Traumatic Brain Injury
Section snippets
Physiology and pathophysiology of traumatic brain injury
A full discussion of the pathophysiology of TBI is beyond the scope of this article; however, major aspects of the physiology and pathophysiology of TBI must be understood because they form the basis of our clinical management. TBI is a dynamic process; a diagram of the contributing factors and cascading pathophysiologic events associated with TBI are shown in Fig. 3. For a more detailed description of brain physiology and pathophysiology following TBI, the reader is referred to several
Secondary brain insults and their relationship to outcome
At the time of head trauma, a series of destructive intracellular and extracellular pathologic processes begin, which include neurochemical, neuroanatomic, and neurophysiologic alterations. Secondary brain insults contribute to these devastating events. Secondary brain insults can be categorized as systemic or intracranial. Examples of systemic secondary brain insults include hypotension, hypoxia, anemia, and hyper- and hypocapnia. Intracranial secondary brain insults include severe
Minor head trauma
Minor head trauma is defined as isolated head injury producing a GCS score of 14 to 15 [23]. It is the most common degree of head injury in patients who present to EDs for evaluation. Most episodes of minor head trauma occur in the context of sports and other recreational activities.
By the time most patients with minor head trauma present to the ED, they are asymptomatic. When symptoms are present, headache is the most common complaint; however, nausea and emesis are common. Patients
Neuroimaging in patients who have minor head injuries
A key management decision for EPs is whether a head CT scan should be obtained on patients who have sustained minor head trauma. Many neurosurgical studies advocate for CT scanning of all patients who have sustained a minor head trauma who give a history of LOC or amnesia for the traumatic event [25], [26]; however, these studies undoubtedly suffer from selection bias, because neurosurgical consultation probably occurs only for a select, more injured population. Other authorities recommend
Concussions
A concussion is a transient brief interruption of neurologic function after minor head trauma, with or without an LOC, usually as a result of acceleration-deceleration forces to the head [30]. Although anyone can sustain a concussion, it is most often a consequence of a sports-related minor head injury. At least 300,000 sports-related concussions are reported yearly to the Centers for Disease Control and Prevention, and as many as 8% of United States high school and college football players
Disposition of patients with concussion
With regard to neuroimaging and disposition, the management decisions faced by the EP for patients with concussion are identical to those for patients with minor head injury. In addition, the EP may be encouraged by coaches, eager parents, and the concussed athletes themselves to allow return to play. From the ED standpoint, patients with a sports-related concussion probably should not be allowed to return to play from the ED even if they are symptom-free; if still symptom-free 1 week after the
Moderate traumatic brain injury: clinical features and acute management
Patients with moderate TBI have a GCS score of 9 to 13. Their clinical presentation can vary widely. Patients may have had LOC, a brief posttraumatic seizure, and be confused, but most patients can follow commands on arrival to the ED. Facial and other systematic trauma often is present. Patients may complain of a worsening headache and nausea. Focal neurologic deficits may be present.
The EP needs to be especially aware of one specific presentation of moderate TBI: the “talk-and-deteriorate”
Epidural hematoma
Epidural hematomas (EDHs) predominately are a result of a direct mechanical force that results in a skull fracture. Most often, this fracture occurs across the middle meningeal artery or a dural sinus. The temporoparietal region is the most likely site for an EDH. EDH is primarily a disease of the young and accounts for 0.5% to 1% of all patients who have experienced TBI [40]. Most often unilateral, the deterioration of a patient who has an EDH from arterial bleeding can be rapid and dramatic.
Prehospital intubations and traumatic brain injury
Controversy exists regarding prehospital intubations in patients with severe and moderate head injuries. It is unclear if field intubations truly improve neurologic outcome or survival. Unsuccessful attempts at field intubations may add to out-of-hospital time and increase the risk for aspiration or hypoxia.
It has long been a tenet in prehospital care that patients who have sustained a severe head injury need necessary airway interventions to prevent hypoxia. Hypoxia and hypotension have been
References (83)
- et al.
Congenital and acquired brain injury. 1. Brain injury: epidemiology and pathophysiology
Arch Phys Med Rehabil
(2003) - et al.
Assessment of coma and impaired consciousness. A practical scale
Lancet
(1974) The management of severe traumatic brain injury
Emerg Med Clin North Am
(1997)- et al.
