traumatic brain injury by niusheng11

VIEWS: 94 PAGES: 57

									Traumatic Brain Injury
       Byron Tsang
          SCHC
               Objectives
 Epidemiology
 Pathophysiology
 Stratification
 Management
               Epidemiology
 Occurs    every 15 seconds
     2-10 million times per year in the U.S.
 Bimodal    distribution
     Age 15-24 (29.6% deaths)
     Age >75
 Trauma     leading cause of death < 1 year
     Head trauma 80%
     Death on scene 5%
     Long term stay 5-10%
               Epidemiology
 Male:Female  2.5:1
 Mild TBI (90%)
 Moderate/severe TBI (10%)
     Direct cost >$25 billion
 Injury   prevention
                      Background
   Traumatic brain injury
       Penetrating
                   Background
   Traumatic brain injury
       Blunt
         • MVC
         • Falls
         • Abuse
                 Anatomy
 Brain cross section
 Potential spaces
                       Anatomy
 Intracranial
  compartments
 Dural structures
       Tentorium cerebelli
       Falx cerebri
                         Anatomy
   Pediatric
       Larger head in
        proportion to BSA
       Stability dependent on
        ligamentous structures
       Higher water content
         • 88% vs 77%
         • Prone to acceleration-
           deceleration injury
       Unmyelinated
       Open sutures
          Pathophysiology
 Primary injury
 Secondary injury
               Pathophysiology
 Primary injury
 Scalp injury
 Skull fracture
 Basilar skull fracture
 Concussion
 Contusion
 Hematoma
       Epidural
       Subdural
   Hemorrhage
       Intraventricular
       Subarachnoid
   Diffuse axonal injury
Pathophysiology
                Pathophysiology
 Secondary injury
 Intracranial events
       Inflammatory changes
         • Microciruculatory
           disruption
         • Neuronal disintegration
       Pathophysiologic
        events
         • Cerebral edema
         • Traumatic axonal injury
         • Ischemia
           Pathophysiology
 Secondary    injury
     Systemic events
      • Hypotension
      • Hypoxia
      • Hypercapnia
           Pathophysiology
 FixedCompartment
 Volume (i/c) = 1500 ml
     Brain 85%
     Cerebral blood volume 10%
     Cerebral spinal fluid <3%
         Monro-Kellie doctrine
   V (I/c) = V (brain) + V(CSF) + V (blood)
            Pathophysiology
 Cerebral   perfusion pressure (CPP)
     CPP = MAP - ICP
     MAP = [(2 x DBP) + SBP] / 3
            Pathophysiology
 Metabolism
     Cerebral blood flow
       • 50ml/100g/minute
       • <20ml/100g/minute = poor outcome
 Cerebral    perfusion pressure (>70 mm Hg)
     Autoregulation
       • Maintain cerebral blood flow between MAP 50-150
                   Prehospital
 Initial stabilization
 Assessment
       Blood pressure
       GCS
       Pupils
       SaO2
                    History
   Injury mechanism
   Loss of
    consciousness
   Amnesia
   Intoxication
   Bleeding diathesis
                Exam
 ATLSprotocol
 Remember cervical spine
 Remember tetanus
                Exam
 Primarysurvey
 Secondary survey
           Primary survey
 Airway
 Breathing
 Circulation
 Disability/Neurological   exam
 Exposure
                       Exam
   Secondary survey
       Head
       HEENT
       Neck
       Heart
       Lungs
       Abdomen
       GU
       Extremity
       Neurological
Exam
                               Exam
   HEENT/face
       Soft tissue injury
       Basilar skull injury
       Pupil exam
       Facial injury
         • Lefort
       Dental exam
                         Exam
   Neck
       Cervical spine
        stabilization
       Palpation
       NEXUS, CCR
                           Exam
   NEXUS                           CCR
                                    High risk
       Posterior midline
                                        Age >65
        tenderness
                                        Dangerous mechanism
       Intoxication                    Parasthesia
       Normal alertness            Low risk
       No focal neuro deficit          Simple MVA
                                        Sitting in ED
       No distracting injury
                                        Ambulatory
                                        Delayed neck pain
                                        No midline tenderness
                                    Rotate 45 degrees
                                     actively
                     Exam
 Neurological
     GCS
     Brainstem
     Motor exam
     Sensory exam
     Reflex exam
                     Workup
 “Trauma”    labs
     CBC
     Chemistry
     PT/PTT
     Type and cross
     ABG/VBG/CBG
     Urine toxicology
 EKG
                    Workup
 Imaging
     Plain films
     CT scan
     MRI
     Angiography
                   Workup
 CT   scan
     Post traumatic seizure
     Amnesia
     Progressive headache
     Unreliable history
     LOC >5 minutes
     Basilar skull fracture
     Repeated vomiting/vomiting >8h post injury
                   Classification
   Closed head injury
