance (Ca) hours after primary injury

Diffuse Axonal Injury (DAI)

Diffuse axonal injury (DAI) occurs commony (**2/3**) at the junction of...

grey and white matter

**Coma for 6-24hrs**, usually recover without long term sequela

Mild DAI

**Coma \>24 hours**, but do wake up. will have long term cogntive deficits\*

**Moderate** diffuse axonal injury (DAI)

**Prolonged coma** Persistent vegetative state (90%)

**Severe** DAI

Tx for DAI?

Supportive measures only

can lead to increased ICP **secondary to blockage of CSF outflow at 3rd and 4th ventricles**

Traumatic Subarachnoid Hemorrhage

If asymptomatic..admit for observation, get neurosurgical consult if symptomatic..neurosurgical consult. may require ICP monitoring **can be missed on early CT (\<6hrs)**

Traumatic Subarachnoid Hemorrhage

Suspect if pt has.... * *persistent HA** * *photophobia** * *nausea**

Traumatic subarachnoid hemorrhage

slow, **venous bleed** high risk in ppl with cerebral atrophy (ie alcoholics, elderly) **concave (crescent shaped) hematoma on CT scan**

Subdural hematoma

**crescent shape on CT scan** HA, lethargy, to coma may be acute (within 24 hours) or chronic (\> 2 weeks from injury)

Subdural hematoma

brief LOC followed by lucid period ## Footnote **arterial bleed, HIGH PRESSURE MC = middle meningeal artery**

Epidural hematoma

MC artery involved in an epidural hematoma

Middle meningeal artery

Fixed, dilated pupil on ipsilateral side with contralateral hemiparesis (late findings) **seen on CT as lenticular (bi-convex or football shaped) lesion**

Epidural hematoma

Arterial bleed Bi-convex, football shaped lesion on CT scan IMMEDIATE neurosurg consult need to decompress to prevent brain herniation

Epidural hematoma

1. subfalcial (cingulate) 2. uncal 3. downward (central, transtenorial) 4. external 5. tonsillar

types of **brain herniations**

subfalcial (cingulate) herniation uncal herniation tonsillar herniation ..usually caused by?

focal, ipsilateral space occupying lesions (ie tumor, axial or extra-axial hemorrhage)

Normal ICP?

0-10 mmHg

Pathologic ICP?

greater or equal to 20 mmHg

Cerebral Perfusion Pressure (CPP)= MAP - ICP ## Footnote **CPP is critical at what range?**

50-70 mmhG

You can adjust CPP by ___ MAP or _____ ICP

**increasing** MAP **decreasing** ICP

You can increase MAP with...

IVF Pressors

You can decrease ICP with...

Osmotic diuresis HOB elevation (above 30 degrees) Drain CSF with Burr Hole