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Head Traumatic Brain Injury
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Learning Objectives
Explain the pathophysiology of CNS trauma
Identify the different types of brain injuries
Describe the assessment and managementof patients with traumatic brain injuries
Determine the Glasgow Coma Scale whenpresented with several trauma case studies.
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Head & Brain Trauma
Worldwide, approximately: 200 to 300 cases of TBI per 100,000 population
25 cases of severe TBI per 100,000 population
In the United States, approximately: 4 million head injuries per year
1.4 million treated in hospitals 300,000 admitted per year
Approximately 90,000 have residual neurologicaldeficit.
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Pathophysiology of CNS Injury
Primary injury Damage that occurs at the moment of impact
Secondary injury Damage that occurs subsequent to the initialimpact
Systemic causes
Intrinsic causes
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Primary Brain Injury
Diffuse brain injury Concussion
Diffuse axonal injury
Focal brain injury Contusion
Intracranial hemorrhage Epidural or extraduralSubdural
Subarachnoid Intracerebral
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Range from mild concussion to severe ischemic insult
Normal T Diffuse Injury
Diffuse Brain Injury
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Classification of TBI byMorphology
From Saatman et al., J Neurotrauma, July2008, 25(7): 719-738.
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Secondary Brain Injury
Can occur from minutes to days followinginitial injury
Hypotension SBP < 90 mm Hg (Adults), Children: age-dependent
ICP, MAP, CPP
Hypoxia SpO2< 90%
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Pathophysiology of CNS Injury
Systemic causes Hypoxia
Hypotension
Increased or decreasedCO2
Anemia (blood loss)
Increased or decreasedblood glucose
Intrinsic causes Seizures
Edema
Hematomas
Increased intracranialpressure (ICP)
Secondary Injury
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Blood Pressure and TBI
Intracranial Pressure (ICP)must be lower thansystemic BP) CPP = MAP ICP
Mean arterial pressure =(2x diastolic + systolic)/3
As ICP rises, CPP willdecrease if BP does notrise
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Hypoxia
SpO2< 90% have significant negativeoutcomes
Continuous monitoring
Correct difficulty breathing early
Keep intubation times short to hypoxic
time
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Assessment
Accurate blood pressure readings Use the most accurate method available
Repetitive neurologic exams
GCS is designed to allow providers to repeatthe exam through continuum of care
Pupillary responses
Continuous SpO2
& EtCO2
measurements
Frequent reassessments
**Change in LOC is the earliest and best indicator of patients ICP
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Pupil Response
Assess eyes for traumato the eye orbits
Oculomotor nerve
provides function topupils
Assess pupils afterresuscitation andstabilization
Both eyes must beassessed and compared
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Pupil Assessment
Pupil asymmetryis > 1 mm < 1 mm is a
normal finding Unilateral or
bilateral dilatedpupils
Fixed and dilatedpupils < 1 mm responseto bright light
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Intracranial Pressure
An increase in the volume of any of thesethree contents may cause increased ICP: Swelling of brain tissue
Bleeding
CSF accumulation
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Intracranial Pressure
As ICP increases, everything in the skull iscompressed Blood vessels
CSF
Brain
You can displace a small amount of blood.
You can displace a small amount of CSF. But
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Increasing ICP
Early signs Vomiting (with orwithout nausea)
Headache Dizziness
Amnesia
Visual disturbances
Altered LOC Seizures
Late signs Cushings Triad
Hypertension (with
widening pulsepressure)
Bradycardia
Irregular respirations
Pupil changes Coma
Posturing
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The Brain Death Cycle
In the case of EDH or SDH, we can also add
the effect of the expanding hematoma.Copyright 2012 by Mosby, Inc., an affiliate of Elsevier Inc. 18
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Clinical Effects of ICP
19
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Respiratory Patterns
Altered respiratorypatterns Cheyne-Stokes
Central neurogenichyperventilation
Biots
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Management of Oxygenation
Oxygen to maintain normoxia (>94% SaO2)
Begin ventilations at signs of ineffective
breathing 10 to 12/min for adults
15 to 20/min for infants and children
Intubation or airways may increase ICP
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Management of Fluids
Assess patient for bleeding
TBI patients are often hypertensive Restrict fluids to prevent edema
Hypotension must be treated with fluid
Blood pressure should be kept above90 mm Hg systolic Crystalloid fluids for bolus
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Volume-Pressure Curve
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Cerebral Herniation Signs of herniation
Dilated and unreactive pupils
Asymmetric pupils
Extensor posturing
Drop in GCS of 2 or more with initial GCS < 9
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Management of Cerebral
Herniation In patients who are already well ventilated,
hyperventilation may be indicated
Adults 20 breaths/min Child 25 breaths/min
Infant (< 1 year) 30 breaths/min
Temporizing until signs of herniation resolve
Goal: Ventilate to ETCO2of 30 to 35 mm Hg
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Mechanics of Hyperventilation
CO2is a vasodilator
CO2makes blood vessels in the head
expand, taking up more space CO2makes them constrict, thereby taking
up less space
Caveat: when vessels are small, they have aharder time carrying oxygenated blood
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Pharmacologic Therapy
Diuretics Mannitol may take 15 to 30 min
Furosemide may not reduce fluid in brain
Seizures Benzodiazepines
Antiepileptic medications
Steroids should not be used
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Transport
Minimize on-scene time
Supine position (unless patient is at risk foraspiration- then elevate HOB 30)
Appropriate receiving facility
Frequent reassessment
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The Bottom Line
Most of the bad TBI stuff presents about thesame way: Headache
Vomiting
Altered mentation
Neurological deficits
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Optimal Management
Priorities: ABCDE
Minimize secondary brain injury
Administer oxygen Maintain adequate ventilation
Maintain blood pressure (systolic > 90 mm Hg)
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Summary
Primary survey: identify and treat life-threatening conditions first.
