Download Traumatic Brain Injury

Project: Ghana Emergency Medicine Collaborative
Document Title: Traumatic Brain Injury
Author(s): Mark Rosner MD, 2012
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Traumatic Brain Injury
Mark Rosner MD
September 15, 2010
3
Goals and Objectives








Demographics of TBI
Pathophysiology of TBI – Primary & Secondary
Injury
Assessment & Treatment of Mild TBI /
Concussion
Second Impact Syndrome and Return to Play
guidelines
Post Concussive Syndrome
TBI & Binocular Vision Dysfunction (VH)
Management of Severe TBI
Management of Post Traumatic Agitation
4
STRAP UP!
Leo Dirac (Flickr) 2007
5
TBI – Demographics
 1.5
million new cases per year in the US
 Could be 15-20% higher due to
underreporting of mild TBI / concussions
 Leading cause of death in US for ages 145
6
TBI – Demographics
Risk factors:
 Sex:
males 2.5:1 females
 Lower socioeconomic status
 Age
– 0-4
– 15-24 (1/2 of all injuries)
– >65
7
TBI – Demographics
 Mortality
= 2%
 ER & Go Home (mild TBI) = 65%
 ER & Admit (mod / severe) = 16%
 Never came to the ER (mild TBI /
concussion) = approximately 17%
8
TBI – Demographics
Leading causes of TBI:
 Falls (older) = 30%
 MVC (young adults) = 45%
 Violence (lower socioeconomic class)= 5%
 Work accidents = 10%
 Recreational accidents = 10%
9
TBI – Demographics
Recreational Accidents – Sports
 Ice Hockey
 Soccer
 Boxing
 Rugby
 Football
– incidence = 10% college
20% high school
PER YEAR!
10
TBI – Demographics
Combat related
 In a 1 year deployment – head injury:
– 10% had change in MS
– 5% had LOC
 due
–
–
–
–
15% TBI rate
to
Blasts / explosions
Falls
MVA
Penetrating wounds
11
TBI – Demographics
Disability
 1-2% US population (3-5 million) has LTD
(neurologic and functional impairment)
due to mod / severe TBI
 What
about mild TBI!! Under-recognized
as cause of disability
 Military has not been considering soldiers
w/ mild TBI for Purple Heart
12
TBI – Classification
Clinical Severity Scores:
GCS:
 Severe < 8
 Moderate = 9-12 (13)
 Mild = 13 (14) - 15
13
TABLE 1
Using Glasgow Coma Scale
scores to evaluate brain
injury severity
Component
Best eye response
Best verbal response
Best motor response
Response
Score
No eye opening
1
Eye opening to pain
2
Eye opening to verbal command
3
Eyes open spontaneously
4
No verbal response
1
Incomprehensible sounds
2
Inappropriate words
3
Confused
4
Oriented
5
No motor response
1
Extension to pain
2
Flexion to pain
3
Withdrawal from pain
4
Localizing pain
5
Obeys commands
6
GCS total score ≥12 is mild injury, 9 to 11 is moderate, and ≤8 is severe (90% of patients with scores ≤8 are in a coma). Coma is defined as not opening eyes, not obeying
commands, and not saying understandable words. Composite scores with eye, verbal, and motor responses (such as E3V3M5) are clinically more useful than totals.
14
Source: Reference 2.
Source Undetermined
Michael Spencer (Flickr) 2009
15
TABLE 1
Using Glasgow Coma Scale
scores to evaluate brain
injury severity
Component
Best eye response
Best verbal response
Best motor response
Response
Score
“Only a Couple” Beers
No eye opening
1
Eye opening to pain
2
Eye opening to verbal command
3
Eyes open spontaneously
4 XXX
No verbal response
1
Incomprehensible sounds
2
