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Traumatic Brain    Injury         TBINabeel Kouka, MD, DO, MBA      www.brain101.info
Brain Injuries Congenital brain injury         Acquired Brain InjuryPre-birth      During birth        After birth process...
What is a TBI?Sudden damage to the brain due to an external force.2 Types• Closed Head Injury- Occurs when the head  force...
Epidemiology   Percentage of Average Annual Traumatic Brain Injury-Related EmergencyDepartment Visits, Hospitalizations, a...
National Prevalence Rates of Various            Disabilities             400,000 w/ Spinal Cord Injuries                  ...
TBI in the United States (by Cause)                         Motor Vehicle                         - Traffic             9%...
Two types of TBIOPEN-HEAD               CLOSED-HEADINJURY                  INJURY(penetrating)                        Exam...
Two Classes of Brain Injury•   PRIMARY                       • SECONDARY    THE INJURY IS MORE              THE INJURY EVO...
TBI Severity Levels• Mild- Only when there is a change in the mental status  at the time of the injury; concussion.• Moder...
TBI in children     can be especially devastating,as a child’s brain is in an almost constant           state of developme...
Brain Rates of Development                            5 Distinct                            Periods of                    ...
Cerebral CortexNumerical Data Number of neuronal cells in cerebral cortex   neurons ----------- 10-15 billion   glial cel...
Normal Brain CT Scan              QuickTime™ and a   TIFF (Uncompressed) decompressor      are needed to see this picture.
Brain Concussion• Impaired function (varying time frame)• No structural damage to speak of directly• Can lead to degradati...
Brain Concussion             QuickTime™ and a  TIFF (Uncompressed) decompressor     are needed to see this picture.
Brain Contusion            QuickTime™ and a TIFF (Uncompressed) decompressor    are needed to see this picture.
Contusion w/Contra-Coup Injury                      QuickTime™ and a           TIFF (Uncompressed) decompressor           ...
Diffuse Axonal Injury               QuickTime™ and a    TIFF (Uncompressed) decompressor       are needed to see this pict...
Intraventricular Haemorrhage                   QuickTime™ and a        TIFF (Uncompressed) decompressor           are need...
Intraventricular Haemorrhage                    QuickTime™ and a         TIFF (Uncompressed) decompressor            are n...
Brainstem Haemorrhage           QuickTime™ and a                     QuickTime™ and aTIFF (Uncompressed) decompressor     ...
Subarachnoid Hemorrhage           QuickTime™ and a                     QuickTime™ and a                         QuickTime™...
Intracranial Haematomas• Epidural  – arterial bleeding  – quick onset  – less common• Subdural  – venous bleeding  – wide ...
Acute Subdural Haematoma                QuickTime™ and a     TIFF (Uncompressed) decompressor        are needed to see thi...
Acute Subdural Haematoma w/Midline               Shift                     QuickTime™ and a          TIFF (Uncompressed) d...
Chronic Subdural Haematoma                                     * Heterogeneous mass                                     a....
Acute Epidural Haematoma                QuickTime™ and a     TIFF (Uncompressed) decompressor        are needed to see thi...
ManagementThe specific goals in the acute management ofsevere traumatic brain injury are:1. Protect the airway & oxygenati...
Significant Head Injuries• Signs of increased intercranial pressure  – Visual difficulties  – Vomiting  – Dyspnea  – Decre...
Glascow Coma Scale
Intracranial Pressure (ICP)v.Intracranial (constant) = v.Brain + v.CSF + v.Blood + v.Mass Lesion                          ...
Indications for ICP MonitoringIndications for ICP monitoring                  Risk of raised ICPSevere Head Injury (GCS 3-...
Key RecommendationsMaintenance of CPP reduces mortality in severe head injury.• ICP monitoring is recommended in most coma...
How Brain Injuries treated?
How Brain Injuries treated?
