Traumatic Brain Injury (TBI)

Notes

## Basic introduction

  • It is also known as intracranial injury
  • TBI is defined as an insult to the brain that is caused by an external physical force or penetration of the skull by a foreign object.
  • The difference between head injury and TBI is that head injury refers to any visible lacerations, abrasions, or contusions to the face or skull which may not necessarily result in an injury to the brain while in TBI there some forms of brain injury. All traumatic brain injuries are head injuries

## Statistics

  • Globally, 10 million people sustain TBI annually
  • Globally, TBI is responsible for > 4.5 million deaths annually (about 10% of totally deaths annually)
  • Globally, 1.25 million people die in road accidents annually (out of 50 million people who are involved in road accidents annually), with most of them affecting young people of 15-29 years in low and middle income countries. About 50% of these deaths are pedestrians, cyclists and motorcyclists. More than 70% of road accidents affect men.
  • Although Africa has about 4% of the world’s motor vehicles it account for 11% of all motor vehicle related deaths in the globally.
  • In Kenya, about 3,000 people die in road accidents annually, with nearly one-third of them being passengers and the rest being vulnerable road users (pedestrians, motorcyclists, and cyclists).
  • A study in 2007 at Kenyatta National Hospital, Kenya, showed that severe TBI accounted for 14.3% of all ICU admissions of which 29% had persistent vegetative state or severe disability.
  • The WHO predicts that by the year 2020, TBI will be the leading cause of mortality and disability in the world.
  • Due to its high mortality rate and the fact that most of its consequences are not obvious, TBI has often been referred to as “the silent epidemic”.

## Causes of TBI

  • Road accidents (60%)
  • Falls (25%)
  • Non-motor-vehicle-related accidents and acts of violence including child abuse (15%)

## Glasgow Coma Scale (GCS) as a measure of the extent of brain injury

  • Eye opening ability (E)

_Spontaneous (score of 4)

_To voice (score of 3)

_To pain (score of 2)

_To none (score of 1)

  • Motor response (M)

_Normal (score of 6)

_Localized to pain i.e. purposeful movement toward site of pain (score of 5)

_Withdraws to pain (score of 4)

_Abnormal flexion to pain such as an abnormal posture that can include rigidity, clenched fists, legs held straight out, and arms bent inward toward the body with the wrists and fingers bent and held on the chest (score of 3)

_Abnormal extension to pain such as an abnormal posture that can include rigidity, arms and legs held straight out, toes pointed downward, head and neck arched backwards (score of 2)

_None (score of 1)

  • Verbal response (V)

_Normal conversation (score of 5)

_Disoriented conversation (score of 4)

_Words, but not coherent (score of 3)

_No words, only sounds (score of 2)

_None (score of 1)

  • Criteria used to classify TBI severity according to GCS

_Score: Eye score (E) + Motor score (M) + Verbal score (V) = 3 to 15

_Mild (total score of 13 - 15)

_Moderate (total score of 9 - 12)

_Severe (total score of 3 - 8)

Symptoms

## Mild cases

  • Loss of consciousness for a short while
  • Headache
  • Lack of motor coordination
  • Nausea
  • Vomiting
  • Dizziness
  • Bad taste in the mouth
  • Blurred vision
  • Difficulty balancing
  • Fatigue
  • Lightheadedness
  • Ringing in the ears
  • Sleep disorder
  • Behavioral or mood changes
  • Confusion
  • Loss of concentration
  • Memory lapse
  • Bloody CSF from the ear or the nose (as a sign of basal skull fracture)
  • Depressed skull fracture
  • Neurologic shock

## Moderate to severe cases

  • Prolonged headache
  • Vomiting or nausea
  • Convulsions
  • Agitation
  • Aphasia
  • Confusion
  • Dilation of one or both pupils
  • Dysarthria
  • Loss of coordination
  • Numbness in the limbs
  • Restlessness
  • Slurred speech
  • Somnolence
  • Unusual social behavior
  • Weakness in the limbs
  • Poor social judgment
  • Challenges in sustaining attention
  • Alexithymia
  • Intracranial pressure
  • Decreasing level of consciousness
  • Paralysis
  • Blown pupil
  • Bradycardia
  • Hypertension
  • Respiratory depression
  • Anisocoria (unequal pupil size)
  • Abnormal posturing
  • Skull fractures