Management of head-injured patients in the emergency department: a practical protocol
Surg Neurol
(1997) - et al.
The Canadian CT Head Rule for patients with minor head injury
Lancet
(2001) - et al.
Patients who talk and deteriorate
Ann Emerg Med
(1993) - et al.
The association between field Glasgow Coma Scale score and outcome in patients undergoing paramedic rapid sequence intubation
J Emerg Med
(2005) - et al.
Out-of-hospital endotracheal intubation and outcome after traumatic brain injury
Ann Emerg Med
(2004) - et al.
The use of midazolam for prehospital rapid-sequence intubation may be associated with a dose-related increase in hypotension
Prehosp Emerg Care
(2001) - et al.
The impact of aeromedical response to patients with moderate to severe traumatic brain injury
Ann Emerg Med
(2005)
Recombinant factor VIIa for control of hemorrhage: early experience in critically ill trauma patients
J Clin Anesth
Treatment of traumatic bleeding with recombinant factor VIIa
Lancet
Hippocratic writings
Trends in death associated with traumatic brain injury, 1979–1992
JAMA
Traumatic brain injuries evaluated in U.S. emergency departments, 1992–1994
Acad Emerg Med
Epidemiology of brain injury
Head injury
Pathology of brain damage after head injury
Head injury
Vascular aspects of severe head injury
Arterial Pco2 and cerebral hemodynamics
Am J Physiol
Hypocapnia
N Engl J Med
Adverse effects of prolonged hyperventilation in patients with severe head injury: a randomized clinical trial
J Neurosurg
An account of the appearances observed in the dissection of two of the three individuals presumed to have perished in the storm of the third, and his bodies were discovered in the vicinity of Leith on the morning of the 4th November 1821 with some reflections on the pathology of the brain
Trans Med Chir Sci (Edinburgh)
Observation on the structure and function of the nervous system
Predominance of cellular edema in traumatic brain swelling in patients with severe head injuries
J Neurosurg
Recent advances in neuroprotection for treating traumatic brain injury
Expert Opin Investig Drugs
The Brain Foundation and American Association of Neurological Surgeons. Guidelines for the management of severe traumatic brain injury
J Neurotrauma
Emergency care and initial evaluation
Paramedic-administered neuromuscular blockade improves prehospital intubation success in severely head-injured patients
J Trauma
Severe acute brain trauma
Defining acute mild head injury in adults: a proposal based on prognostic factors, diagnosis, and management
J Neurotrauma
Closed head injury
Routine early CT-scan is cost saving after minor head injury
Acta Neurol Scand
Indications for computed tomography in patients with minor head injury
N Engl J Med
Skull X-ray after head injury: the recommendations of the Royal College of Surgeons Working Party report in practice
Arch Emerg Med
Sports-related recurrent brain injuries–United States
MMWR Morb Mortal Wkly Rep
Acute effects and recovery time following concussion in collegiate football players: the NCAA Concussion Study
JAMA
The neurophysiology of concussion: progress in neurobiology
Dissociation of cerebral glucose metabolism and level of consciousness during the period of metabolic depression following human traumatic brain injury
J Neurotrauma
A study of persistent post-concussion symptoms in mild head trauma using positron emission tomography
J Neurol Neurosurg Psychiatr
Cited by (50)
Can a combination of ultrasonographic parameters accurately evaluate concussion and guide return-to-play decisions?
2015, Medical HypothesesCitation Excerpt :However, evidence exists supporting the occurrence of increased intracranial pressure in humans. First, intracranial pressure clearly increases after moderate or severe TBI, as detected by invasive intracranial monitoring in clinical settings, and since concussion is the mild part of the traumatic brain injury spectrum it is assumed that intracranial pressure increases also occur to some degree in concussion [17]. Second, Pomschar and colleagues reported in 2013 that MRI measurements of venous drainage and cerebrospinal fluid flow, as assessed via cine imaging, allow for measurements of brain compliance and intracranial pressure [18].
The protective effects of statins in traumatic brain injury
2024, Pharmacological ReportsHyperosmolar therapy in pediatric traumatic brain injury: a systematic review
2023, Journal of Pediatric and Neonatal Individualized MedicineChemical Kindling as an Experimental Model to Assess the Conventional Drugs in the Treatment of Post-traumatic Epilepsy
2023, CNS and Neurological Disorders - Drug Targets