Traumatic Brain Injury I

Question 1

Traumatic Brain Injury

Answer 1

an insult to he brain, not of degenerative or congenital nature but is caused by an external force that may produce a diminished or altered state of consciousness

Question 2

Epidemiology of TBI

Answer 2

-1.5-1.9 TBI’s occur annually

• # 1 cause of disability in children and young adults
• important because their brain is still developing and learning

Question 3

Demographics variables that determine risk factors for TBI

Answer 3

Age
Ethnicity 
Sex 
Gender 
Substance Abuse 
Recurrent TBI

Question 4

Risk Factor for TBI

Answer 4

• Increased risk for person age 15-24y
• Males>Females 2:1
• Race is too variable to determine
• study found ~56% of person with TBI had a high blood OH+ level
• Risk for recurrent TBI increased 2.8-3x for a 2nd TBI and 7.8-9.3x for a third

Question 5

Closed Head Injury(CHI)

Answer 5

Non-penetrating; blunt had trauma

Meninges remain intact (skull may be fractured) (brain itself has not been penetrated)

Associated with diffuse injury (damage is more wide spread; more all over the brain)

More common than OHI

ex. shaken baby syndrome

Question 6

Open Head Injury (OHI)

Answer 6

Penetrating

Covering of the brain are ruptured due to tearing of the dura by skull fragments and/or other penetrating force

Associated with focal injury

More common in wartime
ex. ppl in military have this a lot

Question 7

TBI Etiologies

Answer 7

• Falls are the most common cause of TBI per age overall
• MVAs account for 50% of TBIs in persons age 15-24y
• BI impacts 1 in 5 household in KY; KY rate is more than twice the national average
• 1/3rd of all ED visits in children is due to BI; a childs skull is only 1/8th as strong as an adult’s skull
• KY is highest # of fatalities for ATVs in the nation

Question 8

BI and Sports/Recreation

Answer 8

• BI is the leading cause of sports related deaths; 65% of all sports related BI treated annually occur in individuals age 5-18y
• Activities associated with the greatest # of ED visits annually include: bicycling, football, playground activates, basketball, horseback riding, and riding ATV’s
• Estimated that number of concussion rates than males in sports played by both
• mTBI= mild traumatic brain injury (ex. concussion)

Question 9

Primary Brain Damage

Answer 9

Damage that is complete at the time of impact

• skull fracture
• contusion (bruise)
• hematoma (blood clot)
• laceration
• nerve damage (DAI= Defuse axonal injury; wide spread)

Parts of the brain damaged > than the size of the overall injury

Question 10

Secondary Brain Damage

Answer 10

Damage that evolves over time

• edema (swelling of the brain; bodies attempt at healing itself)
• increased ICP (internal cranial pressure; edema can cause this)
• infection
• fever
• anemia (iron deficiency; low iron)
• epilepsy
• hypo/hyperthermia (can not control body temp)
• abnormal blood coagulation
• cardiac changes
• pulmonary changes
• nutritional changes

Question 11

Classic Closed Head Injury

Answer 11

BI that occurs secondary to impact of the head causing deformation of the brain resulting in characteristic pathological changes
-MVA’s, assaults, suicides, falling objects and falls

• leading cause of death under the age of 45y
• accounts for 25-33% of all deaths related to trauma

Question 12

Coup/Contrecoup Injuries

Answer 12

Brain acceleration vs. deceleration

Part of classic closed head injury

-the coup injury is when the brain is moved forward and hits the front of the skull and the contrecoup injury is when the brain is then moved back and hits the back of the skull

Question 13

Penetrating Head Injury

OHI

Answer 13

Occur secondary to the penetration of an object be it a: bullet, knife, bolt, shrapnel, nails, teeth, screwdriver, or the Eiffel Tower

These injuries are often described as being: depressed, penetrating or perforating

• mortality rate appears lower for AP wounds (25%) than lateral wounds (83%)
• penetrating head injuries are less common than CHI

Question 14

Depressed

Answer 14

object does not enter the cranial vault but cause a depressed fracture and cortical contusions

Question 15

Penetrating

Answer 15

object enters the cranial cavity but does not pass through to the other side

Question 16

Perforating

Answer 16

object traverses the cranial cavity and exits through a wound characteristically larger than the entry wound

Question 17

TBI and the Military

Answer 17

• as a result of recent warring activities in the Middle East and the surrounding world the US is now treating more TBIs than chest or abdominal wounds
• 1/3rd combat forces are at risk for TBI
• TBI is separate from PTSD but both are co-related

Question 18

Blast Injuries

Answer 18

Explosion resulting in over-pressurization related trauma

-blast induced BI associated most frequently with high-power explosives

Question 19

Four(+) Basic Mechanisms of Blast Injury

Answer 19

1. Primary
2. Secondary
3. Tertiary
4. Quaternary
5. Quinary
   +Psychological Trauma (PTSD)

Question 20

Primary (Blast Injury)

Answer 20

occurs secondary to over-pressurization impulse created by a detonated high-explosive usually impacting the auditory, GI, and/or pulmonary systems

-the blast wave causes the primary

Question 21

Secondary (Blast Injury)

Answer 21

Injuries that occur secondary to flying objects

Question 22

Tertiary (Blast Injury)

Answer 22

Injuries that occur due to the person becoming airborne

Question 23

Quaternary

Answer 23

References burns and crushing injuries from falling objects

Question 24

Quinary

Answer 24

Chemical, biological, and/or radiological exposure

Question 25

Explosives

Answer 25

are categorized as either high-order or low-order High Order (HE): TNT, dynamite, ammonium nitrate Low Order (LE): results in shrapnel-like injuries Improvised Explosive Devices (IEDs): contain both HE and LE