Shock is a late finding in patients withtraumatic brain injury; consider thepossibility of internal hemorrhage.
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Summary The primary goal of treatment for patients
with suspected TBI is to prevent secondarybrain injury.
The most important sign of traumatic braininjury is a change in mental status.
Key aspect is to determine whether baselineassessment findings are changing and inwhich direction (better or worse). Frequent Reassessments
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Summary
Treatment keysminimize secondary injuryof the brain. Correct or prevent hypoxemia (Goal SpO2 >
94%). Correct or prevent hypotension (Goal: SBP >90mmHg).
Avoid hyperventilation.
Transport to an appropriate facility.
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Practice Session:
Glasgow Coma Scale
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35
0
Developed to assess level of consciousness aftertrauma
Scored from 3-15 (no 0)
Initially developed in 1974 - University of Glasgow
Assesses a patients best Eye Response, Verbal Response, & Motor Response
Brain Injury based on severity: Severe: GCS 3-8
Moderate: GCS 9-12 (controversial)
Minor: GCS 13
Incorporated into several ICU scoring systems(APACHE, SAPS, SOFA)
Glasgow Coma Scale
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35
0
Glasgow Coma Scale:
Eye Opening
Eye opening
Score Response
4 Opens eyes spontaneously
3 Verbal: Opens eyes in response to verbal stimuli
2 Pain: Opens eyes in response to painful stimuli1 None: Patient does not open eyes
GCS for Adults
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0
Glasgow Coma Scale :
Verbal Response
Best Verbal Response
Score Response
5 Oriented: To person, place, and time, conversesnormally
4 Disoriented: Patient is conversant but confused
3 Nonsensical Conversation: Inappropriate use of words
2 Patient makes incomprehensible sounds (e.g. moans)
1 No response: Patient does not respond verbally
* If the pt. is intubated or has a tracheostomy aTshould be added to the comments
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35
0
Glasgow Coma Scale Score:
Motor ResponseBest Motor Response
Score Response
6 Follows commands: Obeys simple commands
5 Localizes pain: Purposeful movement toward painful stimuli
4 Withdraws from pain: Patient withdraws from pain
3 Decorticate: Patient flexes arms inward towards the chest
2 Decerebrate extension: Patient extends arms outward from
the body1 No response: Patient does not move
*If the pt. is sedated or chemically paralyzed a Por Sshould be added to the comments
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0
CASE 1 57 y/o M fall from bicycle. On exam, eyes are
open, he is holding the Rt. side of his head, andanswering questions inappropriately.
Obvious laceration from his Rt. eyebrow to hisear
GCSEye Opening 1-4
Verbal Response 1-5Motor Response 1-6
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What is the patients GCS?
A. GCS 14
B. GCS 12
C. GCS 10D. GCS 9
E. GCS 5
GCSEyes are open =4
Response inappropriate =3Localizes pain =5
GCS = 12
i i di l d i
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CASE 2
24 y/o F found on the ground after being struck by acar. Her eyes are closed, and she is moaningincomprehensible sounds. She does not open her
eyes to verbal or painful stimuli.
Arms are down and hands are extended outwardwith increased tone.
GCSEye Opening 1-4Verbal Response 1-5Motor Response 1-6
C i i M di l Ed i T
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What is the patients GCS?
A. GCS 12
B. GCS 10
C. GCS 9D. GCS 7
E. GCS 5
GCSEyes no response =1
Incomprehensible sounds =2Extensor posturing =2
GCS = 5
C ti i M di l Ed ti T
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0
CASE 3 37 y/o M driver of vehicle involved in a
roadside IED explosion. Vehicle turned on toside with extensive damage.
Patient opens eyes to painful stimuli, pullshands away as you pinch his fingernails, andmoans without making coherent words.
GCSEyes Opening 1-4Verbal Response 1-5Motor Response 1-6
C ti i M di l Ed ti T
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What is the patients GCS?