Inappropriate words
3
Confused
4 XXX
Oriented
5
No motor response
1
Extension to pain
2
Flexion to pain
3
Withdrawal from pain
4
Localizing pain
5
Obeys commands
6 XXX
14
GCS total score ≥12 is mild injury, 9 to 11 is moderate, and ≤8 is severe (90% of patients with scores ≤8 are in a coma). Coma is defined as not opening eyes, not obeying
commands, and not saying understandable words. Composite scores with eye, verbal, and motor responses (such as E3V3M5) are clinically more useful than totals.
16
Source: Reference 2.
Source Undetermined
Gorivero (Wikimedia Commons) 2007
17
TABLE 1
Using Glasgow Coma Scale
scores to evaluate brain
injury severity
Component
Best eye response
Best verbal response
Best motor response
Response
Score
“Way Too Many” Beers
No eye opening
1
Eye opening to pain
2XXX
Eye opening to verbal command
3
Eyes open spontaneously
4
No verbal response
1
Incomprehensible sounds
2
Inappropriate words
3XXX
Confused
4
Oriented
5
No motor response
1
Extension to pain
2
Flexion to pain
3
Withdrawal from pain
4XXX
Localizing pain
5
Obeys commands
6
9
GCS total score ≥12 is mild injury, 9 to 11 is moderate, and ≤8 is severe (90% of patients with scores ≤8 are in a coma). Coma is defined as not opening eyes, not obeying
commands, and not saying understandable words. Composite scores with eye, verbal, and motor responses (such as E3V3M5) are clinically more useful than totals.
18
Source: Reference 2.
Source Undetermined
TBI – Classification
Neuroimaging Scales
 Marshall
 Rotterdam
Not for ED – predicts risk of ICP
19
Pathophysiology - Primary Injury
 Occurs
at the time of trauma
 Due to transfer of external mechanical
forces to intracranial contents
– Direct impact to skull / brain
– Rapid accel / rapid decel without external
skull impact (whiplash - coup / contra coup)
– Penetrating injury
– Blast wave
20
Pathophysiology - Primary Injury
Damage
 Hematoma / hemorrhage (extra-axial)
 Contusion
 Shearing of white matter = diffuse axonal
injury (DAI)
 Edema / swelling
21
Pathophysiology - Primary Injury
Extra-axial Injuries
 Epidural
hematoma
 Subdural hematoma
 SAH
The deeper the injury, the larger the
amount of energy transferred
22
Pathophysiology - Primary Injury
Epidural Hematomas
 Torn dural vessels (middle meningeal
artery
 Lenticular
 Almost always associated with skull
fracture
 Tend NOT to be associated with brain
damage
23
24
Source Undetermined
Pathophysiology - Primary Injury
Subdural Hematoma
 Bleeding from bridging veins OR from
cortical contusion
 Crescent shaped
 Usually ARE associated with brain injury
25
Source Undetermined
26
Pathophysiology - Primary Injury
 SAH
– disruption of small pial vessels
 Intraventricular
– tearing of subependymal veins
27
Hawaii.edu
Learning Radiology.com
SAH
28
Pathophysiology - Primary Injury
 Most
common injury - Focal cerebral
contusions
 Occur at basal frontal and basal temporal
regions due to striking basal skull surfaces
29
http://mksforum.net/forum/showthread.p
hp?p=204094
http://www.itriagehealth.com/wl/dis
ease/cerebral-contusion-(bruise-ofbrain)
30
Pathophysiology - Primary Injury
Diffuse Axonal Injury
 Due to shearing forces
 Seen better on MRI
 Is present even in concussion / mild TBI
31
Diffuse Axonal Injury

