Grand Rounds TBI

8/12/2019 Grand Rounds TBI

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Traumatic Brain InjuryGrand Rounds

Susan Kartiko MD PhD

10/30/13


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Traumatic brain injury

The most common cause of disability and death among youngpeople.

1.7 million people annually seek help to ED for TBI

52000 deaths and 80000 with permanent neurologcal disabilities.

In both more or less developed countries motor vehicles are themajor cause deaths and disabilities , particularly among youngpeople.

Falls are the major cause of death and disabilities for people age>65 yo.

Estimated 2% of US population is living with TBI related disabilities

Ghajar, Lancet 2000: 356: 923-29.


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Ghajar, Lancet 2000: 356: 923-29.


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Classifications of TBI


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Mild TBI

Defn: an acute alteration in brain function caused by ablunt external force and is characterized by

a GCS score of 13 to 15,

loss of consciousness for 30 minutes or less,duration of posttraumatic amnesia of 24 hours or less.

If a brain CT scan has been performed, its result must benormal.

The terms mild traumatic brain injuryand concussionmay be

used interchangeably.Estimated 1.1 million suffered from mild TBI, 75% fromtotal TBI

East Guideline, J Trauma. 73(5):S307-S314, November 2012
http://journals.lww.com/jtrauma/Fulltext/2012/11004/Evaluation_and_management_of_mild_traumatic_brain.6.aspxhttp://journals.lww.com/jtrauma/Fulltext/2012/11004/Evaluation_and_management_of_mild_traumatic_brain.6.aspxhttp://journals.lww.com/jtrauma/Fulltext/2012/11004/Evaluation_and_management_of_mild_traumatic_brain.6.aspxhttp://journals.lww.com/jtrauma/Fulltext/2012/11004/Evaluation_and_management_of_mild_traumatic_brain.6.aspx


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Mild TBI: criteria for

dischargeHolmes et al 2011: children GCS 14-15 with negative CT scancan be safely discharged home

Livingstone 2000: CT scan have a 99.7% negative predictivevalue in GCS 14-15 patients

Kaen 2009: 1.4% patients with therapeutic INR and anegative CT scan have a positive CT scan in 24hr.

Cohen 2006: patient with GCS13-15, supratherapeutic INR,and negative CT scan should be admitted and have theirINR reversed at least to a therapeutic range.

East Guideline, J Trauma. 73(5):S307-S314, November 2012
http://journals.lww.com/jtrauma/Fulltext/2012/11004/Evaluation_and_management_of_mild_traumatic_brain.6.aspxhttp://journals.lww.com/jtrauma/Fulltext/2012/11004/Evaluation_and_management_of_mild_traumatic_brain.6.aspxhttp://journals.lww.com/jtrauma/Fulltext/2012/11004/Evaluation_and_management_of_mild_traumatic_brain.6.aspxhttp://journals.lww.com/jtrauma/Fulltext/2012/11004/Evaluation_and_management_of_mild_traumatic_brain.6.aspx


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Moderate/Severe TBILong lasting effects: cognitive defects, psychiatric disorders (ie.Depressive and behavioral disorders, PTSD), social functional disorder

Cognitive: attention, memory, speed of processing, confusion,preseveration impulsiveness, language processing, executivefunctioning

Speech and language: reactive and expressive aphasia, slurred speech,problems writing/ reading

Vision/hearing/smell/taste

Seizures

Physical changes: chronic pain, control of bowel and urinary function,loss of stamina

Social/ emotion: aggression, depression, disinhibition, irritability, lack ofmotivation, denial/lack of awareness

Maas, et al Lancet Neurology vol7: 728-741


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Moderate/Severe TBI

Primary damage: brain damage result from external forceMacroscopic level: shearing of white matter tracts, focalcontusions, hematoma, diffuse swelling

Cellular level: microporation of membrane, leaky ion

channels, stearic conformation of protein, micro-hemorrhage from torn blood vessels

Secondary damageDevelop over hours and days, include neurotransmitterrelease, free radical generation, calcium-mediated damage,

gene activation, mitochondrial dysfunction and ,inflammatory responseInflammatory response causes brain swelling, and brain cellnecrosis



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Management of Moderate/Severe TBI

Pre hospitalAim: reduce hypotension and hypoxia to prevent secondarybrain injury

Odds ratio 2.1 and 2.7 respectively to poor outcome

Keep SBP >90 mmHg

Keep PaO2 > 60, or O2 sat >90.

Admission

To neurosurgical facilities (2-15 odds of death if treated in

non-neurosurgical facilities)Aim: early detection and intervention if needed (ie. STAT CT)

In penetrating injury: dural closure with debridement orsimple wound closure and antibiotic treatment



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ICP monitoringCerebral hypertension occur in 77% of patients

Raised ICP is correlated to poorer outcome

0.5% risk of hemorrhage, 2 % risk of infection

Intraventricular catheter is prefered because can be

therapeutic vs intraparenchymalMaintenance of CPP> 70 with vaso-pressors and fluid bolusesincreased the risk of ARDS

Chestnut et al , NEJM 2012 (367): 2471-81; Maas, et al Lancet Neurology vol7: 728-741


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NeuroICUNO steroids!!!

Increased mortality

Osmotherapy

Mannitol and hypertonic saline

Sedation and artificial ventilation to prevent high ICP

Propofol, barbiturates, paralytic

Decompressive creniectomy

Controversial on what is the indication.Needs to be large enough (ie. 15x15 cm)

DECRA, RescueICP



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DECRA


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Prognosis of moderate to severe TBI

Outcome is usually assessed at 6 mo85% of recovery occur during this time period

Medical complication after TBI prevents early rehab

UTI, pulmonary complications, electrolytesderangement, liver function derangement,hydrocephalus, seizure

Happen to 60-70% of TBI patients.



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Rehabilitation in TBI

WHO International classifications:

Impairment: any loss or impairment of psychological,physiological or anatomical structure or function

Disability: any restriction or lack of activity resultingfrom an impairment to perform an activity in themanner or in the range considered normal for thepeople of similar age, sex, or culture.

Handicap: a disadvantage of a given individual

resulting from an impairment or disability that limitsor prevents the fulfillment of a role that wouldotherwise be normal for that individual


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Components of

rehabilitationGoal settingShort and long term goals

Attainable goals to build confidence

Outcome measurements

Ie. timed 10 m tests, nine hole peg test

Setting of rehab

Recovery curve is steepest in the 3-4 months posttrauma- needs to be capitalized

Inpatient vs day-center rehab

Barnes, British Medical Bulletin 1995. 55 (4): 927-943


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McKay 1992: rehab vs no rehab on matched groups ofsevere TBI showed coma length, rehab stay andlengths of stay is better in rehab

Rehab: PT, OT, speech therapy94% rehab group went home vs 57% no rehab group

Blackerby 1990: increased intensity of rehab (5-8h/day) decreases length of stay in the hospital andrehab setting



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From: Cognitive Rehabilitation for Traumatic Brain Injury: A Randomized Trial

JAMA. 2000;283(23):3075-3081. doi:10.1001/jama.283.23.3075


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Ghua et al Annal Acad of Sin a ore 200 6: 1- 2


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Ghua et al Annal Acad of Sin a ore 200 6: 1- 2


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Issues during rehab

periodPressure soresSpasticity

Nutrition

Cognitive problem

Behavioral issues



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Return to work/ society


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GCS and classifications

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