2. Case study #1
A 75 year old female patient status post ground level fall is
brought into an Emergency Medical Services. She has a
known history of DM, chronic kidney disease, HTN,
hypothyroidism and congestive heart failure.
Upon initial exam you find that the patient has a small
laceration over her right eye, but no obvious signs of skull
fracture or penetrating injuries.
When you assess the patient you find that she has a
Glasgow Coma Scale (GCS) of 13 (E3, V4, M6) with no
focal neurological deficits.
The patient has a 3mm laceration over her right eye.
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3. Brain trauma or TBI results from a blow, bump, jolt, or
penetrating injury to the head that disrupts the normal
function of the brain
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6. 5/31/2023 TBI
The brain’s cerebral cortex is
the outermost layer that
gives the brain its
characteristic wrinkly
appearance.
The cerebral cortex is divided
into two cerebral
hemispheres connected by
the corpus callosum. Each
of the hemispheres has
divided into four lobes:
frontal,
parietal,
temporal and
occipital.
8. Types of TBI
There are two broad types of head injuries:
Penetrating TBI (also known as open TBI) happens
when an object pierces the skull (e.g., a bullet, shrapnel,
bone fragment, or by a weapon such as hammer or knife)
and enters the brain tissue.
Penetrating TBI typically damages only part of the brain.
Non-penetrating TBI (also known as closed head
injury or blunt TBI) is caused by an external force strong
enough to move the brain within the skull.
Causes include falls, motor vehicle crashes, sports
injuries, blast injury, or being struck by an object.
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9. • Some accidents such as explosions, natural
disasters, or other extreme events can cause
both penetrating and non- penetrating TBI
in the same person.
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11. Epidemiology
TBI has been one of the leading causes of morbidity, disability and
mortality across all ages
Globally, more than 50 million individuals suffer from TBIs
annually (https://intbir.nih.gov)
The global incidence rate of TBIs is estimated at 200/100,000
people per year. (www.internationalbrain.org)
• Certain groups of individuals are at risk for TBI
– Individuals partaking in high risk behavior(s)
• Alcohol use, drug use, team sports, not using seat belts
– Men > women
– Very young (<10 years) and very old (>65 years)
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12. The leading causes of TBI are
MVA/RTA
falls, and
assaults
Most severe TBIs result from
motor vehicle collisions and
falls.
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13. Mechanism of Injury
Blunt
• Motor vehicle crash
• Falls
• Intentional assaults
• Recreational and sport injuries
Penetrating
• Firearm use
• Knife injuries/stabbings
Blast
• Explosives
blunt (most common)
penetrating (most fatal)
blast.
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14. Check Point - Test your Understanding
• Based on this presentation the information
presented on the patient and traumatic brain
injuries….
• What type of mechanism of injury does she
have?
A. Blunt
B. Penetrating
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15. Classification of traumatic brain injury
Based on the Glasgow Coma Scale (GCS) score, it is
classified as (GCS within 24 hours of injury)
Mild Brain Injury
– GCS: 13 – 15 also called concussion
Moderate Brain Injury
– GCS: 9 – 12
Severe Brain Injury
– GCS: 3 - 8
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16. Check Point - Test your Understanding
She has a Glasgow Coma Scale (GCS) of 13 (E3, V4,
M6) with no focal neurological deficits. Which
classification of brain injury does she have?
