CME ON TRAUMATIC BRAIN INJURY

Dr. Fahad IslamHonorary Medical Officer

Physical Medicine& Rehabilitation DepartmentChittagong Medical University

Date:10.06.2014

TBI is defined as injury to the brain caused

by external forces.

Definition of TBI

1.Mild Head injury 2. Moderate Head injury 3.Severe Head injury & 4.Persistent Vegetative State

Degree of Severity

1. Mild Head Injury: Most common. Also

known as Post concussion syndrome.

Degree of severity--continue

symptom of these syndrome include headache, dizziness, poor concentration& information processing, memory loss, fatigue& irritability.

Mild head injury-continue

Currently the most accepted operational Definition of mild Head injury originates from work at the Medical college of Virginia. Dx consist of –

--Constellation of brief( less than 20mins) loss of consciousness --GCS score ≥13 --No focal neurological findings --No abnormality on CT scan or Skull radiographs --Discharge from the hospital with in 48 hours

Mild Head injury--continue

2.Moderate Head Injury: Proposed

criteria are initial GCS score 9-12,10-12 or 8-10

*McMillan & associates have used a definition of admission to a hospital for head trauma associated with a post traumatic amnesia lasting between 1-24hrS.

Degree of severity--continue

3.Severe Head Injury: 10% of total TBI patient.

*Patients who have Head Injury severe enough to produce an obvious disabling deficit but who regain the capacity for conscious activity

Degree of Severity--continue

4. Persistent Vegetative State: A small Percentage of surviving Patients with TBI whose extent of injury is sufficiently severe don’t regain consciousness but enter into the persistent vegetative state.

Degree of Severity--continue

Rating System

TBI Patient

1.Glascow coma scale(GCS) 2.Glascow outcome scale 3.Rappaport disability scale 4.Level of cognitive functioning scale

Rating of a TBI patient

A.Glasgow Coma Scale(GCS): Eyes:

*spontaneous -4 *To Speech -3 *To Pain -2 *No Response -1

Motor Response: *Obeys verbal commands -6

Responds to painful stimulations by---- *Purposeful Localization -5

*Withdrawal -4 *Flexor Posturing -3 *Extensor Posturing -2 *No Response -1

Verbal Response: *Oriented & Converses -5

*Disoriented& Converses -4 *Inappropiate words -3 *Incomprehensible Sounds -2 *No Response -1

GCS Score: 3-15

Rating System

B.Glasgow Outcome Scale: Develop by Jennett’s . It Is total 5 point scale.

1.Death 2.Persistent Vegetative State 3. Severe disability 4.Moderate Disability 5.Good Recovery

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C.Rappaport Disability Scale: Scale ranges from 1-30 points. where 30 represents death & 0 represents No measurable deficit. It is more finely graduated measure of Functional outcome than the GCS.

Rating System--continue

4.Level of Cognitive functioning scale: developed by Ranchos Los Amigos Hospital in California , is an 8 level global measure of cognition & behavior rated as follows:

Rancho level Clinical correlate I No Response II Generalized Response III Localized Response IV Confused-agitated V Confused-inappropiate VI Confused-appropiate VII Automatic-appropiate VIII Purposeful-appropiate

Rating System--continue

Pathology of TBI

TBI continue

1.Primary Brain Injury 2.Secondary Brain Injury 3.Concommitant Injury 4.Military Blast Injury

Pathology of TBI

1.Primary Brain Injury: 2 major types cerebral contusions& axonal stretch injuries.

The cortex tends to be more affected, followed by the diencephalic structures, with mid-brain & brain stem structures affected least.

Pathology of TBI

MRI is superior than CT in demonstrating both the diffuse long tract lesions & focal cerebral contusions of TBI& extent and location of these lesions.

Pathology of TBI--continue

2.Secondary Brain Injury: Develops over Hrs& days after the initial impact & is associated with disruption of cerebral blood flow& metabolism, massive release of neurochemicals ,cerebral edema& disruption of Ion homeostasis leading to cellular Injury& eventual cell death.

Pathology of TBI--continue

3.Concomitant Injury: TBI especially with more severe cases like high speed vehicles crashes that associated with longer acute care lengths of stay& need for Rehabilitation

Pathology of TBI--continue

4.Military Blast Injury

*Primary effect *Secondary effect *Tertiary effect

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Etiology of TBI

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Causes of injuries:

1.Falls, 2.RTA, 3.Violence, 4.Struck by/against

events(sports), 5.other injuries

Etiology of TBI

Causes of TBI..

Risk Factors related to Traumatic Brain Injury..

TBI continue

1.Age & Gender: usual age group 0-4yrs ; 15-19 Yrs; Over 65Yrs & more in Women.

