Traumatic Brain Injury Final 2013.5.29

Continuing Medical Education Trauma
The Gordon Center for Research in Medical Education
Head Traumatic Brain Injury
Division of Prehospital and Emergency Healthcare

Learning Objectives
Explain the pathophysiology of CNS trauma
Identify the different types of brain injuries
Describe the assessment and management

of patients with traumatic brain injuries
Determine the Glasgow Coma Scale when

presented with several trauma case studies.

Head & Brain Trauma
Worldwide, approximately:
200 to 300 cases of TBI per 100,000 population
25 cases of severe TBI per 100,000 population
In the United States, approximately:
4 million head injuries per year

1.4 million treated in hospitals
300,000 admitted per year
Approximately 90,000 have residual neurological
deficit.

Pathophysiology of CNS Injury
Primary injury
Damage that occurs at the moment of impact
Secondary injury
Damage that occurs subsequent to the initial
impact
Systemic causes
Intrinsic causes

Primary Brain Injury
Diffuse brain injury

Concussion
Diffuse axonal injury
Focal brain injury

Contusion
Intracranial hemorrhage
Epidural or extradural
Subdural
Subarachnoid
Intracerebral

Diffuse Brain Injury
Normal CT
Diffuse Injury
Range from mild concussion to severe ischemic insult

Classification of TBI by
Morphology
From Saatman et al., J Neurotrauma, July

2008, 25(7): 719-738.

Secondary Brain Injury

Can occur from minutes to days following
initial injury
Hypotension
SBP < 90 mm Hg (Adults), Children: agedependent

ICP, MAP, CPP
Hypoxia
SpO2 < 90%

Pathophysiology of CNS Injury

Secondary Injury
Systemic causes
Hypoxia
Hypotension
Increased or decreased
CO2
Anemia (blood loss)
Increased or decreased
blood glucose
Intrinsic causes
Seizures
Edema
Hematomas
Increased intracranial
pressure (ICP)

Blood Pressure and TBI
Intracranial Pressure (ICP)

must be lower than
systemic BP)
CPP = MAP ICP
Mean arterial pressure =
(2x diastolic + systolic)/3
As ICP rises, CPP will

decrease if BP does not
rise

Hypoxia
SpO2 < 90% have significant negative

outcomes
Continuous monitoring
Correct difficulty breathing early
Keep intubation times short to hypoxic

time

Assessment
Accurate blood pressure readings

Use the most accurate method available
Repetitive neurologic exams

GCS is designed to allow providers to repeat
the exam through continuum of care
Pupillary responses
Continuous SpO2 & EtCO2 measurements
Frequent reassessments
**Change in LOC is the earliest and best indicator of patients ICP


Pupil Response
Assess eyes for trauma
to the eye orbits
Oculomotor nerve
provides function to
pupils
Assess pupils after
resuscitation and
stabilization
Both eyes must be
assessed and compared

Pupil Assessment
Pupil asymmetry
is > 1 mm
< 1 mm is a
normal finding
Unilateral or
bilateral dilated
pupils
Fixed and dilated
pupils
< 1 mm response
to bright light

Intracranial Pressure
An increase in the volume of any of these

three contents may cause increased ICP:
Swelling of brain tissue
Bleeding
CSF accumulation

Intracranial Pressure
As ICP increases, everything in the skull is

compressed
Blood vessels
CSF
Brain
You can displace a small amount of blood.

You can displace a small amount of CSF.
But

Increasing ICP
Early signs
Vomiting (with or
without nausea)
Headache
Dizziness
Amnesia
Visual disturbances
Altered LOC
Seizures
Late signs
Cushings Triad
Hypertension (with
widening pulse
pressure)
Bradycardia
Irregular respirations
Pupil changes
Coma
Posturing

The Brain Death Cycle
In the case of EDH or SDH, we can also add

the effect of the expanding hematoma.
Copyright 2012 by Mosby, Inc., an affiliateDivision
of Elsevier
18
ofInc.
Prehospital and Emergency
Healthcare

Clinical Effects of ICP
19
Division of Prehospital and Emergency
Healthcare

Respiratory Patterns
Altered respiratory
patterns
Cheyne-Stokes
Central neurogenic
hyperventilation
Biots