www.learningradiology.com/archives2008/COW%20...
32
Pathophysiology - Secondary Injury
A cascade of molecular injury mechanisms
that are initiated at the time of the TBI &
continue for hours – days
Accelerated release of excitatory
neurotransmitters Ach, glutamate and aspartate,
– generates free radicals - injure cell membranes
 Mitochondrial dysfunction
 Inflammatory responses
 Secondary ischemia from vasospasm, focal
microvascular occlusion, vascular injury

All cause cell death, cerebral edema and ICP
33
Pathophysiology - Secondary Injury
Exacerbating factors
 HTN (systemic and intracranial)
 O2 delivery
 Fever
 Seizures
 glucose
34
TBI Definition
TBI
GCS
LOC
P-T
CT
Amnesia abnl
<20 min
<24 hrs
Moderate 9 - 12
20 min – 7d
24 hrs – 7d
Severe
>7d
>7d
(initial in ED at 30
minutes from the
injury)
Mild
13 - 15
<8
No
Yes
35
Mild TBI
 Mild
TBI is oxymoronic (nothing mild
about it)
 Is
only describing the visible brain injury,
not describing functional impairment
 Can
have severe disability from Mild TBI
36
Concussion - ?Definition?
 Concussion
is less severe than Mild TBI,
but…terms difficult to differentiate ---consider all concussions to be Mild
TBI’s
 Reflects
functional disturbance rather than
major structural injury
37
The American Academy of Neurology
(AAN) definition of Concussion:




Trauma-induced alteration in mental status
Confusion and amnesia - hallmarks of concussion
Occurs w/i 5 minutes of the head trauma
May or may not involve loss of consciousness
This definition recognizes three concussion grades:
 Grade 1: concussion sxs lasts <15 minutes, w/o LOC
 Grade 2: concussion sxs lasts >15 minutes, w/o LOC
 Grade 3: LOC.
38
Concussion & Mild TBI
Signs of Concussion - CONFUSION
– Inability to focus attention
– Vacant stare
– Memory deficits
– Delayed verbal expression
– Disorientation
39
Concussion & Mild TBI
Signs of Concussion – SPEECH,
COORDINATION, EMOTIONAL
– Slurred or incoherent speech
– Gross observable incoordination
– Emotionality out of proportion to
circumstances
– Any period of LOC
40
HOW TO REMEMBER THESE SYMPTOMS?
41
Signs of Concussion – CONFUSION
HOW DO LECTURES MAKE ME FEEL?
•Inability to focus
attention
•Vacant stare (befuddled
facial expression)
Victor M. Campos, Jr. (Flickr) 2009
John Morgan (Flickr) 2009
•Disorientation
Delayed verbal expression
42
•Memory deficits
Signs of Concussion – SPEECH, COORDINATION,
EMOTIONAL
HOW DOES DRINKING MAKE ME FEEL?
•Slurred or incoherent speech
•Gross incoordination
•Emotionality out of proportion
to circumstances
Paukrus (Flickr) 2012
•Any period of LOC (coma, unresponsiveness to
stimuli)
43
Concussion & Mild TBI
Other Symptoms
Occurs within mins to hours:
 Headache, dizziness / vertigo / imbalance
Occurs within mins – days:
 Mood & cognitive disturbances, sensitivity
to light & noise, sleep disturbances
44
Concussion & Mild TBI:
Neurological Sequela
Seizures
 Considered 2/2 TBI if it onsets within 7d
 NOT epilepsy
 Occurs in < 5% of mild / mod TBI
 Increased occurrence with severe TBI
– 25% occur within 1 hr
– 50% occur within 1 day

The risk of epilepsy:
– 6% (s/p TBI)
– 25% (s/p TBI with seizure)