Traumatic brain-injury-tbi1117
Traumatic brain-injury-tbi1117
Traumatic brain-injury-tbi1117
Traumatic brain-injury-tbi1117
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Traumatic brain-injury-tbi1117

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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 of "Traumatic brain-injury-tbi1117"

    1. 1. Traumatic Brain Injury TBINabeel Kouka, MD, DO, MBA www.brain101.info
    2. 2. Brain Injuries Congenital brain injury Acquired Brain InjuryPre-birth During birth After birth process Traumatic Brain Injury (external physical force) Non-traumatic Brain Injury Closed Head Open Head Injury Injury
    3. 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 doesnt 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. 4. Epidemiology Percentage of Average Annual Traumatic Brain Injury-Related EmergencyDepartment Visits, Hospitalizations, and Deaths, by External Cause, United States, 1995-2001 Suicide, 1% Unknown, 9% Other Transport, Other, 7% 2% Falls, 28% Pedal Cycle (non MV), 3% Assault, 11% Motor Vehicle- Traffic, 20% Struck By/Against, 19%
    5. 5. National Prevalence Rates of Various Disabilities 400,000 w/ Spinal Cord Injuries 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 5.3 million with TBI disability7.3 million Americans with mental retardation
    6. 6. TBI in the United States (by Cause) Motor Vehicle - Traffic 9% 20% Falls Ass ault 32% 28% Other 11% Unknown
    7. 7. Two types of TBIOPEN-HEAD CLOSED-HEADINJURY INJURY(penetrating) Example:Example: • Coup-Contra Coup• Skull fracture that • Diffuse axonal injurypenetrates the brain• Gunshot wound
    8. 8. Two Classes of Brain Injury• PRIMARY • SECONDARY THE INJURY IS MORE THE INJURY EVOLVES OVER OR LESS COMPLETE A PERIOD OF HOURS TO AT THE TIME OF DAYS AFTER THE INITIAL IMPACT TRAUMA 1. SKULL FRACTURE 1. BRAIN SWELLING/EDEMA 2. CONTUSION/ BRUISING OF 2. INCREASED INTRACRANIAL PRESSURE THE BRAIN 3. INTRACRANIAL INFECTION 4. EPILEPSY 3. HEMATOMA/BLOOD CLOT 5. HYPOXEMIA (LOW BLOOD OXYGEN) ON THE BRAIN 6. HIGH OR LOW BLOOD PRESSURE 4. DIFFUSE AXONAL INJURY 7. ANOXIA/HYPOXIA (LACK OF OXYGEN TO THE BRAIN)
    9. 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. 10. TBI in children can be especially devastating,as a child’s brain is in an almost constant state of development.
    11. 11. Brain Rates of Development 5 Distinct Periods of Maturation P - O parietal/ occipitalP-O C central (limbic & brainstem) C P-O T T temporal T C F-T C P-O F - T frontal/F-T temporal F-T
    12. 12. Cerebral CortexNumerical 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
    13. 13. Normal Brain CT Scan QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
    14. 14. 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
    15. 15. Brain Concussion QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
    16. 16. Brain Contusion QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
    17. 17. Contusion w/Contra-Coup Injury QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
    18. 18. Diffuse Axonal Injury QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
    19. 19. Intraventricular Haemorrhage QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
    20. 20. Intraventricular Haemorrhage QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
    21. 21. Brainstem Haemorrhage QuickTime™ and a QuickTime™ and aTIFF (Uncompressed) decompressor TIFF (Uncompressed) decompressor are needed to see this picture. are needed to see this picture.
    22. 22. Subarachnoid Hemorrhage QuickTime™ and a QuickTime™ and a QuickTime™ and aTIFF (Uncompressed) decompressor TIFF (Uncompressed) decompressor TIFF (Uncompressed) decompressor are needed to see this picture. are needed to see this picture. are needed to see this picture. a. Subarachnoid Hemorrhage b. Transtentorial herniation c. Intraventricular hemorrhage e. Diffuse axonal (shearing) injury
    23. 23. Intracranial Haematomas• Epidural – arterial bleeding – quick onset – less common• Subdural – venous bleeding – wide range of onset time – can build on each other without symptoms
    24. 24. Acute Subdural Haematoma QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
    25. 25. Acute Subdural Haematoma w/Midline Shift QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
    26. 26. Chronic Subdural Haematoma * Heterogeneous mass a. Focal convexity of medial margin QuickTime™ and aTIFF (Uncompressed) decompressor b. Dilated Ipsilateral Ventricle are needed to see this picture. c. Midline Shift d. Diffuse Brain Edema e. Scalp Hematoma
    27. 27. Acute Epidural Haematoma QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
    28. 28. ManagementThe specific goals in the acute management ofsevere traumatic brain injury are:1. Protect the airway & oxygenation2. Ventilate to normocapnia3. Correct hypovolaemia & hypotension4. CT Scan when appropriate5. Neurosurgery if indicated6. Intensive Care for further monitoring and management
    29. 29. Significant Head Injuries• Signs of increased intercranial pressure – Visual difficulties – Vomiting – Dyspnea – Decreased pulse
    30. 30. Glascow Coma Scale
    31. 31. Intracranial Pressure (ICP)v.Intracranial (constant) = v.Brain + v.CSF + v.Blood + v.Mass Lesion CPP = MAP - ICP QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. CPP: Cerebral Perfusion Pressure MAP: Mean Arterial Pressure ICP: Intracranial Presure
    32. 32. Indications for ICP MonitoringIndications for ICP monitoring Risk of raised ICPSevere Head Injury (GCS 3-8)* Abnormal CT scan 50-60%* Normal CT Scan Age > 40 or BP < 90 mm Hg 50-60% or abnormal motor posturing* Normal CT scan 13% No risk factorsModerate Head Injury (GCS 9-12)* If anaesthetised/sedated Approx. 10-20% will deteriorate* Abnormal CT scan to severe head injuryMild Head Injury (GCS 13-15)* Few indications for ICP measurement Only around 3% will deteriorate
    33. 33. Key RecommendationsMaintenance of CPP reduces mortality in severe head injury.• ICP monitoring is recommended in most comatose patientswith severe head injury.• ICP should be treated when > 20 mm Hg, but maintenance Hgof CPP is probably more important.
    34. 34. How Brain Injuries treated?
    35. 35. How Brain Injuries treated?
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