Management of Oxygenation
Oxygen to maintain normoxia (>94% SaO2)
Begin ventilations at signs of ineffective

breathing
10 to 12/min for adults
15 to 20/min for infants and children
Intubation or airways may increase ICP

Management of Fluids
Assess patient for bleeding
TBI patients are often hypertensive

Restrict fluids to prevent edema
Hypotension must be treated with fluid
Blood pressure should be kept above

90 mm Hg systolic
Crystalloid fluids for bolus

Volume-Pressure Curve

Cerebral Herniation
Signs of herniation
Dilated and unreactive pupils

Asymmetric pupils
Extensor posturing
Drop in GCS of 2 or more with initial GCS < 9

Management of Cerebral
Herniation
In patients who are already well ventilated,

hyperventilation may be indicated
Adults 20 breaths/min
Child 25 breaths/min
Infant (< 1 year) 30 breaths/min
Temporizing until signs of herniation resolve
Goal: Ventilate to ETCO2 of 30 to 35 mm Hg


Mechanics of Hyperventilation
CO2 is a vasodilator
CO2 makes blood vessels in the head

expand, taking up more space
CO2 makes them constrict, thereby taking

up less space
Caveat: when vessels are small, they have a

harder time carrying oxygenated blood

Pharmacologic Therapy
Diuretics
Mannitol may take 15 to 30 min
Furosemide may not reduce fluid in brain
Seizures
Benzodiazepines
Antiepileptic medications
Steroids should not be used

Transport
Minimize on-scene time
Supine position (unless patient is at risk for

aspiration- then elevate HOB 30)
Appropriate receiving facility
Frequent reassessment

The Bottom Line
Most of the bad TBI stuff presents about the

same way:
Headache
Vomiting
Altered mentation
Neurological deficits

Optimal Management
Priorities:
ABCDE
Minimize secondary brain injury
Administer oxygen
Maintain adequate ventilation
Maintain blood pressure (systolic > 90 mm Hg)

Summary
Primary survey: identify and treat lifethreatening conditions first.
Shock is a late finding in patients with

traumatic brain injury; consider the
possibility of internal hemorrhage.

Summary
The primary goal of treatment for patients

with suspected TBI is to prevent secondary
brain injury.
The most important sign of traumatic brain

injury is a change in mental status.
Key aspect is to determine whether baseline

assessment findings are changing and in
which direction (better or worse).
Frequent Reassessments

Summary
Treatment keysminimize secondary injury

of the brain.
Correct or prevent hypoxemia (Goal SpO2 >
94%).
Correct or prevent hypotension (Goal: SBP >
90mmHg).
Avoid hyperventilation.
Transport to an appropriate facility.

Practice Session:
Glasgow Coma Scale

Glasgow Coma Scale
Developed to assess level of consciousness after

trauma
Scored from 3-15 (no 0)
Initially developed in 1974 - University of Glasgow
Assesses a patients best
Eye Response, Verbal Response, & Motor Response
35
Brain Injury based on severity:

Severe: GCS 3-8
Moderate: GCS 9-12 (controversial)
Minor: GCS 13
Incorporated into several ICU scoring systems
(APACHE, SAPS, SOFA)

Glasgow Coma Scale:

Eye Opening
GCS for Adults
Eye opening
Score
35
Response
Opens eyes spontaneously
Verbal: Opens eyes in response to verbal stimuli
Pain: Opens eyes in response to painful stimuli
None: Patient does not open eyes

Glasgow Coma Scale :

Verbal Response
Best Verbal Response
Score
35
Response
Oriented: To person, place, and time, converses

normally
Disoriented: Patient is conversant but confused
Nonsensical Conversation: Inappropriate use of words
Patient makes incomprehensible sounds (e.g. moans)
No response: Patient does not respond verbally

* If the pt. is intubated or has a tracheostomy a
T should be added to the comments

Glasgow Coma Scale Score:

Motor Response
Best Motor Response
Score
6
Follows commands: Obeys simple commands
Localizes pain: Purposeful movement toward painful stimuli
Withdraws from pain: Patient withdraws from pain
Decorticate: Patient flexes arms inward towards the chest
Decerebrate extension: Patient extends arms outward from

the body
No response: Patient does not move
35
Response
*If the pt. is sedated or chemically paralyzed a P

or S should be added to the comments

CASE 1
57 y/o M fall from bicycle. On exam, eyes are

open, he is holding the Rt. side of his head, and
answering questions inappropriately.
Obvious laceration from his Rt. eyebrow to his

ear
GCS
Eye Opening
1-4
Verbal Response 1-5
Motor Response 1-6

What is the patients GCS?