80% of post-traumatic epilepsy onsets w/i 2 yrs
45
Concussion & Mild TBI:
Neurological Sequela
Progression of Symptoms
 Indicates bleeding and / or progressive
edema
 Worsening headache, confusion, lethargy,
focal neurological signs
46
Concussion & Mild TBI
Evaluation and Management:
Cognitive assessment
 Simple orientation questions inadequately
sensitive
 SAC –Standardizes Assessment of
Concussion
 Tool for sideline assessment of athletes –
change in 1 point signifies concussion
47
Figure 1: Standard Assessment
of
Concussion –SAC
Name:__________________________________
__
Team:_________________Examiner:__________
Date of Exam:__________Time:______________
Exam(Circle One): Bline Injury Post-Px/Game
Day1 Day2 Day3 Day5 Day7 Day90
Neurologic Screening:
Loss of Consciousness/ No Yes
Witnessed Unresponsiveness Length:
Post-Traumatic Amnesia? No Yes
Poor recall of events after injury Length:
Retrograde Amnesia? No Yes
Poor recall of events before injury Length:
Introduction: I am going to ask you some questions.
Please listen carefully and give your best effort.
Strength Normal Abnormal
Right Upper Extremity
Left Upper Extremity
Right Lower Extremity
Left Lower Extremity
Orientation:
Sensation- examples:
Finger-to-Nose/ Rhomberg
Coordination- examples:
Tandem walk
Finger-nose-finger
What month is it? 0 1
What’s the date today? 0 1
What’s the day of the week? 0 1
What year is it? 0 1
What time is it right now? (within1 hr)0 1
Award 1 point for each correct answer.
Orientation Total Score
48
Immediate Memory: I am going to test your memory. I will
read you a list of words and when I am done, repeat back as
many words as you can remember, in any order.
List Trial 1 Trial 2 Trial 3
Elbow 0 1 0 1 0 1
Apple 0 1 0 1 0 1
Carpet 0 1 0 1 0 1
Saddle 0 1 0 1 0 1
Bubble 0 1 0 1 0 1
Total
Trials 2&3: I am going to repeat that list again. Repeat back as
many words as you can remember in any order, even if I said the
word before.
Complete all 3 trials regardless of score on trial 1&2. Score 1pt.
for each correct response. Total score equals sum across all 3
trails. Do not inform the subject that delayed recall will be
tested.
Concentration
Digits Backward: I am going to read you a string of numbers
and when I am done, you repeat them back to me backwards, in
reverse order of how I read them to you. For example, if I say 71-9, you would say 9-1-7.
If correct, go to next string length, if incorrect, read trial 2.
Score 1 pt. for each string length. Stop after incorrect on both
trials.
4-9-3 6-2-9 0 1
3-8-1-4 3-2-7-9 0 1
6-2-9-7-1 1-5-2-8-6 0 1
7-1-8-4-6-2 5-3-9-1-4-8 0 1
Months in Reverse Order: Now tell me the months of the year
in reverse order. Start with the last month and go backward. So
you’ll start with December, November…Go ahead.
1 pt. for entire sequence correct.
Dec-Nov-Oct-Sept-Aug-Jul-Jun-May-Apr-Mar-Feb-Jan 0 1
Immediate Memory Total Score
Concentration Total Score
Exertional Maneuvers: If subject is not displaying or reporting
symptoms, conduct the following maneuvers to create
conditions under which symptoms are likely to be elicited and
detected. These measures need not be conducted if a subject
is already displaying or reporting any symptoms. If not
conducted allow 2 minutes to keep time delay constant before
testing Delayed Recall. These methods should be administered
for baseline testing of normal subjects.
5 Jumping Jacks 5 Push-Ups
5 Sit ups 5 Knee Bends
Delayed Recall:
Do you remember that list of words I read a few times earlier?
Tell me as many words from the list as you can remember in any
order. Circle each word correctly recalled. Total score equals
number of words recalled.
Elbow Apple Carpet Saddle Bubble
Delayed Recall Total Score
SAC Scoring Summary: Exertional Maneuvers & Neurologic
Screening are important for examination, but are not
incorporated into SAC Total Score.
Orientation /5
Immediate Memory /15
Concentration /5
Delayed Recall /5
49
SAC Total Score /30
Concussion & Mild TBI
Revised WPTAS (Westmead Post-Traumatic Amnesia Scale)
-1 wrong answer indicates cognitive impairment










