Traumatic Brain

Injury
Almario G. Jabson MD
Section Of Neurosurgery
Asian Hospital And Medical Center

Brain Injury Incidence: 200/100,000

Prehospital Brain Injury Mortality Incidence:
20/100,000
Hospital Admissions by Severity:
Mild: 80%
Moderate: 10%
Severe: 10%

RACE AND GENDER

Peak Incidence:
15 - 24 years old
Secondary Peak Incidence:
Infants and children
Elderly
M:F = 2-3:1

DIAGNOSIS
HISTORY

DOI: DATE OF INJURY

TOI: TIME OF INJURY
POI: PLACE OF INJURY
MOI: MECHANISM OF INJURY

MECHANISM OF INJURY
MVA/TRANSPORT RELATED
FALLS
INTERPERSONAL VIOLENCE
SPORTS RELATED
WORK RELATED

HISTORY
HEADACHE
LOSS OF CONSCIOUSNESS
AMNESIA
NAUSEA/VOMITTING
SEIZURES
ALCOHOL INTAKE

DIAGNOSIS
PHYSICAL/NEUROLOGIC EXAM
RAPID INITIAL ASSESSMENT
SYSTEMIC
NEUROLOGIC (GCS, LATERALIZING SIGNS, INC.
INTRACRANIAL PRESSURE)

COMPREHENSIVE PHYSICAL AND NEUROLOGIC

EXAM

GLASGOW COMA SCALE

POINTS BEST EYE BEST VERBAL BEST MOTOR
6

OBEYS

ORIENTED

LOCALIZES PAIN

SPONTANEOUS

CONFUSED

WITHDRAWS TO PAIN

TO SPEECH

INAPPROPRIATE

DECORTICATE

TO PAIN

INCOMPREHENSIBLE

NONE

NONE

NONE

DECEREBRATE

INITIAL NEUROLOGIC EXAM

LATERALIZING SIGNS
PUPIL SIZE AND REACTIVITY
WEAKNESS

INCREASED ICP
CUSHINGS TRIAD
INCREASING BP
DECREASING HR
DECREASING RR

DIAGNOSIS
DIAGNOSTIC WORK-UP
LABORATORY WORK-UP
RADIOGRAPHIC EVALUATION
X-RAYS
CT-SCAN

X-RAYS
SKULL AP-LATERAL
CERVICAL FILMS
CERVICAL AP-LATERAL
OPEN MOUTH VIEW

CT SCAN

EMERGENT CONDITIONS DETECTED

ON PLAIN CT SCAN

BLOOD
HYDROCEPHALUS
CEREBRAL SWELLING
CEREBRAL ANOXIA
SKULL FRACTURES
ISCHEMIC INFARCTION
PNEUMOCEPHALUS
MIDLINE SHIFT

PATHOLOGIES IN HEAD INJURY

CLOSED HEAD INJURY
PRIMARY INJURY
SECONDARY INJURY
PENETRATING HEAD INJURY
GUNSHOT WOUND
NONGUNSHOT WOUND INJURY

PRIMARY INJURY/IMPACT DAMAGE

FOCAL INJURIES
CONTUSIONS
LACERATIONS
FRACTURES
HEMATOMAS
DIFFUSE INJURIES
DIFFUSE AXONAL INJURY
CONCUSSION

SECONDARY INJURY

EVENTS WHICH OCCUR AFTER ONSET OF

PRIMARY INJURY
AGGRAVATING CONDITIONS

ISCHEMIA
HYPOXEMIA
EDEMA
COMPRESSION FROM MASS LESIONS

SPECIFIC PATHOLOGIES
SCALP INJURIES

LACERATION
CONTUSION
HEMATOMA
AVULSION

SPECIFIC PATHOLOGIES
SKULL FRACTURES
LINEAR
PINGPONG
DEPRESSED
OPEN
CLOSED

COMMINUTED
BASAL SKULL
DIASTATIC

SPECIFIC PATHOLOGIES
INTRACRANIAL LESIONS
HEMATOMAS
EPIDURAL
SUBDURAL
INTRACEREBRAL
INTRAVENTRICULAR
SUBARACHNOID HEMORRHAGE

