Head Trauma

In Traumatic Brain Injury (TBI), what additional assessment is required?

Cervical spine assessment

What is the definition of Traumatic Brain Injury (TBI)

“Alteration in brain function, or other evidence of brain pathology, caused by an external force, and characterized by:”

What are the characteristics of a TBI

any period of loss or decreased level of consciousness, any loss of memory for events immediately before (retrograde) or after (posttraumatic) the injury, any neurologic deficits, any alteration in mental state at the time of injury

What is the classification of Mild Traumatic Brain Injury (TBI)

Mild TBI → GCS 13 – 15 [70–95% of TBIs] “concussion”

What is the classification of Moderate Traumatic Brain Injury (TBI)

Moderate TBI → GCS 9 – 12

What is the classification of Severe Traumatic Brain Injury (TBI)

Severe TBI → GCS 3 – 8

What is the significance and reclassification consideration for a GCS of 13

intracranial lesions associated with a GCS of 13, some say to change a GCS of 13 to a moderate TBI.

What are the components of the Glasgow Coma Scale (GCS)

• Eye opening (1–4)

• Verbal response (1–5)

• Motor response (1–6)

What are the GCS eye opening responses

• Spontaneous—open with blinking at baseline (4)

• To verbal stimuli, command speech (3)

• To pain only (not applied to face) (2)

• No response (1)

What are the GCS verbal responses

• Oriented (5)

• Confused conversation, but able to answer questions (4)

• Inappropriate words (3)

• Incomprehensible speech (2)

• No response (1)

What are the GCS motor responses

• Obeys commands for movement (6)

• Purposeful movement to painful stimulus (5)

• Withdraws in response to pain (4)

• Flexion in response to pain (decorticate) (3)

• Extension in response to pain (decerebrate) (2)

• No response (1)

What are the characteristics of decorticate posturing

Upper extremity flexion and lower extremity extension

What does decorticate posturing indicate

Indicates severe intracranial injury above the level of the midbrain

What are the characteristics of decerebrate posturing

Arm extension and internal rotation with wrist and finger flexion and internal rotation and extension of the lower extremities

What does decerebrate posturing indicate

Indicates an injury lower in the brainstem

What is the decorticate posturing score

motor score 3

What is the decerebrate posturing score

motor score 2

What is the arm position in decorticate posturing

arms to the core

What is the arm position in decerebrate posturing

extended

What are the mechanisms of TBI

• Strike by object

• rapid accel/decel

• penetrating wound

• explosion

What are the major causes of TBI

• Falls – 45%

• Traffic-related – 25%

• Interpersonal violence – 9%

• Other (sports, explosions) – 9%

What is the peak incidence of TBI

old age (75 years+) and childhood

What are additional TBI risk factors

• Male

• ETOH/Drugs

• Baseline neuro/psych conditions

• Baseline functional impairment (e.g. strength, gait)

• Low socioeconomic status

When does primary brain injury occur

at the time of injury

What causes primary brain injury

Due to forces transmitted to the brain

When does secondary brain injury develop

develops over days to weeks after initial injury

What causes secondary brain injury

Secondary to the primary brain injury

What causes TAMVI

Due to shear force on neuronal axons from rotational forces and rapid deceleration injuries (e.g. MVA)

What are the associated findings of TAMVI

Can be associated with microhemorrhages (“gliding contusions”), midline tissue tears (best seen on MRI)

What is the imaging finding in TAMVI

imaging is commonly negative

What are the types of primary intracranial hemorrhage

• Intracerebral hemorrhage

• Epidural Hematoma

• Subdural Hematoma

• Subarachnoid hemorrhage

• Intraventricular hemorrhage

What is the note regarding hematomas

Hematomas can exert mass effect

What are the primary brain injury pathophysiology issues

1. traumatic axonal and/or microvascular injury (TAMVI)

2. intracranial hemorrhage

What are the secondary brain injury pathophysiology factors

• Ischemia

• neurotransmitter excitotoxicity (e.g. glutamate)

• cortical spreading depression

• BBB disruption/increased permeability

• inflammatory response (e.g. cytokine release)