What is your name?
What is the name of this place?
Why are you here?
What month are we in?
What year are we in?
What town are you in?
How old are you?
What is your date of birth?
What time of day is it (morning, afternoon, evening?)
Three pictures are presented for subsequent recall
Cathy Calamas 2011 (Flickr)
Plaisanter 2010 (Flickr)
50
Sassy Bella Melange 2008 (Flickr)
Neuroimaging
 CT
is the preferred modality for acute
evaluation of TBI
 GCS of 15 = 5% abnormal scans
 GCS of 13 = 30% abnormal scans
 Only 1% of abnormal scan need to
go to the OR
 MRI – sees more (contusions, DAI, small
bleeds), but doesn’t change clinical
management
51
Neuroimaging
Canadian CT Head Rule for mild TBI
 GCS < 15 two hours after injury
 Suspected open or depressed skull fracture
 Any sign of basilar skull fracture
(hemotympanum, raccoons, Battles, CSF leak)
 >2 episodes of vomiting
 >65 years old
 Amnesia before impact > 30 minutes
 Dangerous mechanism (pedestrian / MVA,
ejected, fall from > 3 feet or > 5 stairs)
 Neuro deficit, seizure, coagulopathy
52
Acute evaluation and
disposition of patients with
mild TBI
Data from: Vos, PE. Eur J Neurol 2002; 9:207 and
Borg, J. J Rehabil Med 2004; S43:61.
Normal exam and normal HCT
(and no CI’s) = home
observation
Source Undetermined
53
Source Undetermined
Increase the number of CT’s
54
Source Undetermined
Increase
the number
of
admissions
55
If the HCT and Neuro Exam are
Normal, then why Observe?
• None of 542 “mild” TBI’s admitted to the
hospital overnight deteriorated
• GCS = 15, normal Neuro exam and normal
HCT and no coagulopathy DO NOT
deteriorate
• - so, why home observation?
just in case?
CYA?
56
Home Observation of Mild TBI
Return to ER if:
• Awakened q2 hr for 24
hours
• Avoid strenuous activity
for 24 hours
Won’t wake
up
Worsening
headaches
New
somnolence or
confusion
Restless,
unsteady
Vision
difficulties
Vomiting
Fever, stiff neck
Incontinence
bowel or
bladder
Seizure
57
Second Impact Syndrome
 Diffuse
2nd
cerebral edema occuring after a
concussion while the patient is still
symptomatic from the 1st concussion
 Rare
 Controversial
 Doesn’t
occur frequently in boxers
(shouldn’t it?)
 But just in case it’s real….RTP
58
Second Impact Syndrome - RTP
None are evidenced based / prospectively
validated
 Cantu,
 Grade
Colorado, AAN
1
 Concussion
Grade 2
Grade 3
symptoms, amnesia, LOC
59
Cantu Guideline for Concussion
Management
Presentation
Grade 1
Grade 2
Grade 3
1. No loss of
consciousness
2. Post-traumatic
amnesia or other
signs lasting
less than 30
minutes
1. Loss of
consciousness for
less than 1 minute
OR
2. Post-traumatic
amnesia or other
symptoms for
more than 30
minutes, less than
24 hours
1. Loss of consciousness
for longer than 1 minute
OR
2. Post-traumatic amnesia
or other symptoms for
longer than 24 hours
Athlete may return
to play in 2 weeks
if asymptomatic at
rest and on
exertion for 7 days
Athlete may return to play
in one month if
asymptomatic at rest and
on exertion for 7 days
Management Athlete may
return to play if
asymptomatic
for one week
Adapted from: Cantu, RC, J Athl Train 2001; 36:244
60
Colorado Guideline for Concussion
Management
Grade 1
Presentation 1. Confusion
without amnesia
2. No loss of
consciousness
Management Evaluate athlete
immediately and
every 5 minutes.
Athlete may
return to play if
amnesia or
symptoms do
not appear for
20 minutes.
Grade 2
Grade 3
1. Confusion with
amnesia
2. No loss of
consciousness
1. Loss of consciousness
of any duration
Examine the athlete
the next day. Athlete
may return to play
after one week if
asymptomatic during
that time.
Transport athlete to the
emergency department;
athlete may return to play
if asymptomatic for
2 weeks and cleared by
neurologist or
neurosurgeon.
Colorado Medical Society, Report of the Sports Medicine Committee, 1991.
61
American Academy of Neurology - RTP
Grade 1
Grade 2
Grade 3
Presentation
1. Transient
confusion
2. No loss of
consciousness
3. Concussion
symptoms for
less than 15
minutes
1. Transient
confusion
2. No loss of
consciousness
3. Concussion
symptoms for
more than 15
minutes
1.
Management
Athlete may return
to play if
asymptomatic at
15 minutes.
Athlete can
return to play if
asymptomatic
for one week.
American Academy of Neurology, Neurology 1997; 48:581
Loss of
consciousness of any
duration
Transport to the hospital
and observe overnight.
Athlete may return to
play when symptomatic
for one week (if loss of
consciousness was
brief, i.e., seconds) or
for two weeks (if loss of
consciousness was
prolonged).
62
Second Impact Syndrome - RTP
None are evidenced based / prospectively validate
Grade 1
15 minute
Grade 2