## Complications of TBI

  • Coma
  • Brain death
  • Persistent vegetative state
  • Bed sores
  • Pneumonia
  • Progressive multiple organ failure
  • Deep venous thrombosis
  • Pulmonary embolism
  • Meningitis
  • Brain abscesses
  • Vasospasm
  • Aneurysms
  • Stroke
  • Tremor
  • Ataxia
  • Cerebral herniation
  • Post-traumatic seizures
  • Altered vision, hearing, or smell
  • Diabetes insipidus
  • Electrolyte disorders
  • Hypopituitarism
  • Cognitive deficits
  • Memory loss
  • Second-impact syndrome
  • Chronic traumatic brain injury
  • Dementia pugilistica (mainly by career boxers)
  • Parkinsonism
  • Emotional instability
  • Depression
  • Mania
  • Irritability
  • Suicidal ideation
Diagnosis
  • Clinical review (that include assigning Glasgow Coma Scale values)
  • CT scan
  • MRI
  • EEG
Differential
  • Consider other diseases like meningitis and stroke
Prevention
  • Use of seat belts
  • Motorcycle helmets
  • Enforcement of traffic laws
  • Safety education programs
Reference

1. Kenyan Ministry of Health. Clinical guidelines for management and referral of common conditions at levels 4-6. Hospitals. 2009; 3:259-261.http://apps.who.int/medicinedocs/documents/s21000en/s21000en.pdf

2. Ministry of Health, Kenya. Kenya Essential Medicine List (2016). http://publications.universalhealth2030.org/uploads/KEML-2016Final-1.pdf

3. Opondo, and (2007). Outcome of severe traumatic brain injury at a critical care unit: a review of 87 patients. Annals of African Surgery. Vol 1

4. Teasdale, G., and Jennett, B. (1974). Assessment of coma and impaired consciousness: A practical scale. Lancet, 2(7872), 81–84.

5. The impact of traumatic brain injuries: A global perspective. NeuroRehabilitation, 22, 341-353. , Google Scholar Medline

  1. World Health Organization. (2002). Projections of mortality and burden of disease from 2002 to 2030 (Deaths by Income Group), Geneva, Switzerland: Author. , Google ScholarHyder A. A., Wunderlich C. A., Puvanachandra P., Gururaj G., Kobusingye O. C. (2007).
Management
  • Management depends on the magnitude of injury
  • Oxygen (which can sometimes be administered through endotracheal intubation and mechanical ventilation)
  • Controlling the raised intracranial pressure (ICP) by such as tilting the patient's bed and straightening the head to promote blood flow through the veins of the neck, careful use of hypertonic saline and mannitol
  • IV fluids to prevent hypotension
  • Antibiotic cover such as IV Benzyl penicillin 2gm QID and IV chloramphenicol I gm QID x 1/52 then continue with oral chloramphenicol for 1/52.
  • Maintain environmental temperatures to appropriate range
  • Analgesics such as paracetamol (avoiding narcotic analgesics at all cost)
  • Control of seizures (risks of hypotension!):

_IV Diazepam 10-20mg and IM Phenobarbitone daily

  • Surgery to remove contusions, hematomas, and foreign objects as an emergency
  • Surgical repair of hemorrhaging blood vessels
  • Surgery to debride damaged tissue
  • Craniotomy (sometimes to remove debris or severely damaged parts of the skull)
  • Decompressive craniectomy or DC (to relieve ICP)
  • Rehabilitation that may involve, counseling, occupational therapy, physiotherapy, recreation therapy, speech therapy, and vision therapy
  • Supported employment
  • Community support
  • Nutritional support
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