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Traumatic Brain Injury Almario G. Jabson MDSection Of NeurosurgeryAsian Hospital And Medical CenterBrain 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 GENDERPeak Incidence:15 - 24 years old

Secondary Peak Incidence:Infants and childrenElderly

M:F = 2-3:1DIAGNOSISHISTORYDOI: DATE OF INJURYTOI: TIME OF INJURYPOI: PLACE OF INJURYMOI: MECHANISM OF INJURYMECHANISM OF INJURYMVA/TRANSPORT RELATED FALLSINTERPERSONAL VIOLENCESPORTS RELATEDWORK RELATEDHISTORYHEADACHELOSS OF CONSCIOUSNESSAMNESIANAUSEA/VOMITTINGSEIZURESALCOHOL INTAKEDIAGNOSISPHYSICAL/NEUROLOGIC EXAMRAPID INITIAL ASSESSMENTSYSTEMICNEUROLOGIC (GCS, LATERALIZING SIGNS, INC. INTRACRANIAL PRESSURE)COMPREHENSIVE PHYSICAL AND NEUROLOGIC EXAM GLASGOW COMA SCALEPOINTS BEST EYE BEST VERBAL BEST MOTOR

6 OBEYS

5 ORIENTED LOCALIZES PAIN

4 SPONTANEOUS CONFUSED WITHDRAWS TO PAIN

3 TO SPEECH INAPPROPRIATE DECORTICATE 2 TO PAIN INCOMPREHENSIBLE DECEREBRATE

1 NONE NONE NONEINITIAL NEUROLOGIC EXAMLATERALIZING SIGNSPUPIL SIZE AND REACTIVITYWEAKNESS INCREASED ICPCUSHINGS TRIADINCREASING BPDECREASING HR DECREASING RRDIAGNOSISDIAGNOSTIC WORK-UPLABORATORY WORK-UPRADIOGRAPHIC EVALUATIONX-RAYSCT-SCANX-RAYSSKULL AP-LATERALCERVICAL FILMSCERVICAL AP-LATERALOPEN MOUTH VIEW

CT SCANEMERGENT CONDITIONS DETECTED ON PLAIN CT SCANBLOODHYDROCEPHALUSCEREBRAL SWELLINGCEREBRAL ANOXIASKULL FRACTURESISCHEMIC INFARCTIONPNEUMOCEPHALUSMIDLINE SHIFTPATHOLOGIES IN HEAD INJURYCLOSED HEAD INJURYPRIMARY INJURYSECONDARY INJURY PENETRATING HEAD INJURYGUNSHOT WOUNDNONGUNSHOT WOUND INJURYPRIMARY INJURY/IMPACT DAMAGEFOCAL INJURIES CONTUSIONS LACERATIONS FRACTURES HEMATOMAS

DIFFUSE INJURIES DIFFUSE AXONAL INJURY CONCUSSIONSECONDARY INJURYEVENTS WHICH OCCUR AFTER ONSET OF PRIMARY INJURYAGGRAVATING CONDITIONSISCHEMIAHYPOXEMIAEDEMACOMPRESSION FROM MASS LESIONS

SPECIFIC PATHOLOGIESSCALP INJURIESLACERATIONCONTUSIONHEMATOMAAVULSIONSPECIFIC PATHOLOGIESSKULL FRACTURESLINEARPINGPONGDEPRESSEDOPENCLOSEDCOMMINUTEDBASAL SKULL DIASTATICSPECIFIC PATHOLOGIESINTRACRANIAL LESIONSHEMATOMASEPIDURALSUBDURALINTRACEREBRALINTRAVENTRICULARSUBARACHNOID HEMORRHAGECONTUSIONSHEMORRHAGIC CONTUSIONCONTUSION HEMATOMAEpidural Hematoma

