Traumatic Brain and Head Injury

Question 1

Define TBI

Answer 1

Non-degenerative, non-congenital insult to the brain from an external mechanical force, possibly leading to temporary or permanent impairment of cognitive, physical and psychosocial function

Question 2

What are the high risk groups for TBI

Answer 2

Young men & elderly
Previous head injuries
Residents of inner city
Alcohol and drug abuse
Low-income

Question 3

What are the principles of ATLS

Answer 3

Airway with C spine control
Breathing
Circulaiton

Question 4

Describe the assessment of a patient with TBI?

Answer 4

ATLS management
(GCS, pupils, other)

Secondary survey
(other injuries- C-spine)

History

• what happened and when
• age
• pre-existing PMH
• Drugs (anticoagulants)

Question 5

What is the eye opening scale in GCS?

Answer 5

Open spontaneously
To speech
To pain
No eye opening

Question 6

What is the verbal scale in GCS?

Answer 6

Orientated
Confused
Inappropriate
Incomprehensible
No Verbal

Question 7

What is the motor scale in GCS?

Answer 7

Obeying
Localising
Flexing
Abnormal Flexing
Extending
No motor response

Question 8

GCS Scale score for;
Medium
Moderate
Severe

Answer 8

Medium: 14 or 15, brief LOC
Moderate: 9-13
Severe: 3-8

Question 9

Patients who have sustained a head injury with any of the following should have a CT scan within 1 hour;

Answer 9

• GCS<13 on initial assessment in the ED
• GCS <15 at 2 hours after injury
• Suspected open or depressed skull fracture
• Any sign of basal skull fracture
• Post traumatic seizure
• Focal Neurological Deficit
• More than one episode of vomiting
• Suspicion of NAI

Question 10

CT scan should be immediately requested in patients with any of the following factors (if they have experienced some loss of consciousness or amnesia since the injury);

Answer 10

• Age 65 years or more
• Coagulopathy
• Dangerous mechanism of injury

Question 11

What is the classic presentation of an extradural haematoma?

Answer 11

• Injury with LOC
• Recovery “lucid interval”
• Rapid progression of neurological symptoms
• Deteriorating GCS

Possible hemiparesis
Unilateral fixed and dilated pupil
Apnoea and death

Question 12

Describe history and examination of a TBI patient?

Answer 12

Age
GCS
Other injuries- harm-dynamically stable
PMH and drug hx
Blood results- coag, platelets

Question 13

What is the medical management of raised ICP?

Answer 13

• Sedation
• Maximise venous drainage of brain
• CO2 control
• osmotic diuretics (mannitol, hypertonic saline)
• CSF release

Question 14

What is used for sedation in raised ICP?

Answer 14

Propofol, benzodiazepines, barbiturates

Question 15

how can the venous drainage of brain be maximised?

Answer 15

Head of bed tilt

Cervical collars, ET tube ties

Question 16

What effect will anti-epileptics have on seizures?

Answer 16

Will reduce early seizures but not late seizures

Question 17

What is DAI?

Answer 17

Diffuse axonal injury

Occurs under sheering forces?

Question 18

Where does DAI occur?

Answer 18

Where there is the greatest density difference (grey/white interface)

Question 19

What is the pathophysiology of DAI?

Answer 19

Excitotoxicity and apoptosis

Inflammatory mediator release

Question 20

What is excitotoxicity?

Answer 20

• Excitatory amino acids (glutamate)
• Activates NMDA receptors
• Calcium mediated activation of proteases and lipases
• Further cell death

Question 21

What inflammatory mediators are related in DAI?

Answer 21

Cytokines, interleukins

IL6 levels higher in non-survivors

Question 22

Describe brainstem death

Answer 22

• No pupil response
• no corneal reflex
• no gag reflex
• no vestibule-ocular reflex
• no motor response
• no respiration