Week 10: TBI medical management

Glasgow coma scale

assesses function of brainstem and cerebrum

GCS range

3-15

mild brain injury

13-15

moderate brain injury

9-12

severe brain injury

less than equal to 8

Eye opening scale

1 none

2 to pain

3 to speech/sound

4 spontaneous

best motor response scale

1 none

2 extensor response (decerebrate)

3 abnormal flexion

4 withdraws

5 localizes

6 obeys commands

Verbal response scale

1 none

2 incomprehensible sounds

3 inappropriate words

4 confused conversation

5 oriented

Initial management before hospital: look at....

oxygenation, BP, cognitive function, pupillary function, signs of brain herniation

Goal of the emergency room

resuscitation and prevention of secondary injury

what things do the ER do

CT scan, neurosurgical eval, airway production/ventilation, monitor for cerebral perfusion, monitor ICP, fluid management, hyperosmolar therapy, sedation, prophylaxis of infection/dvt/seizures/hypothermia

CT scan assesses for

hemorrhage and edema

Surgical intervention examples

ICP monitor and/or extra-ventricular drain placement, burr holes, craniotomy, decompressive craniectomy

ICP monitor and/or extraventricular drain placement

catheter inserted into anterior horn of lateral ventricle, connected to a transducer for ICP monitoring

Burr holes

subdural hematoma evacuation

craniotomy

open skull to evacuate bleeding, commonly fronto-temporo-parietal

decompressive craniectomy

remove portion of skull to relieve pressure, stored in abdomen or freezer

pharmacological ways to decrease intracranial pressure

osmotic agents (mannitol, hypertonic saline)

pharmacological ways to control BP and CPP

vasopressors (phenylephrine, norepinephrine)

pharmacological ways to decrease intracranial bleeding

hemostatic drugs, antifibrinolytics to increase clot stability

pharmacological ways to control seizures

anti convulsants often given prophylactically because seizures are a common secondary injury

pharmacological ways to prevent brain cell death

hypothermia has possible neuroprotective effects, progesterone reduces cerebral edema and neuronal loss in acute TBI

pharmacological ways to prevent infection

antibiotics especially if penetrating injury or need for invasive monitoring (ICP monitor/EVD drain)

pharmacological ways for treating aggression

carbamazepine, valproate, propanolol

pharmacological ways to treat depression

SSRI

pharmacological ways to treat attention to deficits

CNS stimulates

pharmacological ways to treat impaired arousal

amantadine

pharmacological ways to affect motor function and spasticity

baclofen, diazepam, dantrolene sodium, tizanidine

Other organ injuries that may occur at same time of TBI

cardiac contusions, pulmonary contusions, liver lacerations, bowel injuries

Fractures that may occur at same time as TBI

limbs, spinal, facial/orbital

Other neurological injuries at same time as TBI

SCI

other surgical repairs at same time as TBI

ex lap, other organs, fracture repairs

Ligament damage at same time as TBI

often not noted or treated until after healing of other injuries

Chronic traumatic Encephalopathy (CTE)

brain degeneration likely caused by repeated head trauma

-only Dx at death

-mainly in those with contact sports or military with blast injury

symptoms of CTE

cognitive impairments, depression, memory loss, emotional liability, substance misuse