AAN –

Cantu –

Colorado – 20 minute 1 week
1 week
1 week
Grade 3
1-2 weeks
2 weeks 4 weeks
2 weeks
.
63
Second Impact Syndrome - RTP
None are evidenced based / prospectively validate
Grade 1
Grade 2
1 week

AAN –
15 min

Cantu –
1 week

Colorado – 20 minute 1 week
Grade 3
1-2 weeks
2 weeks 4 weeks
2 weeks
Bottom Line:
No RTP while symptomatic
Go to ER if:
LOC > 1 minute OR concussion symptoms > 15-30 mins
64
UpToDate
65
Post Concussive Syndrome
Symptoms
 Headache
 Dizziness / vertigo
 Fatigue
 Noise sensitivity, light sensitivity
 Cognitive impairment (decreased ability to remember, to
process info, to concentrate)
 Neurobehavioral & Neuropsychiatric symptoms (change
in personality, behavior, irritability, anxiety, depression,
insomnia)


Most commonly d/t Mild TBI. Less common with
whiplash, Mod / Severe TBI
LOC not needed for diagnosis
66
Post Concussive Syndrome
CONTROVERSIAL
 Symptoms are vague, subjective, common
with many other conditions, difficult to
measure / test
 Doesn’t correlate to severity of TBI, GCS,
length of LOC, length of amnesia, CT /
MRI abnormalities
 Underlying pathophysiology is unknown
67
Post Concussive Syndrome
30-80% of mild – mod TBI will have some
symptoms of PCS
 Many are better at 1 month, most are better at
3 months
 10-15% are still symptomatic at 1 year –
headache, dizziness, anxiety, cognitive

– The Miserable Minority

Physiologic / functional neuroimaging has same
changes as does migraine, depression
68
Post Concussive Syndrome
Psychogenic?
 symptoms similar to anxiety / PTSD,
depression – headache, dizziness, sleep
impairment
 Cognitive impairments are seen in anxiety
/ depression
 PTSD is the strongly associated with PCS
69
Post Concussive Syndrome

Bottom line: association of psych disease w/ PCS
is not established
– Maybe psych patients more likely to get TBI?
– Maybe psych patients more likely to get PCS after
TBI?
– Maybe TBI is causing the psych symptoms? (TBI can
cause VH, which can cause psych)

Be very careful about diagnosing malingering

Litigation?
– Many who sue aren’t severe
– Many that are severe don’t sue
 No correlation
70
Post Concussive Syndrome
Treatment of symptoms
 No magic bullet that addresses all
symptoms (maybe VH?)
 Treat Headache, dizziness, psych per SOP
– no special tx d/t TBI etiol
 Each patient has their own unique
symptom set
– “When you know 1 TBI, you know 1 TBI”
– “Snowflakes”
71
TBI and Vertical Heterophoria
What is VH?
 Phoria – the position an eye points (line of
sight) when it is not attempting to fuse an
image / fusion is disrupted with a red lens
– eg – exo phoria, eso phoria
 Vertical
Hetero
Phoria:
– Line of sight of one eye is higher than the
other eye when not attempting to fuse an
image
72
Source Undetermined
73
TBI and Vertical Heterophoria

As compared to Heterotropia (strabismus), patients with
Heterophoria are still able to maintain a single image but
at great expense

Brain avoids diplopia at all costs - overexert EOM’s –
elevators and depressors

Overuse and fatigue of EOM’s causes symptoms:
– dizziness, dizziness, anxiety, neck pain, reading difficulties

Postconcussive symptoms and VH symptoms
overlapdizziness, headache, anxiety, neck pain, reading
difficulty [cognitive, change in personality, behavior,
irritability, depression, insomnia]
74
TBI and Vertical Heterophoria

As compared to Heterotropia (strabismus), patients with
Heterophoria are still able to maintain a single image but
at great expense

Brain avoids diplopia at all costs - overexert EOM’s –
elevators and depressors

Overuse and fatigue of EOM’s causes symptoms:
– dizziness, dizziness, anxiety, neck pain, reading difficulties

