Traumatic Brain Injury - TBI

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  • THIS SLIDE SHOWSHOW DIFFERENT TYPES OF BRAIN INJURIES ARE CLASSIFIED THE TYPE OF INJURY WE WILL FOCUS ON TODAY IS TRAUMATIC BRAIN INJURY
  • Falls were the leading cause of traumatic brain injury (28%), followed by motor vehicle-traffic (20%) and assaults (11%).
  • TRAINER: WE WILL LOOK AT TWO TYPES OF TRAUMATIC BRAIN INJURIES THAT CAN OCCUR FROM AN EXTERNAL PHYSICAL FORCE OPEN-HEAD INJURIES INCLUDE THOSE WHERE THE SKULL HAS BEEN PENETRATED INJURIES THAT INVOLVE PENETRATION OF THE SKULL AND BRAIN CAN BE MORE LOCALIZED CLOSED HEAD INJURIES AND INJURIES OF A NON-TRAUMATIC NATURE (I.E. STROKE OR ANOXIA FROM NEAR DROWNING) CAN CAUSE MORE DIFFUSE OR GLOBAL DAMAGE
  • TRAINER: #1: THE GREATES PERCENT OF BRAIN MATURATION OCCURS IN THE EARLY YEARS, BIRTH THRU AGE 5. WE LEARN MORE DURING THIS TIME THAN AT ANY OTHER TIME IN OUR LIFE LEARNING TO WALK/RUN (P-O), SPEAK/USE LANGUAGE(T), BONDING EMOTIONALLY WITH FAMILY, ETC. DESPITE MYTHS THAT INJURY DURING THIS TIME IS OF LITTLE CONSEQUENCE, WE NOW KNOW THATTBI DURING THIS TREMENDOUS STAGE OF BRAIN DEVELOPMENT CAN BE DEVASTATING CHILDREN WITH DAMAGE TO THEIR FRONTAL LOBES FROM TBI BEFORE AGE 5 FREQUENTLY HAVE LIFELONG CHALLENGES WITH SOCIAL AND BEHAVIORAL ISSUES #2: CAN HANDLE SEPARATION (C), WRITING(P-O),FOLLOWING DIRECTIONS & IMPULSE CONTROL (F-T) #3: BECOMING MORE COORDINATED(P-O) (ex)playing team sports #4: LEARNING 2ND LANGUAGE, COMMUNICATE SOCIALLY W/PEERS & ADULTS, REMEMBERING MORE ACADEMIC INFO(T); EMOTIONS BECOMING MORE ADULT-LIKE(C) #5: ACCEPTING MORE RESPONSIBILITY, PLANNING LIVES(F-T)

