Mild TBI

Traumatic Brain Injury (TBI)

Head injury due to contact or acceleration/deceleration forces

Criteria for TBI to be Mild

Adults = GCS 13-15 after 30 min from injury

Children > 2 = Cutoffs differ from 13 to 15 with no abnormal or focal neuro findings and no evidence of skull fracture

Infants up to 2 = Hx and PE signs of blunt trauma to the scalp, skull, or brain who is alert or awakens to voice or light touch

TBI Severity Based on GCS

13 -15 = Mild

9-12 = Moderate

8 or less = Severe

Causes of TBI

MVAs

Falls/accidents

Assaults

Contact sports

Soldiers

What occurs during a TBI

The brain experiences contusion due to coup (Primary Impact) and Contrecoup (Opposite side second impact) injury

Axons and vasculature is damage from the shearing force

Causes axonal swelling, decreased blood flow, and impaired blood flow

Wallerian degeneration

A degenetation of the axon distal to an injury site

Occurs during TBIs

Symptoms at Time of TBI

Confusion (up to a few minutes later)

Amnesia of Event (+/- Anterograde and Retrograde Amnesia)

May have LOC

Early Concussion Signs

Headache

Dizziness

Visual Changes

Lack of awareness

N/V

Late Concussion Signs

Mood and cognitive disturbances

Photo/phonophobia

Sleep Disturbances

While rare for Mild TBIs, there is a risk of developing

Seizures

Antieplitics with a TBI will NOT be effective in preventing

Seizures after 1 week

Post-Trauma Epilepsy

Any patient with a suspected concussion / TBI should recieve

Neurologic Assessment

Mental Status Testing

Standard Cognitive Assessment Tool (Standardized Assessment of Concussion (SAC) OR Sport Concussion Assessment Tool (SCAT6) )

Neuro Findings of Concussion

Difficulty with cerebellar function testing

Ataxia

Gait Difficulty

Speech Impairments

Mental Status Findings for Concussion

Slow Response to questions

Incoherent speech

Disoriented

Difficulty with attention or concentration

Memory deficits

Foca Deficits in the setting of TBIs can indicate

ICH

Spinal Cord injury

Indications for Neuroimaging in Mild TBIs

Prolonged unconscious

GCS < 15 after 2 hours

Abnormal Neuro Exam

Signs of Skull Fracture (Hemotypnaum, Raccooon eye , Battle Signs, otorrhea, rhinorrhea)

2+ epsiodes of vomit

Siezure

Amenisa > 30 min prior to event

Age > 65

Anticoagulation Use

Bleeding Disorders

Image of Choice for Mild TBIs

CT Head

Image of Choice for Post-Traumatic Complications of Mild TBIs

MRI

PECRAN

A rule used to determine CT recommendation for peds TBI

Severe Mechanisms of Injury (PERCAN)

Fall > 3 feet

Head Struck by High Impact

Hit by vehicle without Helment

MVA with ejection, rollover, or passenger death

PERCAN Guidelines for < 2 y/o

CT Recommended = AMS or GCS < 15 or Palpable Fx

Observation or CT = LOC > 5 sec or Non-frontal hematoma or Not acting normal or severe mechanism

PERCAN Guidelines for > 2 y/o

CT Recommended = AMS or GCS < 15 or Basilar Skull Fx Signs

Observation or CT = LOC Hx or Vomiting Hx or Severe Headache or severe mechanism

Steps for Mild TBI Disposition

1. determine CT

   1. If not = Outpatient Observation

2. Results of CT

   1. Abnormal = Admit with Neurosurgery Consul

   2. Normal = Consider

3. Is GCS < 15, present bleeding predispostion, seizures, or absent caregiver

   1. Yes = Inpatient Observation

   2. No = Outpatient Observation

Tx for MIld TBI

OTC Acetaminophen / Ibuprofen

Antiepileptics if Seizure Activity

Rest

Guideline for Atheletes and Mild TBIs

Suspected Concussion = Remove from play evaluated by professional

Removed from play until symptoms resolve without medication use

Multiple Concussions= Neuropsychic or Neurology

Persistent neurobehavioral complaints = Counseled on risk of CTE and possible retire sports

Chronic Traumatic Encephalopathy (CTE

repeated concussions resulting in cumulative deficits

Signs of CTE

Cognitive impairment

Neuropsychological symptoms (behavior, personality changes, depression, and suicidality)

Parkinsonism

Speech and gait abnormalities

Post-Concussion Syndrome (PCS)

A syndrome of

• Headache

• Vertigo

• Cognitive Impairments

• Psychological Changes

PCS is greatest at what time

7-10 days post TBI

When should PCS resolve typically

1 month

dx of PCS

Psych Eval

ENT referral

May warrant MRI brain for persistent or severe symptoms

Treatment for PCS headache

Amitriptyline

Treatment for PCS Vertigo

Antihistamine,

Benzodiazepines,

Vestibular Rehab

Treatment for PCS cognitive / psych symptoms

Psychotherapy,

anxiolytics,

antidepressants