Question 26

Concussion

Answer 26

an injury to the brain that is loosely defined as a "jarring" of the brain - when a person sustains a concussion they are said to have an mTBI - most common type of TBI - frequently occurs secondary to violent shaking, a direct blow to the head or whiplash

Question 27

Concussion Grading

Answer 27

Grade I: no LOC; PTA(post traumatic amnesia) < 30 minutes Grade II: LOC< 5 minutes; PTA> 30 minutes, PTA< 24 hours Grade III: LCO> 5 minutes: PTA> 24 hours

Question 28

Pyramidal System

Answer 28

responsible for volitional motor control: direct activation pathways

Question 29

Extrapyramidal System

Answer 29

responsible for modulating and regulating motor movements; indirect activation pathways

Question 30

Cerebellum

Answer 30

does not initiate movement, rather it works in tandem with the EPS to maintain balance/posture and coordination of motor movements; includes motor learning

Question 31

Dementia Pugilistica

Answer 31

-Punch-Drunk Syndrome: Chronic Traumatic Encephalopathy occurs secondary to repeated concussive blows to the head - estimated that 10-25% of boxers ultimately develop post-boxing neurological syndrome characterized by cerebral atrophy, cellular loss in cerebellum, and increased cortical and subcortical neurofibrillary tangles - s/s may begin to appear 12-16y post initiation of boxing career - occurs in both professionals and amateurs (not just boxing) - can only be diagnosed after death with a brain autopsy

Question 32

Dementia Pugiistic Stages

Answer 32

Stage I: affective disorder, mild incoordination Stage II: aphasia, apraxia, agnosia, apathy, flat affect, neuro s/s Stage III: global cognitive decline and parkinsonism

Question 33

Second Impact Syndome

Answer 33

occurs when second TBI occurs prior to he initial TBI completing the healing process - most likely to cause edema and diffuse damage - LOC don't have to be present ``` Long term implications include: Increased muscle tone Rapidly changing emotions Muscle spasms Hallucinations Difficulty thinking and learning ```

Question 34

TBI: Infancy and Childhood

Answer 34

- projected mean of TBI in children younger than 15y is around 180 per 100K - fracture of the skull is present in around 20-40% of cases - abusive head trauma accounts for 25% of hospital admits in children <2y - children with TBI may lack the communication skills to report headaches, sensory problems, confusion, and/or similar symptoms (have to look for signs) SDH is most common intracranial injury following abuse

Question 35

Children with TBI may manifest symptoms by:

Answer 35

- refusing to eat - appear listless and cranky - altered sleep patterns - changes in school performance - loss of interest in preferred activities

Question 36

Abusive Head Trauma

Answer 36

Abusive Head Trauma; aka: Non-Accidental Trauma, Shaken Baby Syndrome, Child Maltreatment, Child Abuse Inconsolable crying is the #1 trigger for shaking a baby - SBS is the leading cause of child abuse deaths - babies (newborn to 4m) are at greatest risk of shaking - 1 in 4 babies that are shaken will die It is rare that a single instance of noted injury present in the ED is the first occurrence; there is usually a chronic history of abuse

Question 37

Possible Abusive Head Trauma S/S

Answer 37

- glassy-eyed; fixed pupils; fixed stare - seizures - lethargy and irritability - somnolence (sleepiness; inactivity - respiratory problems - vomiting - choking - inability to lift head/turn head to the side - decreased appetite - retinal hemorrhage - bluish color

Question 38

Diffuse Axonal Injury

Answer 38

DAI references the neuropathological changes that occur at the axonal level following trauma -damage results from twisting, tearing, and/or shearing of the axon (hard to diagnose)

Question 39

Cerebral Edema

Answer 39

brain swelling (edema) frequently follows trauma -appears to be more of a secondary injury than a primary injury Focal edema is more common in adults Diffuse edema is more common in pediatrics -cerebral edema results in increased cranial pressure (ICP)

Question 40

Intracranial Pressure

Answer 40

ICP should be <20 mmHg (millimeters of Mercury); when exceeded neurosurgical intervention is necessary 3 mechanisms by which ICP can be monitored: 1. EVD: extraventricular drain (intraventricular catheter); thin flexible tube threaded into one of the two lateral ventricles (used more w/kids) 2. Screw/Bolt: placed into the space between arachnoid membrane and cortex (subarachnoid bolt/screw) (used more w/ adults) 3. Epidural Sensor: sensor placed in the epidural space below skull

Question 41

Monroe-Kellie Hypothesis

Answer 41

states that the cranial compartment is incompressible; meaning, the volume is fixed and should not change -the skull, CSF, and brain tissue create a volume equilibrium such that any increase in volume of one of the cranial constituents must be compensated by a decrease in the volume of another

Question 42

Brain Shift and Herniation

Answer 42

If a hematoma continues to enlarge or focal edema of adjacent brain tissue increases, the brain may be shifted away from the growing mass, and structures that normally lie in the midline may be displaced -a hematoma and a tumor both violate the MKH

Question 43

Cushing's Triad

Answer 43

significant sign of intracranial HTN precursor to herniation Comprised of: 1. Hypertension (HTN) (high blood pressure) 2. Bradycardia (slow heart beat) 3. Respiratory Irregularity (breathing slow and breathing fast sometimes)