Postconcussive symptoms and VH symptoms overlap
– dizziness, headache, anxiety, neck pain, reading difficulties
– [cognitive, change in personality, behavior, irritability,
depression, insomnia]
75
TBI and Vertical Heterophoria

Retrospective study
PM R 2010;2:244-253
Identification of Binocular Vision Dysfunction (Vertical Heterophoria)
in Traumatic Brain Injury Patients and Effects of Individualized
Prismatic Spectacle Lenses in the Treatment of Postconcussive
Symptoms: A Retrospective Analysis
Jennifer E. Doble, MD, Debby L. Feinberg, OD, Mark S. Rosner, MD, Arthur J.
Rosner, MD




43 TBI patients
Symptomatic for 3.5 yrs; fully evaluated and treated prior to intervention
Diagnosed w/ VH and treated w/ prismatic lenses
72% subjective improvement in 3.5 months
Conclusion:
 TBI seems to be precipitating / exacerbating VH
 Treatment w/ prismatic lenses improves both VH and PCS
symptoms
76
TBI and VH
Good news Only treatment so far that addresses so
many symptoms
However Only partially addresses cognitive and
neuropsych issues
77
Chronic TBI 
Cumulative neuropsychological impairment
– Cognitive impairment / dementia
Football, soccer
 Dementia pugilistica – boxing

– 20% of prof boxers w/ >20 fights

Helmets – good or bad?
– Decreases TBI in baseball, ice hockey, downhill
skiing, snowboarding, bicycles, motorcycles
– Encourages risky behavior
78
Management of Severe TBI
GCS < 8
Care should be obtained at the most appropriate
facility – Level 1 trauma center
 Secondary brain injury caused by:


– Hypoxemia - keep oxygenated – intubate early
– Hypotension – fluid resuscitate
– Seizures – consider prophylactic antiepileptics
Shock is almost never due to head injury alone –
look for other sources (spinal cord, internal
bleeding)
 Don’t withhold fluids d/t concerns of
exacerbating cerebral edema

79
Management of Severe TBI
ICP monitoring indicated for GCS < 8
These patients are at high risk for intracranial
hypertension (IC HTN), which requires
aggressive tx
 Open fontanels – can still get ICP
 For GCS > 8 if exam can’t be followed (sedation,
paralysis)
 IC HTN predicted by 2/3:


– Systolic HTN
– motor posturing
– age > 40
80
Management of Severe TBI
 Tx
IC HTN when ICP > 20
 Rate of complications from ICP monitors is
low
 cerebral perfusion pressure (CPP) = MAP ICP
 Maintain CPP >70
81
Treatment of IC HTN
 1.
Analgesia and sedation are initial
treatments
 2. If euvolemic, elevate HOB 30 degrees
 3. Paralysis
 4. Can drain CSF to lower ICP through
ventriculostomy catheter (preferred) or via
LP
82
Treatment of IC HTN
5. Osmotic Agents
 Mannitol can be used to decrease ICP –
osmolar agents / dehydrate the brain.
Requires intact BBB – may accumulate in
injured areas of brain – best to use as
boluses
 Mannitol also decreases blood viscosity for
approximately 75 minutes
 3% saline – continuous infusion
83
Treatment of IC HTN
6. Hyperventilation to decrease ICP
 Keep PaCO2 between 30-35
 PaCO2 < 30 second tier option – can
cause decreased CBF 2 / 2
vasoconstriction, causing iatrogenic
ischemia
 Aggressive hyperventilation if herniation or
rapid decline of neuro status
84
Treatment of IC HTN
7. High dose Barbiturates
 Reduces ICP and has neuroprotective
properties – decreases cerebral
metabolism / need for O2 by 50%
 Causes myocardial depression and
hypotension – may need fluids, inotropes
8. Consider therapeutic hypothermia for
refractory IC HTN
85
Treatment of IC HTN
9. Decompressive craniotomy – consider if:
 < 48 hours from injury
 No episode of ICP > 40
 GCS > 3
 Secondary clinical deterioration
 Evolving herniation
86
Source Undetermined
87
Pediatr Crit Care Med 2003 VOL. 4, No. 3 (Suppl.)
88
Source Undetermined
89
Post Traumatic Agitation
Witholeary 2009 (Flickr)
90
Post Traumatic Agitation