• mitochondrial dysfunction, apoptosis

What is the effect of neurotransmitter toxicity

increased calcium influx

What is the definition of cortical spreading depression

Wave of depolarization followed by suppressed cortical activity

What is the effect of cortical spreading depression

worsening excitotoxicity

What is the effect of inflammation and BBB disruption

edema

What are the physical signs and symptoms of TBI

• Headache

• Nausea/Vomiting

• Imbalance

• Dizziness

• Tinnitus

• Visual problems

• Sensitivity to light/noise

• Numbness/tingling

What are the cognitive signs and symptoms of TBI

• Feeling mentally “foggy”

• Difficulty concentrating

• Difficulty remembering

• Confused

• Answers questions slowly

• Repeats questions

What are the emotional signs and symptoms of TBI

• Irritability

• More emotional

• Sadness

• Nervousness

• Change in personality

What are the sleep signs and symptoms of TBI

• Drowsiness

• Trouble falling asleep

• Sleeping less or more than usual

What is included in the initial TBI evaluation

Hemodynamically stable?, Maintaining airway?

What is the note regarding orientation questions

Orientation questions – not adequate

What is the alternative to orientation questions

Ask patient to describe the injury, events leading up, events following

What are the components of the neurological exam

• GCS

• Cranial nerves

• Motor function

• Reflexes

• Sensory function

What standardized assessment tools are used for mild TBI

• SCAT6 (Sport Concussion Assessment Tool)

• SCOAT6 (Sport Concussion Office Assessment Tool)

• Vestibular/Oculomotor Screening (VOMS)

• Acute Concussion Evaluation

What is the SCAT6 used for in mild TBI

For use within 72 hours of injury

What is the SCOAT6 used for in mild TBI

For use >72 hours after injury

What additional SCOAT6 versions exist for mild TBI

There are also versions for patients

What is the note regarding standardized tools for mild TBI

Standardized tools do not definitively rule out or diagnose mild TBI

What baseline symptoms are recorded in VOMS

• Headache 0–10

• Dizziness 0–10

• Nausea 0–10

• Foggiess 0–10

What tests are included in VOMS

• Smooth Pursuits

• Saccades – Horizontal

• Saccades – Vertical

• Convergence (Near Point)

• VOR – Horizontal

• VOR – Vertical

• Visual Motion Sensitivity Test

What defines abnormal convergence in VOMS

Abnl = convergence @ 5cm+

What are the instructions for the vestibular ocular reflex (VOR) in VOMS

Eyes focused on target 3 feet away, patient turns head rapidly from 20 degrees left to 20 degrees right @ 180 BPM, vertically @ 180 BPM. Horizontal x5. Vertical x5.

What are the instructions for the visual motion sensitivity test in VOMS

Standing, patient extends arm forward, focus on thumb. Rotate head and trunk as one unit 80 degrees right to 80 degrees left @ 50 BPM. Perform x5.

How many times is the convergence (near point) test done in the VOMS

perform 3x

What are the NEXUS II criteria for determining who gets a head CT in mild TBI

• Age ≥ 65 years

• Evidence of significant skull fracture

• Scalp hematoma

• Neurologic deficit

• Altered level of alertness (i.e. GCS ≤ 14)

• Abnormal behavior

• Coagulopathy

• Persistent vomiting

Why is coagulopathy included in the NEXUS II criteria for a mild TBI

either due to disease or anticoagulation

What are the New Orleans Criteria for mild TBI

• Headache

• Vomiting (any)

• Age > 60 years

• Drug or alcohol intoxication

• Seizure

• Trauma visible above clavicles

• Short-term memory deficits

What GCS score do the New Orleans Criteria apply to in mild TBI

Only for GCS 15

What are the Canadian CT Head Injury/Trauma Rule criteria for mild TBI

• Dangerous mechanism of injury

• Vomiting > than once

• Age > 65 years

• GCS score < 15, 2 hours post-injury

• Seizure after injury

• Any sign of basal skull fracture

• Possible open or depressed skull fracture

• Amnesia for events 30 minutes before injury

What defines a dangerous mechanism of injury in the Canadian CT Head Rule

• Pedestrian struck by a motor vehicle

• occupant ejected from a motor vehicle, or a fall from >3 feet or >5 stairs

What GCS range does the Canadian CT Head Rule apply to

Only for GCS 13–15

What findings indicate the need for a head CT in mild head trauma

• Glasgow Coma Scale <15

• Suspected open or depressed skull fracture

• Any sign of basilar skull fracture

• Two or more episodes of vomiting

• New neurologic deficit

• Presence of a bleeding diathesis or use of an anticoagulant medication

• Seizure

• Age 60 years or older

What additional factors may indicate the need for head CT in mild head trauma

• Retrograde amnesia of a 30-minute or longer period of time before the traumatic episode