CONTUSIONS
HEMORRHAGIC CONTUSION
CONTUSION HEMATOMA

Epidural Hematoma

Acute Subdural
Hematoma

Chronic Subdural
Hematoma

Contusion Hematoma

Penetrating Injury

MANAGEMENT
RESUSCITATION/CABs
IMMOBILIZATION AS NEEDED
MEDICATIONS
SURGERY
PREVENTION

MANAGEMENT

PRIMARY INJURY
SURGICAL VS. NONSURGICAL

SECONDARY INJURY
MINIMIZE/PREVENT DELETERIOUS
EFFECTS OF FACTORS CAUSING
SECONDARY INJURY

MANAGEMENT ISSUES

MANAGEMENT OF INTRACRANIAL
PRESSURE ( ICP )
CEREBRAL BLOOD FLOW ( CBF )
INDIRECTLY MEASURED BY CEREBRAL
PERFUSION PRESSURE ( CPP )
CPP = MEAN ARTERIAL PRESSURE ( MAP ) INTRACRANIAL PRESSURE ( ICP )

ROUTINE MEASURES

POSITIONING
ELEVATE HOB TO 30-45 DEGREES
KEEP HEAD MIDLINE

LIGHT SEDATION
AVOID HYPOTENSION
CONTROL HYPERTENSION
PREVENT HYPERGLYCEMIA
INTUBATE IF GCS < 8 OR WITH RESPIRATORY DISTRESS
AVOID EXCESSIVE HYPERVENTILATION
DVT Prophylaxis if possible

SPECIFIC MEASURES

HEAVY SEDATION AND/OR PARALYSIS

CSF DRAINAGE
OSMOTIC THERAPY
MANNITOL
FUROSEMIDE
SERUM OSMOLARITY

HYPERVENTILATION
STEROIDS NOT RECOMMENDED

MANAGEMENT ISSUES
INTRACRANIAL PRESSURE MONITOR
Although ICP monitor is widely used,
the overall outcome of severe HI hasnt been
improved by its use.

MANAGEMENT ISSUES
HYPERVENTILATION
Chronic use (>24 hours) of hyperventilation
correlates with poor outcome in sever HI

Recommended for acute ICP increase

Class I Evidence

AACNS/Brain Trauma Foundation

MANNITOL
MECHANISM OF ACTION
INCREASE CBF AND O2 DELIVERY BY IMMED. PLASMA
EXPANSION, REDUCED HCT AND VISCOSITY

DOSE
0.25g/kg to 1gm/kg/dose

ONSET OF ACTION
1 -5 MINUTES

DURATION OF ACTION
PEAKS IN 20 - 60 MINUTES

FUROSEMIDE
MECHANISM OF ACTION
INCREASE SERUM TONICITY
MAY SLOW PRODUCTION OF CSF
ACTS SYNERGISTICALLY WITH MANNITOL

DOSE
ADULTS: 10-20 MG IV
PEDS: 1MG/KG

PRECAUTIONS
SERUM OSMOLARITY
DEHYDRATION

HYPERVENTILATION

MECHANISM OF ACTION
INDICATIONS
TO TIDE PATIENT OVER
IF UNRESPONSIVE TO OTHER MEASURES
HYPEREMIA

ONSET OF ACTON
< 30 SECONDS

DURATION OF ACTION
PEAKS IN 8 MINUTES, EFFECT LESSENED BY 1 HOUR

PRECAUTIONS

MANAGEMENT ISSUES
CORTICOSTEROIDS
The use of corticosteroids does not cause a
decrease in ICP nor does it improve outcome
of HI.

Class I Evidence

AANS/Brain Trauma

Foundation

MANAGEMENT:
Concussion
Special Circumstances in
Concussive Injuries
Impact Seizure
12% (more common than in adults)
not predictive of early or late epilepsy
anticonvulsant treatment is not needed

MANAGEMENT ISSUES
ANTICONVULSANT
Lewis et al , 1993
Pedia HI

Post-traum Sz

GCS 3 - 8

38.7 %

GCS>8 3.8%
Pxs with low GCS, prophylactic treatment reduces posttraumatic seizures

 When Does Surgery Come In?

Basic Principle
To lessen the Impact of Primary Injury and
Prevent Secondary Injury

MANAGEMENT:
Discharge Criteria
Normal level of alertness
Tolerates oral intake
Usual gait