       Mild
       Moderate
       Severe
                Mild TBI
 Most  common
 LOC <20 minutes (30 minutes)
 Brief retrograde amnesia (24 hours)
 GCS 13-15
 Change in mental status
 No focal neurological deficit
 No intracranial complications
 Normal CT findings
          ACEP definition
 Blunt head trauma within 24 hours
 Post traumatic LOC or amnesia
 GCS 15 on presentation
 Age >15
                            Mild TBI
   Low risk for
    intracranial injury
       No LOC
       No amnesia
       Not predictive
         •   Headache
         •   Dizziness
         •   Scalp hematoma
         •   Laceration, abrasion
                       Mild TBI
   Moderate/high risk
       Progressive/severe HA
       Age <2 yo
       Post traumatic seizure
       Focal neuro deficit
       Skull fracture
       Multi trauma
       Blood dyscrasia
                  Mild TBI
   Infants <2…
   Difficult to assess
   Absence of symptoms
   Low threshold for
    scan
   Consider abuse
                    Mild TBI
 Safe   for discharge?
     Observation
     CT scan
 Post   concussive syndromes
     30% @ 3 months
     15% @ 12 months
 Second    impact syndrome
     Cumulative recurrent damage
                     Mild TBI
 Return   to play
     Asymptomatic
     Prior history
 Prevention
      Moderate/Severe TBI
 GCS 8-12
 GCS <8
                          Treatment
   Airway management
       RSI
       Medications
   Ventilator management
       Eucapnia
       Prevent hypoxia
   Post intubation care
       Sedation
       Paralysis
       Analgesia
                      Treatment
   Cardiovascular
    management
       Euvolemia
       MAP > 90
         • Pressors
       CPP 70-80 mm Hg
       CPP = MAP - ICP
                      Treatment
   ICP management
       Elevate head of bed
       Sedation/paralysis
       Diuresis
         • Osmotic
         • Loop
       Hyperventilation
       Barbiturate
                   Treatment
 Hyperosmolar therapy
 Mannitol
       320 mOsm
   Hypertonic saline
       360 mOsm
                        Treatment
   Barbiturates
       Pentobarbital
       Thiopental
   Goals
       ICP <20 mm Hg
       Burst suppression on
        EEG monitor
                       Treatment
   Intracranial pressure
    monitoring
       Intraparenchymal
       Intraventricular
         • Direct CSF drainage
       Epidural
                 Treatment
 Bleeding   management
     Multi-trauma with concominant DIC
     Factor replacement
     Recombinant factor VIIa
                  Treatment
 Seizure    management
     Increase metabolic demand
     Increased risk <2 years (3x older patients)
     Divided into early and late
     Phenytoin for early seizure management
     No support for late management
             Treatment
        decompression
 Surgical
 Decompressive craniectomy
                Disposition
 Moderate/severe      TBI
     Transfer
     Critical care consult
     Neurosurgery consult
     Trauma consult
     Admission ICU
 Mild   TBI
     Consider trauma consult
     Consider discharge/observation
                  Prognosis
 Mild   TBI
     Repetitive brain injury
     Consider neuro-psychiatric referral
 Moderate/severe       TBI
     Significant morbidity/mortality
                 References
 Oman JA, Cooper RJ, Holmes JF, Viccellio P,
  Nyce A, Ross SE, Hofman JR, Mower WR and
  for the NEXUS II investigators. Performance of a
  Decision rule to predict need for computed
  tomography among children with blunt head
  trauma. Pediatrics 2006. 117; 238-246.
 Palchak MJ, Holmes JF, Vance CW, Gelber RE,
  Schauer BA, Harrison MJ, Willis-Shore J,
  Wootton-Gorges SL, Derlet RW, Kupperman N.
  A decision rule for identifying children at low risk
  for brain injuries after blunt head trauma. Ann
  Emerg Med. 2003; 42: 492-506.
                References
 Chapter 19. The role of anti-seizure prophylaxis
  following severe pediatric traumatic brain injury.
  Pediatric Critical Care Medicine: Volume 4(3)
  SUPPLEMENT July 2003 pp S72-S75
 Cushman JG, Agarwal N, Fabian TC, Garcia V, Nagy
  KK, Pasquale MD and Salotto AG. Practice
  management guidelines for the management of mild
  traumatic brain injury. EAST practice management
  guidelines work group. 2001.
                 References
 Schutzman SA, Barnes P, Duhaime A, Greenes
  D, Homer C, Jaffe D, Lewis RJ, Luerssen TG,
  and Schunk J. Evaluation and management of
  children younger than 2 years old with
  apparently minor head trauma: proposed
  guidelines. Pediatrics. 2001. 107(5).
 Chapter 17. Critical pathway for the treatment of
  established intracranial hypertension in
  pediatric traumatic brain injury. Pediatric critical
  care medicine. 2003. Vol 4, No. 3. S65-S67.
             References
 www.trauma.org
 Singh J and Stock A. Head trauma.
  www.emedicin.com/ped/topic929.htm
 Shepard S. Head trauma.
  www.emedicine.com/med/topic2820.htm
 Su F and Huh J. Neurointensive care for
  traumatic brain injury in children.
  www.emedicine.com/ped/topic3082.htm

								
To top