2.Socioecomic Status: Low status, Highly crowded& rural areas

3.Violence(10%)

Demography& Risk Factors..

4.Child abuse: Also known as Shaken baby syndrome (SBS)& Inflicted childhood Neurotrauma, commonly conducted by Parents or Child care Providers.

5.Psychosocial Factors : Substance Use, anxiety, depression& Conduct disorder.

Risk factors..continue

Management of TBI

TBI continue

guidelines grade-1 grade-2 grade-3

1.Colorado 1.Confusion without amnesia2.No loss of Conciousness

1.Confusion with amnesia2.No Loss of Conciousness

Loss of Conciousness(of any duration)

2.AAN 1.Transient confusion2.No loss of conciousness3.Conciousness sypmtoms or mental status changes resolve less than 5 mins

1.Transient confusion2.No loss of conciousness3.Conciousness sypmtoms or mental status changes resolve less than 15 mins

Loss of conciousness(brief/Prolonged)

3.Cantu 1.No loss of Conciousness,OR2.PTA OR,S/S lasts longer than 30 mins

1.Loss of Conciousness lasts less than 1 mins,OR2.PTA lasts longer than 30 mins but less than 24 hr

1.Loss of Conciousness lasts more than 1 mins,OR2.PTA lasts longer than24hr. OR3.Post concussion S/S lasts longer than 7 Days

Mx of Mild TBI..continue

Patient with severe TBI to a Level 1 or 2 trauma center is associated with decreased mortality. Facilities defined for transport include those offering CT scanning, neurosurgical care, ICP monitoring, and treatment capabilities. These facilities can provide 24-hour neurosurgical care and intensive care treatment.

Mx of moderate&severe TBI..

Surgical treatment of TBI is indicated

when intracerebral fluid collections exert a significant mass effect. Surgical treatment can also be used to lower ICP. The use of decompressive craniectomy to decrease ICP .

Mx of Moderate to severe TBI..continue

Prognostic Factor……

TBI continue

1.Duration of Coma& Post traumatic Amnesia(PTA): Most useful prognostic indicators.

Prognosis

PTA- affected overall outcome of Brain injury as well as specific Cognitive& Psycological deficit.

Prognosis

2.Neurological Indicators: Impaired Oculocephalic, oculovestibular & Pupillary reflex responses increase in proportion to the degree of Injury to the CNS& result in a proportionally poorer Outcome.

Prognosis..continue

3.Physiological Indicators: *Ischemic Injury related to deep coma has

worse prognosis. *Biochemical measurements like,CPK,LDH,CK-BB(specific for CNS) * Raised ICP *Lactate in CSF& raised catecholamines have poorer outcome.

Prognosis..continue

4.Electrophysiological Indicators: *EEG *Evoked Potentials

*Computerized Spectral Electroencephalographic analysis

*Brain Imaging-Skull radiographs ,CT Scan ,MRI, Positron emission tomography

Prognosis..continue

5.Age 6.Sex 7.Premorbid capacity 8.Socioeconomic Status 9.Cognitive Predictors 10.Associated Injuries

Prognosis..continue

MRI images of Traumatic Brain Injury

Medical Complication& Management And Rehab

TBI Continue

Posttraumatic seizures (PTS): PTS accounts for 20% of symptomatic seizures.

Medical Complication Management

PTS has commonly been defined as occurring in the immediate period (<24 hours after injury), early period (24 hours to 7 days after injury), and late (>7 days after injury).

Post traumatic Seizure..continue

Phenytoin (Dilantin) is commonly used for PTS prophylaxis and treatment. Phenytoin therapy for 1 week provides protection against early PTS.

Post traumatic Seizure..continue

Heterotopic Ossification: HO after TBI ranges from 11% to 28%.

Rehabilitation..continue

Common prophylactic methods include anti-

inflammatory medications like indomethacin, irradiation and Ca binding chelating agents such as etidronate (Didronel).After maturation is complete, excision of the ectopic bone can often improve joint motion and mobility

Heterotrophic ossification..continue

Deep Venous Thrombosis: pulmonary embolus secondary to DVT

is an important cause of death, and the estimated incidence of DVT is 40%.

Medical Complication Management

use of either heparin or low-molecular-weight heparin within 24 to 72 hours after severe TBI or intracranial bleed.

Deep Venous Thrombosis..continue

Swallowing and Nutrition: Early institution of enteral nutritional

support might decrease morbidity and mortality, shorten hospital length of stay, and potentially improve immune function.

Medical Complication Management

Bowel and Bladder Dysfunction: Injury to cortical and subcortical

structures can lead to loss of control. Incidence of urinary incontinence approximately 62% of patients.