Acute Subdural Hematoma

Chronic Subdural Hematoma

Contusion Hematoma

Penetrating Injury

MANAGEMENTRESUSCITATION/CABsIMMOBILIZATION AS NEEDEDMEDICATIONSSURGERYPREVENTIONMANAGEMENTPRIMARY INJURYSURGICAL VS. NONSURGICAL

SECONDARY INJURYMINIMIZE/PREVENT DELETERIOUS EFFECTS OF FACTORS CAUSING SECONDARY INJURYMANAGEMENT ISSUESMANAGEMENT OF INTRACRANIAL PRESSURE ( ICP )CEREBRAL BLOOD FLOW ( CBF )INDIRECTLY MEASURED BY CEREBRAL PERFUSION PRESSURE ( CPP )

CPP = MEAN ARTERIAL PRESSURE ( MAP ) - INTRACRANIAL PRESSURE ( ICP )ROUTINE MEASURESPOSITIONINGELEVATE HOB TO 30-45 DEGREESKEEP HEAD MIDLINELIGHT SEDATIONAVOID HYPOTENSIONCONTROL HYPERTENSIONPREVENT HYPERGLYCEMIAINTUBATE IF GCS < 8 OR WITH RESPIRATORY DISTRESSAVOID EXCESSIVE HYPERVENTILATIONDVT Prophylaxis if possibleSPECIFIC MEASURESHEAVY SEDATION AND/OR PARALYSISCSF DRAINAGEOSMOTIC THERAPYMANNITOLFUROSEMIDESERUM OSMOLARITYHYPERVENTILATIONSTEROIDS NOT RECOMMENDEDMANAGEMENT ISSUESINTRACRANIAL PRESSURE MONITORAlthough ICP monitor is widely used,the overall outcome of severe HI hasnt been improved by its use.MANAGEMENT ISSUESHYPERVENTILATIONChronic use (>24 hours) of hyperventilationcorrelates with poor outcome in sever HI

Recommended for acute ICP increaseClass I Evidence AACNS/Brain Trauma Foundation MANNITOLMECHANISM OF ACTIONINCREASE CBF AND O2 DELIVERY BY IMMED. PLASMA EXPANSION, REDUCED HCT AND VISCOSITYDOSE0.25g/kg to 1gm/kg/doseONSET OF ACTION1 -5 MINUTESDURATION OF ACTION PEAKS IN 20 - 60 MINUTES

FUROSEMIDEMECHANISM OF ACTIONINCREASE SERUM TONICITYMAY SLOW PRODUCTION OF CSFACTS SYNERGISTICALLY WITH MANNITOLDOSEADULTS: 10-20 MG IVPEDS: 1MG/KGPRECAUTIONSSERUM OSMOLARITYDEHYDRATIONHYPERVENTILATIONMECHANISM OF ACTIONINDICATIONSTO TIDE PATIENT OVERIF UNRESPONSIVE TO OTHER MEASURESHYPEREMIAONSET OF ACTON < 30 SECONDSDURATION OF ACTIONPEAKS IN 8 MINUTES, EFFECT LESSENED BY 1 HOURPRECAUTIONS

MANAGEMENT ISSUESCORTICOSTEROIDSThe use of corticosteroids does not cause a decrease in ICP nor does it improve outcome of HI.Class I Evidence AANS/Brain TraumaFoundation

MANAGEMENT: ConcussionSpecial Circumstances in Concussive InjuriesImpact Seizure12% (more common than in adults)not predictive of early or late epilepsyanticonvulsant treatment is not neededMANAGEMENT ISSUESANTICONVULSANT Lewis et al , 1993Pedia HI Post-traum Sz GCS 3 - 8 38.7 % GCS>8 3.8% Pxs with low GCS, prophylactic treatment reduces post-traumatic seizures When Does Surgery Come In?Basic Principle To lessen the Impact of Primary Injury and Prevent Secondary InjuryMANAGEMENT: Discharge CriteriaNormal level of alertnessTolerates oral intakeUsual gait