Transcript

  • 1. Nabeel Kouka, MD, DO, MBA www.brain101.info Traumatic Brain Injury TBI
  • 2. Brain Injuries Congenital brain injury Pre-birth During birth Acquired Brain Injury After birth process Traumatic Brain Injury (external physical force) Closed Head Injury Open Head Injury Non-traumatic Brain Injury
  • 3. What is a TBI?
    • Sudden damage to the brain due to an external force.
    • 2 Types
    • Closed Head Injury- Occurs when the head forcefully collides with another object (for example the windshield of a car) but doesn't fracture or penetrate the skull.
    • Open Head Injury- Occurs when an object (for example a bullet) fractures the skull and debris enters the brain and rips the soft brain tissue in its path.
  • 4. Epidemiology Percentage of Average Annual Traumatic Brain Injury-Related Emergency Department Visits, Hospitalizations, and Deaths, by External Cause, United States, 1995-2001
  • 5. National Prevalence Rates of Various Disabilities 500,000 with Cerebral Palsy 2 million Americans with Epilepsy 3 million with Stroke disabilities 4 million with Alzheimer’s Disease 5 million with persistent mental illness 7.3 million Americans with mental retardation 400,000 w/ Spinal Cord Injuries 5.3 million with TBI disability
  • 6. TBI in the United States (by Cause) 9% 32%
  • 7. Two types of TBI
    • OPEN-HEAD INJURY (penetrating)
    • Example:
    • Skull fracture that penetrates the brain
    • Gunshot wound
    • CLOSED-HEAD INJURY
    • Example:
    • Coup-Contra Coup
    • Diffuse axonal injury
  • 8. Two Classes of Brain Injury
    • PRIMARY
    • THE INJURY IS MORE OR LESS COMPLETE AT THE TIME OF IMPACT
      • SKULL FRACTURE
      • CONTUSION/ BRUISING OF THE BRAIN
      • HEMATOMA/BLOOD CLOT ON THE BRAIN
      • DIFFUSE AXONAL INJURY
    • SECONDARY
    • THE INJURY EVOLVES OVER A PERIOD OF HOURS TO DAYS AFTER THE INITIAL TRAUMA
    • BRAIN SWELLING/EDEMA
    • INCREASED INTRACRANIAL PRESSURE
    • INTRACRANIAL INFECTION
    • EPILEPSY
    • HYPOXEMIA (LOW BLOOD OXYGEN)
    • HIGH OR LOW BLOOD PRESSURE
    • ANOXIA/HYPOXIA (LACK OF OXYGEN TO THE BRAIN)
  • 9. TBI Severity Levels
    • Mild- Only when there is a change in the mental status at the time of the injury; concussion.
    • Moderate- Loss of consciousness last for minutes to hours; confused for days or weeks. Impairments can be temporary or permanent.
    • Severe- Unconscious state for days, weeks, or months. Impairments are permanent.
  • 10. TBI in children can be especially devastating, as a child’s brain is in an almost constant state of development.
  • 11. Brain Rates of Development 5 Distinct Periods of Maturation P - O parietal/ occipital C central (limbic & brainstem) T temporal F - T frontal/ temporal P-O C T F-T P-O C F-T P-O T C F-T
  • 12. Numerical Data  Number of neuronal cells in cerebral cortex neurons ----------- 10-15 billion glial cells ---------- 50 billion  Estimation of number of cortical neurons von Economo and Koskinas (1925) 14.0 billion Shariff (1953) 6.9 billion Sholl (1956) 5.0 billion Pakkenberg (1966) 2.6 billion Cerebral Cortex
  • 13.  
  • 14.  
  • 15. Normal Brain CT Scan
  • 16. Brain Concussion
    • Impaired function (varying time frame)
    • No structural damage to speak of directly
    • Can lead to degradation over time
    • Extreme variance in severity
      • LOC
    • Diffuse
  • 17. Brain Concussion
  • 18. Brain Contusion
  • 19. Contusion w/Contra-Coup Injury
  • 20. Diffuse Axonal Injury
  • 21.  
  • 22. Intraventricular Haemorrhage
  • 23. Intraventricular Haemorrhage
  • 24. Brainstem Haemorrhage
  • 25. Subarachnoid Hemorrhage a. Subarachnoid Hemorrhage b. Transtentorial herniation c. Intraventricular hemorrhage e. Diffuse axonal (shearing) injury
  • 26. Intracranial Haematomas
    • Epidural
      • arterial bleeding
      • quick onset
      • less common
    • Subdural
      • venous bleeding
      • wide range of onset time
      • can build on each other without symptoms
  • 27. Acute Subdural Haematoma
  • 28. Acute Subdural Haematoma w/Midline Shift
  • 29. Chronic Subdural Haematoma
    • * Heterogeneous mass
    • Focal convexity of medial margin
    • Dilated Ipsilateral Ventricle
    • Midline Shift
    • Diffuse Brain Edema
    • Scalp Hematoma
  • 30. Acute Epidural Haematoma
  • 31. Management
    • The specific goals in the acute management of severe traumatic brain injury are:
      • 1. Protect the airway & oxygenation
      • 2. Ventilate to normocapnia
      • 3. Correct hypovolaemia & hypotension
      • 4. CT Scan when appropriate
      • 5. Neurosurgery if indicated
      • 6. Intensive Care for further monitoring and management
  • 32. Significant Head Injuries
    • Signs of increased intercranial pressure
      • Visual difficulties
      • Vomiting
      • Dyspnea
      • Decreased pulse
  • 33.  
  • 34. Glascow Coma Scale
  • 35. Intracranial Pressure (ICP) CPP = MAP - ICP CPP: Cerebral Perfusion Pressure MAP: Mean Arterial Pressure ICP: Intracranial Presure v.Intracranial (constant) = v.Brain + v.CSF + v.Blood + v.Mass Lesion
  • 36. Indications for ICP Monitoring
  • 37. Key Recommendations
    • Maintenance of CPP reduces mortality in severe head injury.
    • ICP monitoring is recommended in most comatose patients with severe head injury.
    • ICP should be treated when > 20 mm Hg , but maintenance of CPP is probably more important.
  • 38. How Brain Injuries treated?
  • 39. How Brain Injuries treated?