TBI Lecture Flashcards
Young people
Low income
Unmarried
Ethnic minorities
Residents of inner city
Men
Hx of substance abuse
Previous TBI
greatest risk for TBI
Max score on the glascow coma scale?
15
3 categories in the glascow coma scale?
Eye opening (4 possible pts) Verbal response (5 possible pts) Motor response (6 possible pts)
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
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
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
A minor TBI has a GSC score of…
13-15
A moderate TBI has a GCS score of…
9-12
A severe TBI has a GCS score of…
under 8
Compression
Tensile (stretching)
Shear (tissue slides over tissue)
..all examples of what type of injury?
primary injury
What type of injury occurs minutes, hours, days after the initial injury
Secondary injury
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
What does ABCDE stand for?
Airway
Breathing
Circulation
Disability
Expose
must maintain a MAP above…
90 mmHg!
MAP= [dbp + (sbp-dbp)/3]
Battle’s sign
Racoon eyes
CSF rhinorrhea or otorrhea
Hemotympanum
Signs of a basilar skull fracture
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
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
Rapid onset of short lived impairment of neurologic function that resolves spontaneously
Concussion
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
OR
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
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
- subfalcial (cingulate)
- uncal
- downward (central, transtenorial)
- external
- 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
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