A. GCS 8
B. GCS 5
C. GCS 4D. GCS 3
E. GCS 0
GCS
Eyes open to pain =2Response incoherent =2Withdraws from pain =4
GCS = 8
C ti i M di l Ed ti T
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0
CASE 4 19 y/o M is unconscious with eyes closed
following an assault. Patient has multiple gunshot wounds to upper torso area.
Patient does not respond or open eyes to anyverbal or painful stimuli and there is nomovement from the patient.
GCS
Eyes Opening 1-4Verbal Response 1-5Motor Response 1-6
C ti i M di l Ed ti T
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What is the patients GCS?
A. GCS 8
B. GCS 5
C. GCS 4
D. GCS 3
E. GCS 1
GCSEyes none =1Response none =1No movement =1
GCS = 3
Contin ing Medical Ed cation Tra ma
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0
CASE 5 39 y/o M lying on the ground following a fall
from height of 10 feet.
Patient is lying on ground with eyes open, he is
disoriented, and brings his hands to his chestwhen palpated.
GCSEye Opening 1-4
Verbal Response 1-5Motor Response 1-6
Continuing Medical Education Trauma
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What is the patients GCS?
A. GCS 15
B. GCS 14
C. GCS 13
D. GCS 9
E. GCS 7
GCS
Eyes are open =4Response disoriented =4Localizes pain =5
GCS =13
Continuing Medical Education Trauma
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0
CASE 6 33 y/o F lying on the ground following an
ejection from a motor vehicle 30 feet away.
Paramedic is attending to the patient who is
conscious with eyes open, disoriented, strongsmell of ETOH, holding obvious deformity to Rt.femur.
GCSEye Opening 1-4Verbal Response 1-5Motor Response 1-6
Continuing Medical Education Trauma
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What is the patients GCS?
A. GCS 14
B. GCS 13C. GCS 10
D. GCS 8
E. GCS 5
GCSEyes are open =4
Disoriented =4Localizes pain =5
GCS =13
Continuing Medical Education Trauma
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Pediatric Glasgow Coma Scale
(3-15)
> 1 year < 1 year
Score Response Response
4 Spontaneously Spontaneously
3 To verbal command To verbal command
2 Requires painful stimuli to
open eyes
Requires painful stimuli to
open eyes1 No response No response
Eye opening
Continuing Medical Education Trauma
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Pediatric Glasgow Coma Scale:
Verbal Response> 5 years 2-5 years 0-23 months
Score Response Response Response
5 Oriented: To person,place, and time
Appropriate words &phrases
Smiles, coos, orients tosounds, follows objects,
interacts4 Disoriented: Patient
is conversant butconfused
Inappropriate words Cries but consolable
3 NonsensicalConversation:
Inappropriate use ofwords
Cries and/or screams Inappropriate cryingand/or screaming
2 Incomprehensiblesounds (e.g. moans)
Inconsolable, agitated Grunts
1 No response No response No response
Continuing Medical Education Trauma
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Pediatric Glasgow Coma Scale:
Motor Response> 1 year < 1 year
Score Response Response
6 Follows simple commands Normal spontaneous movement
5 Localizes pain: Patient
indicates location of pain
Withdraws from touch
4 Withdraws from pain: Patientwithdraws from pain
Withdraws from pain: Patientwithdraws from pain
3 Decorticate: Patient flexesarms inward towards thechest
Decorticate: Patient flexes armsinward towards the chest
2 Decerebrate extension:Patient extends arms outwardfrom the body
Decerebrate extension: Patientextends arms outward from thebody
1 No motor response No motor response
Continuing Medical Education Trauma
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0
CASE 7 10 y/o F conscious, eyes open and lying on a gym
mat, following a fall from the exercise bars. Thecoach tells you that she was unconscious prior toyour arrival.
She has an abrasion on her forehead, and no otherobvious injuries, she knows were she is but doesnot remember what happened. Pt. squeezes yourhands when asked.
GCSEye Opening 1-4Verbal Response 1-5Motor Response 1-6
Continuing Medical Education Trauma
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What is the patients GCS?
A. GCS 15
B. GCS 14
C. GCS 13
D. GCS 10
E. GCS 8
GCS
Eyes are open =4Inappropriate response =4Follows Commands =6
GCS=14
Continuing Medical Education Trauma
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0
CASE 8 2 y/o M sitting in a car seat after an MVC. Patient
is restrained with minor bleeding from theforehead. The child appears very calm.
Child stares into space, when you try to talk to himhe begins to cry inconsolably and becomesagitated. He withdraws his hand when you pinchhim.
GCSEye Opening 1-4Verbal Response 1-5Motor Response 1-6
Continuing Medical Education Trauma
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What is the patients GCS?
1. GCS 14
2. GCS 10
3. GCS 9
4. GCS 8
5. GCS 6
GCS
Eyes are open =4Response inappropriate =2Withdraws from pain =4
GCS=10
Continuing Medical Education Trauma
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ANY QUESTIONS
Continuing Medical Education Trauma
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Thank You!
Michael S. Gordon Center for Research in Medical Education
University of Miami Miller School of Medicine