Haldol - reports of affecting cognitive function; NMS w/
high parenteral doses; longer periods of post traumatic
amnesia
– Also reports of multiple doses w/o problems

olanzapine (Zyprexa), ziprasidone (Geodon) considered
safer
Acute management of agitation in ED (my choices):
 Benzodiazepines
 Narcs
 Haldol
 Don’t have experience yet w/ olanzapine & ziprasidone
91
TABLE 3
Medications with potential to
impede TBI recovery*
Medications
Class
Alpha-2 agonist
Clonidine
Antidepressant
Trazodone
Antiepileptic
Phenytoin, phenobarbital
Benzodiazepine – impairs memory – not
for long term use
Diazepam
Neuroleptic – causes decline in cognitive
performance; NMS; amnesia
Haloperidol, thioridazine
*Suggested by animal or clinical studies
Source: References 11-20
92
Drugs considered safe
and effective for TBI
neurobehavioral sxs
Apathy
Drug
Usual daily dosage*
Amantadine
100 to 400 mg
Bromocriptine
1.25 to 100 mg
Cognition
Donepezil
Inattention
Dextroamphetamine
5 to 60 mg
Methylphenidate
10 to 60 mg
Depression, PTSD symptoms
Fluoxetine
20 to 80 mg
Agitation, mood
stabilization
Anticonvulsants
Lamotrigine
25 to 200 mg
Divalproex sodium
10 to 15 mg/kg/day†
Carbamazepine
400 to 1,600 mg‡
Atypical antipsychotics
Olanzapine (Zyprexa)
2.5 to 20 mg 2.5-10 mg IM
Quetiapine
50 to 800 mg
Risperidone
0.5 to 6 mg
Ziprasidone (Geodon)
20 to 160 mg 10-20 mg IM
Beta blocker
Propranolol
20 to 480 mg
PTSD: posttraumatic stress disorder
* Dosage may be divided; see full prescribing information.
† Adjust dosage to achieve serum level of 50 to 100 mcg/mL.
‡ Adjust dosage to achieve serum level of 4 to 12 mcg/mL.
93
Goals and Objectives








Demographics of TBI
Pathophysiology of TBI – Primary & Secondary
Injury
Assessment & Treatment of Mild TBI /
Concussion
Second Impact Syndrome and Return to Play
guidelines
Post Concussive Syndrome
TBI & Vertical Heterophoria
Management of Severe TBI
Management of Post Traumatic Agitation
94
Martin Lopatka 2008 (Flickr)
95
Bibliography








Phan N, Hemphill, JC. Traumatic brain injury: Epidemiology, classification,
and pathophysiology. UpToDate January 2010
Evans R. Concussion and mild traumatic brain injury. UpToDate. January
2010
Evans R. Postconcussion Syndrome. UpToDate. January 2010
Carney N, Chestnut R, Kochanek P. Guidelines for acute medical
management of severe traumatic brain injury in infants, children and
adolescents. Pediatr Crit Care Medication 2003. 4(3): Supplement S1-S71.
Bellamy CJ, Kane-Gill SL, Falcione BA, Seybert AL. Neuroleptic malignant
syndrome in traumatic brain injury patients treated with haloperidol. J
Trauma. 2009 Mar;66(3):954-8.
Doble JE, Feinberg DL, Rosner MS, Rosner AJ. Identification of binocular
vision dysfunction (vertical heterophoria) in traumatic brain injury patients
and effects of individualized prismatic spectacle lenses in the treatment of
postconcussive symptoms: a retrospective analysis. PM R 2010
April.2(4):244-253
Rosati DL. Early polypharmocological intervention in brain injury agitation.
Am J Phys Medication Rehabil 2002 Feb. 81(2):90-3
Daniels JP. Traumatic brain injury: choosing drugs to assist recovery. J Fam
Prac. 2006 May;5(5)
96
Questions
97