A. Mild
B. Moderate
C. Severe
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22. Primary Brain Injury
Scalp Wound/extracranial hematoma
Highly vascular
Bleeds briskly
Assess for skull fracture
Assess for shock (due to blood loss)
Apply direct pressure
Suture or staple wound
Appropriate dressing
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23. Skull injury
Different types of skull fractures include:
Linear
– Singular fracture line of the skull
Comminuted
– Splintering or shattering of the skull into pieces
Depressed
– Depressed fragment of the skull
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24. Primary Brain Injury: Focal Brain Injury
CONTUSION
Bruising of brain tissue
Most common area of injury is frontal or temporal
lobe
Injury at site of impact is called “Coup” injury
Injury at the opposite site of impact is called
“Countercoup” injury
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25. Epidural hematoma
Most frequently a tear of the middle meningeal artery tear
due to temporal skull fracture but may also be frontal or
occipital
Arterial bleeding between skull and dura
Present with unconscious – conscious – unconscious –
“talk and die syndrome”
Has a fluctuating consciousness levels
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26. Subdural hematoma
Is a venous bleed (superior sagittal sinus, bridging
veins)
Bleeding is between the dura and arachnoid
― Acute subdural hematoma
Symptoms occurs < 48 hours post injury
– Subacute subdural hematoma
Symptoms occur up to 2 weeks post injury
– Chronic subdural hematoma
Symptoms occur after 2 weeks post injury
Occurs in elderly and alcoholics
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27. Traumatic Hemorrhage
Intracerebral/intracranial/ in brain parenchyma
– Traumatic bleeding into the cerebral tissue
Intraventricular
– Traumatic bleeding into the ventricles
Subarachnoid
– Traumatic bleeding into the subarachnoid space
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28. Penetrating Injury
Most lethal brain injury
High mortality rate
Due to
– Use of a handgun, rifle, and/or shotgun
– Objects such as knives, scissors, or nails
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29. Presenting Neuro Status
– Awake = likely to survive
– Comatose = death more likely
Path of Bullet
– Single hemisphere = likely to survive
– Bilateral hemispheres = death more likely
Caliber & Velocity of Bullet
– Small & slow = likely to survive
– Large & fast = death more likely
Predictors of Penetrating Head Injury
Outcomes
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30. Cont.…….
Time to Treatment
– Quick arrival to Emergency Department = survive
– Delay in arrival to Emergency Department = death
Nature of Shooting
– Assault = survive
– Suicide = death
Age
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31. Which of the following patients is most likely to survive a
penetrating head injury?
1. An 85 year old female was at the park walking her dog and was
stabbed several times in multiple areas of her head. She was
found four hours later lethargic with unequal pupils and minimal
movement.
2. A 26 year old male suffered a self inflicted gunshot wound to the
face last night and was found by his family this morning
breathing, but not opening his eyes despite aggressive attempts to
awaken him.
3. A 42 year old man about 1 hour ago, had a witnessed ground level
fall landing on a steel rake that penetrated the left side of his head.
He is awake and following commands.
Check Point - Test your Understanding
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32. Primary Brain Injury: Diffuse Brain Injury
Mild Head Injury - Concussion
Violent shaking of the brain
Shearing stress on reticular formation
Shaking disrupts brain’s normal chemical balance
No focal neurologic deficits or CT findings
Assess for Post Concussion Symptoms
– Symptoms include the following
Confusion, forgets things, loses temper, impulsive,
difficulty with new learning, problems at work/school,
personality change
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33. Mechanism of injury is an angular acceleration and
deceleration
Causes stress at gray-white mater interface
MRI is preferred diagnostic test, it can play a role in
predicting length of coma
CT scan results show no intracranial lesion
Provide supportive care
Recovery depends on amount of axonal injury
– Grade 1 – brief loss of consciousness, recovery possible
– Grade 2 – coma of duration, unclear recovery process
– Grade 3 – immediate coma, posturing, incomplete recovery
Diffuse Axonal Injury
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34. Secondary Brain Injury
Hypoxia/ischemia
Any degree of respiratory failure is particularly
hazardous for the TBI patient.
Loss of consciousness following a TBI may be
accompanied by decreased respirations and can lead to
severe hypoxia.
Any hypoxia will aggravate cerebral ischemia and
increases cerebral blood flow and cerebral blood
volume, thus increasing intracranial pressure.
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35. Hypotension
The level of systolic blood pressure (SBP) plays
a critical role in secondary brain injury.
Hypotension has been shown to correlate with
diffuse brain swelling.
If autoregulation is not intact, there is
dependency on SBP to prevent cerebral ischemia,
which has been attributed to be the single most
important secondary insult.
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36. Cerebral edema
Caused by aquaporin dysfunction
– Aquaporin are proteins that create water channels
– Transports water in and out of cells
Cerebral edema can have multiple peaks
– First is at 1-2 days
– Lasts 5-6 days
– May have a late peak
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Clear fluids draining from the
nose or ears
Nausea and vomiting
New neurologic deficit, such as
slurred speech; weakness of
arms, legs, or face; loss of balance
Problems remembering, concentrating,
or making decisions
Changes in sleep patterns (e.g., sleeping
more, difficulty falling or staying asleep);
inability to waken from sleep
Frustration, irritability
Headache, dizziness, confusion, and fatigue tend to start
immediately after an injury but resolve over time.
Emotional symptoms such as frustration and irritability tend to
develop during recovery