A.
B.
C.
D.
E.
GCS
GCS
GCS
GCS
GCS
14
12
10
9
5
GCS
Eyes are open
=4
Response inappropriate =3
Localizes pain
=5
GCS = 12

CASE 2
24 y/o F found on the ground after being struck by a

car. Her eyes are closed, and she is moaning
incomprehensible sounds. She does not open her
eyes to verbal or painful stimuli.
Arms are down and hands are extended outward

with increased tone.
GCS
Eye Opening
1-4
Verbal Response 1-5
Motor Response 1-6


A.
B.
C.
D.
E.
GCS
GCS
GCS
GCS
GCS
12
10
9
7
5
GCS
Eyes no response
=1
Incomprehensible sounds =2
Extensor posturing
=2
GCS = 5

CASE 3
37 y/o M driver of vehicle involved in a

roadside IED explosion. Vehicle turned on to
side with extensive damage.
Patient opens eyes to painful stimuli, pulls

hands away as you pinch his fingernails, and
moans without making coherent words.
GCS
Eyes Opening
1-4
Verbal Response 1-5
Motor Response 1-6


A.
B.
C.
D.
E.
GCS
GCS
GCS
GCS
GCS
8
5
4
3
0
GCS
Eyes open to pain
Response incoherent
Withdraws from pain
=2
=2
=4
GCS = 8

CASE 4
19 y/o M is unconscious with eyes closed

following an assault. Patient has multiple gun
shot wounds to upper torso area.
Patient does not respond or open eyes to any

verbal or painful stimuli and there is no
movement from the patient.
GCS
Eyes Opening
1-4
Verbal Response 1-5
Motor Response 1-6


A.
B.
C.
D.
E.
GCS
GCS
GCS
GCS
GCS
8
5
4
3
1
GCS
Eyes none
Response none
No movement
=1
=1
=1
GCS = 3

CASE 5
39 y/o M lying on the ground following a fall

from height of 10 feet.
Patient is lying on ground with eyes open, he is

disoriented, and brings his hands to his chest
when palpated.
GCS
Eye Opening
Verbal Response
Motor Response
1-4
1-5
1-6


A.
B.
C.
D.
E.
GCS
GCS
GCS
GCS
GCS
15
14
13
9
7
GCS
Eyes are open

Response disoriented
Localizes pain
=4
=4
=5
GCS =13

CASE 6
33 y/o F lying on the ground following an

ejection from a motor vehicle 30 feet away.
Paramedic is attending to the patient who is

conscious with eyes open, disoriented, strong
smell of ETOH, holding obvious deformity to Rt.
femur.
GCS
Eye Opening
1-4
Verbal Response 1-5
Motor Response 1-6


A.
B.
C.
D.
E.
GCS
GCS
GCS
GCS
GCS
14
13
10
8
5
GCS
Eyes are open
Disoriented
Localizes pain
=4
=4
=5
GCS =13

Pediatric Glasgow Coma Scale

(3-15)
Eye opening
Score
> 1 year
< 1 year
Response
Response
Spontaneously
Spontaneously
To verbal command
To verbal command
Requires painful stimuli to

open eyes
Requires painful stimuli to

open eyes
No response
No response

Pediatric Glasgow Coma Scale:

Verbal Response
> 5 years
2-5 years
0-23 months
Score
Response
Response
Response
Oriented: To person,
place, and time
Appropriate words &

phrases
Smiles, coos, orients to

sounds, follows objects,
interacts
Disoriented: Patient
is conversant but
confused
Inappropriate words
Cries but consolable
Nonsensical
Conversation:
Inappropriate use of
words
Cries and/or screams
Inappropriate crying
and/or screaming
Incomprehensible
Inconsolable, agitated Grunts
sounds (e.g. moans)
No response
No response
No response

Pediatric Glasgow Coma Scale:

Motor Response
Score
> 1 year
< 1 year
Response
Response
Follows simple commands
Normal spontaneous movement
Localizes pain: Patient

indicates location of pain
Withdraws from touch
Withdraws from pain: Patient

withdraws from pain
Withdraws from pain: Patient

withdraws from pain
Decorticate: Patient flexes

arms inward towards the
chest
Decorticate: Patient flexes arms

inward towards the chest
Decerebrate extension:
Patient extends arms outward
from the body
Decerebrate extension: Patient

extends arms outward from the
body
No motor response
No motor response

CASE 7
10 y/o F conscious, eyes open and lying on a gym

mat, following a fall from the exercise bars. The
coach tells you that she was unconscious prior to
your arrival.
She has an abrasion on her forehead, and no other
obvious injuries, she knows were she is but does
not remember what happened. Pt. squeezes your
hands when asked.
GCS
Eye Opening
1-4
Verbal Response 1-5
Motor Response 1-6


A.
B.
C.
D.
E.
GCS
GCS
GCS
GCS
GCS
15
14
13
10
8
GCS
Eyes are open
=4
Inappropriate response =4
Follows Commands
=6
GCS=14

CASE 8
2 y/o M sitting in a car seat after an MVC. Patient

is restrained with minor bleeding from the
forehead. The child appears very calm.
Child stares into space, when you try to talk to him

he begins to cry inconsolably and becomes
agitated. He withdraws his hand when you pinch
him.
GCS
Eye Opening
Verbal Response
Motor Response
1-4
1-5
1-6


1.
2.
3.
4.
5.
GCS
GCS
GCS
GCS
GCS
14
10
9
8
6
GCS
Eyes are open
Response inappropriate
Withdraws from pain
=4
=2
=4
GCS=10

ANY QUESTIONS

Thank You!
Michael S. Gordon Center for Research in Medical Education

University of Miami Miller School of Medicine

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Continuing Medical Education Trauma

The Gordon Center for Research in Medical Education

Head Traumatic Brain Injury

Division of Prehospital and Emergency Healthcare

Continuing Medical Education Trauma

Explain the pathophysiology of CNS trauma

Identify the different types of brain injuries

Describe the assessment and management

Determine the Glasgow Coma Scale when

Continuing Medical Education Trauma

Head & Brain Trauma

In the United States, approximately:

4 million head injuries per year

Continuing Medical Education Trauma

Pathophysiology of CNS Injury

Division of Prehospital and Emergency Healthcare

Continuing Medical Education Trauma

Primary Brain Injury

Diffuse brain injury

Focal brain injury

Division of Prehospital and Emergency Healthcare

Continuing Medical Education Trauma

Diffuse Brain Injury

Range from mild concussion to severe ischemic insult

Division of Prehospital and Emergency Healthcare

Continuing Medical Education Trauma

From Saatman et al., J Neurotrauma, July

Continuing Medical Education Trauma

Secondary Brain Injury

SBP < 90 mm Hg (Adults), Children: agedependent

Division of Prehospital and Emergency Healthcare

Continuing Medical Education Trauma

Pathophysiology of CNS Injury

Division of Prehospital and Emergency Healthcare

Continuing Medical Education Trauma

Blood Pressure and TBI

Intracranial Pressure (ICP)

As ICP rises, CPP will

Division of Prehospital and Emergency Healthcare

Continuing Medical Education Trauma

SpO2 < 90% have significant negative

Correct difficulty breathing early

Keep intubation times short to hypoxic

Division of Prehospital and Emergency Healthcare

Continuing Medical Education Trauma

Accurate blood pressure readings

Repetitive neurologic exams

**Change in LOC is the earliest and best indicator of patients ICP

Continuing Medical Education Trauma

Division of Prehospital and Emergency Healthcare

Continuing Medical Education Trauma

Continuing Medical Education Trauma

An increase in the volume of any of these

Division of Prehospital and Emergency Healthcare

Continuing Medical Education Trauma

As ICP increases, everything in the skull is

You can displace a small amount of blood.

Division of Prehospital and Emergency Healthcare

Continuing Medical Education Trauma

Division of Prehospital and Emergency Healthcare

Continuing Medical Education Trauma

The Brain Death Cycle

In the case of EDH or SDH, we can also add

Continuing Medical Education Trauma