Medical Complication Management

The patterns of dysfunction include an uninhibited overactive bladder as well as

poor perception Of bladder fullness common.

Bowel and Bladder Dysfunction..continue

Treatment options include behavioral

interventions such as timed voiding. Caution must be used in initiating anticholinergic medications because of their adverse cognitive effects. Bowel dysfunction after TBI includes incontinence and constipation.

Bladder and Bowel dysfunction..continue

Airway and Pulmonary Management: pneumothorax, haemothorax, flail chest,

and rib fractures. Pneumonia is the most common complication observed in acute care and rehabilitation, occurring in 60% of patients.

Medical Complication Management

Spasticity and Contractures:

The incidence has been reported to be as high as 84%.The risk factors for spasticity development include more severe injury (lower GCS),motor dysfunction (hemiplegia or tetraplegia), associated anoxic injury, spinal cord injury, and age..

Medical Complication Management

1.Electrical stimulation. 2.Dantrolene.3.Baclofen. 4.Other oral agents -benzodiazepines,

tizanidine, and clonidine.5.Focal chemodenervation

Spasticity Management..continue

6.Phenol.

7.Chemo denervation with botulinum toxin A and B

8.Baclofen can also be delivered intrathecally.

Spasticity Management..continue

Normal pressure hydrocephalus:

Incidence of 45%. CT scan of the head without contrast to evaluate ventricular size is necessary in evaluation.

Medical Complication Management

Endocrine Dysfunction Associated With Traumatic Brain Injury: 80% of patients with acute TBI have some type of acute pituitary dysfunction.

Medical Complication Management

Rehabilitation Programe

TBI Patient

AIM: The Prevention &Rx of contractures through an effective Bed positioning programme .

Bed Positioning

Bed Design

Bed Design

Supine Position

LOWER EXTREMITY FEET-Positioned with entire Planter surface

firmly against the foot board. Contact with post. heel is avoided by placing it in the space between the mattress& the foot-board that has been created by 4 inches thick block.

Supine Position

LEGS-Placed in a neutral position with the toes pointed towards the ceiling. This Position is maintained by friction of the feet against the foot board& a cloth roll placed under the Greater Trochenter (trochanteric roll)

Supine positioning..continue

KNEE&HIP-Positioned in Extention to prevent Hip& knee flexion contractures.Hip flexion contractures in presence of lower extremity weakness are the principle deterrents to ambulation for patient with hemiplegic,paraplegic& above knee amputation.

Supine Positioning..continue

Shoulder, Elbow& Forearm-Position-1:

Shoulder:90 degree abducted& slightly internally rotated

Elbow: 90 degree flexed Forearm: Partially pronated 

Upper Extremity

Position-2:

Shoulder: 90 degree or more abducted& Externally rotated to greatest degree compatible with comfort.

Elbow: 90 degree flexed Forearm: Pronated

Bed

Positioning..continue

Position-3:

Shoulder: Slight abduction Elbow: Extended Forearm: Supinated

Bed Positioning..continue

Bed Positioning

Wrist &Hand

The wrist from neutral to a Fully extended position, a full ROM in MCP Joint, Flexion of IP joint& opposition of the Thumb.

Bed Positioning..continue

Position-1:

Wrist: Extended MCP&IP: Partially flexed Thumb: Abducted, opposed& slightly flexed

at IP joints

Bed

Positioning..continue

Position-2:

Same as Position-1 except MCP&IP joints of fingers are extended. A Palmar positioning Splint can be used to maintain this position.

Bed Positioning..continue

Hemiplegic Patient: Most comfortable lying on their uninvolved

side. Paraplegic& Quadriplegic Patient: Should be positioned on either side. The top

leg Is placed in a position of flexion at the Hip&knee,through use of pillows Contact with the under leg is avoided. The inner arm is externally rotated& partially extended& the outer arm is kept away from the patients chest.

Side Lying Position

Side Lying Position

High advantages in maintaining full extension of hips& relieving pressure over vulnerable post. bony prominences. The prone position has its vulnerable points such as skin over sternum,iliac spines,the patella& the dorsum of foot.These areas are inspected frequently.

Prone Lying Position

Prone Lying Position

The arm is abducted slightly, extended elbow& supinated forearm,wrist extended& finger flexed are achieved through the use of Hand roll.Shoulder roll are placed length wise under each shoulder.

Prone Lying

position

FREQUENCY OF TURNING: *Every 2 hourly is safe,it is best to order the

more prolonged positioning periods for the night hours.Thus lessening the amount of turning at night& enabling the patient more satisfactorily

*More frequent turning is needed during day to allow the desire position for the patients daily activities.

Bed Positioning..continue

Prevention of Traumatic Brain Injury

Traumatic Brain Injury

Thank You

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