• Potentially high impact injury

• Intoxication, headache, or abnormal behavior

What findings require inpatient observation in mild head trauma, if the head CT was negative

• Glasgow Coma Scale <15

• Bleeding diathesis or anticoagulation

• Seizures

• No responsible caregiver at home

Is the head CT in the acute evaluation of an adult with mild head trauma done with or without contrast

without

If trauma occurred >7 days ago, if available, what is the most appropriate form of evaluation

MRI without contrast

If a noncontrast imaging suggested a vascular injury, what is the next step

IV contrast may be administered for CT or MR angiography of the head and neck

What should be monitored in mild TBI management

deterioration of neurologic status

What are indications for in-hospital observation in mild TBI

• Altered neurologic status

• Abnormal imaging

• Anticoagulated

• Absence of others

What findings define altered neurologic status in mild TBI

• Glasgow Coma Scale (GCS) <15

• Seizures

• Other neurologic deficit

• Recurrent vomiting

What abnormalities on head CT indicate in-hospital observation in mild TBI

• intracranial hemorrhage

• ischemia, mass effect, midline shift

What defines anticoagulation risk in mild TBI

Abnormal bleeding parameters from underlying bleeding diathesis or oral anticoagulation

What is the social indication for in-hospital observation in mild TBI

No reasonable person at home to observe

What return precautions should be given to outpatient mild TBI patients

• Fever

• Confusion

• Weakness or numbness involving any part of the bod

• Unsteadiness

• Seizures

• Severe or worsening headaches

What is the first step in managing an athlete with suspected concussion

Remove from play immediately if concussion expected

When can an athlete return to play after mild TBI

until asymptomatic without medication

What is the recommended timeframe for return to play after mild TBI

No hard and fast timeframe recommended – individualized

What rest is recommended after mild TBI

Total rest (mentally and physically) until resting symptoms resolve

What screen time recommendations are given after mild TBI

Limit screen time: no cell phones, TV, video games, etc.

What are the steps in the return to activity process after mild TBI

• Symptom-limited activity

• Light aerobic activity

• Sport specific activity

• Noncontact drills

• Full contact practice

• Return to play

What is the prognosis for mild TBI?

Most people recover fully in a few weeks, though this is not definitive.

What should be done if mild TBI symptoms persist?

consider TBI specialist referral.

What GCS scores define moderate and severe TBI?

GCS 9–12/13 (moderate) and GCS 3–8 (severe)

What is the head CT management for moderate to severe TBI?

Manage bleeds/fractures as indicated

What inpatient monitoring is required for moderate to severe TBI?

Serial neurologic reassessment (e.g. q1–2h x at least 24–48h)

What should be avoided in moderate to severe TBI?

Avoid hypotension and hypoxia

How is increased intracranial pressure monitored and managed in moderate to severe TBI?

clinical assessment, transcranial doppler/invasive monitoring.

When is invasive monitoring preferred in moderate to severe TBI over transcranial doppler?

GCS 8 or less, hypotension, abnormal CT imaging.

What is step 1 in elevated ICP management?

Repeat CT scanning and surgical removal of an intracranial mass lesion, ventricular drainage, or decompressive surgery

What is step 2 in elevated ICP management?

IV sedation to attain a motionless, quiet state

What is step 3 in elevated ICP management?

Pressor infusion if CPP

What is step 4 in elevated ICP management?

Mannitol 0.25–1.0 g/kg IV every 2–6 h as needed or 7.5–23.4% hypertonic saline 0.5–2 mL/kg via central line over 20 min

What is step 5 in elevated ICP management?

Targeted temperature management with a feedback providing cooling device 33–36 °C

What is step 6 in elevated ICP management?

High-dose pentobarbital/thiopental therapy (load with 5–20 mg/kg, maintain with 1–4 mg/kg/h)

What are persistent concussion symptoms in PCS?

Physical, emotional, sleep, cognitive

What is the typical duration of PCS?

Majority of PCS resolves in 3 months

What is the management of PCS?

Brain MRI if not already performed