​Kembara Xtra - Medicine - Traumatic Brain Injury

​Kembara Xtra - Medicine - Traumatic Brain Injury

Introduction
Traumatic brain injury (TBI) is characterized as a change in brain function or other signs of brain pathology brought on by an outside impact.
Neurologic, mental, circulatory, endocrine/metabolic, gastrointestinal, and pulmonary system(s) are affected.
Synonym(s): concussion, head damage

Incidence and prevalence in Epidemiology 
Incidence It is estimated that 69 million people suffer a traumatic brain injury each year.
In the United States, there are 801.700 ER visits, 326.600 hospital admissions, and 61,000 deaths annually. Of these, injury-related deaths account for 30% of all fatalities.

Prevalence Males outnumber females by a ratio of 2:1 (predominant age groups: 0 to 4 years, 15 to 19 years, and >65 years).


Pathophysiology
According to Centers for Disease Control and Prevention (CDC) TBI data from 2017, hospitalized patients' mechanism of injury was more likely to be male than female.
- Inadvertent declines (35.6 compared to 23.9)
- Traffic accidents (22.5 vs. 10.8)
- Accidentally coming into contact with or being struck by an object (2.3 vs. 0.9)
- Self-harm done on purpose (0.8 vs. 0.3)
- Agression (7.5 vs. 1.7)
- Children ages 0 to 17
○ Falls (7.7)
 Traffic collisions (6.8)
45% of children's sports- and recreation-related TBI emergency room visits are due to contact sports.
Primary insult: actual physical harm
Secondary insult: activation of intricate cellular and molecular processes that encourage cerebral edema, ischemia, and apoptosis

Risk Elements

Male sex, seizure disorder, ADHD, contact sports, past or ongoing head injuries, alcohol and drug use
 

Aspects of Geriatrics
Elderly people frequently get subdural hematomas following a fall or blow; the symptoms may be modest and not appear for days after the incident. Antiplatelet or anticoagulation medication is being used with a lot of older people.

Prevention measures include wearing seat belts, wearing motorcycle and bicycle helmets, and wearing protective headgear while participating in contact sports.

Child Safety Considerations
Consider child abuse if the child was dropped or fell more than four feet (for example, off a bed or couch), had a suspicious past, had a serious injury at the time, or had any retinal hemorrhages.


Presenting History Epidural bleeding from physical trauma: 30% with a "lucid interval" (first LOC followed by recovery of consciousness and then LOC recurs and remains) Headache, vomiting, forgetfulness, disorientation, dizziness, and sensitivity to light

clinical assessment
Testing of the nervous and cognitive systems is crucial.
Repeat neurologic evaluations every 30 minutes for the next two hours, then hourly for four hours, and finally every two hours once the Glasgow Coma Scale (GCS) hits 15.
Signs of elevated intracranial pressure (ICP) include elevated blood pressure, a reduced heart rate, or delayed or irregular breathing (the "Cushing triad"; only 30% of patients have all three).
Raccoon eyes, the Battle sign, hemotympanum, and CSF rhinorrhea or otorrhea are symptoms of a basilar skull fracture.

Multiple Diagnoses 

Other factors that can affect mental state, such as toxicologic, viral, metabolic, and vascular factors


Examinations and diagnostic procedures
Cognitive screening measures for mild TBI and concussions as part of the initial tests (lab and imaging)
Look into coagulopathy.
Type and check for surgical intervention that might be necessary.
Conduct a drug and alcohol test.
The preferred study to examine bone windows, tissue windows, and subdural space is a noncontrasted CT head.

Child Safety Considerations
When abuse is suspected, skull radiographs are not recommended but can still pick up fractures that are invisible to CT; physical activity should not resume until the patient is symptom-free and returning to school should come first.


Treatment-Related General Steps

Injury severity affects how quickly an injury is managed. Most patients don't require any interventions.
Determine who needs more therapy, imaging tests (CT), and hospitalization in order to stop future harm.

Early education is helpful for recovery in patients who have just minor injuries.
- Gradual return to cognitive and physical activities in the absence of obvious physical, cognitive, emotional, or behavioral symptoms as determined by neuropsychological and clinical evaluation
For patients who have suffered moderate to severe injuries, prevent hypotension or hypoxia. ICP rises after a head injury as a result of edema, hence cerebral perfusion pressure (CPP) needs to be kept between 60 and 70 mm Hg.
- A 30-degree head tilt lowers ICP and raises CPP.
Use of hyperventilation (hypocapnia) should be restricted to patients with impending herniation while preparing for definitive therapy or during surgery; there is a risk of exacerbating cerebral ischemia and organ damage.- Although mild systematic hypothermia lowers ICP, it increases the risk of pneumonia. Selective brain cooling may also lower ICP with better results two years after the damage. A meta-analysis revealed that the largest mortality decrease and the best neurologic outcomes occurred when hypothermia was maintained for longer than 48 hours.
- Both mannitol and 3% hypertonic saline efficiently lower ICP; however, 3% hypertonic saline also effectively raises CPP, whereas mannitol has an effect on ICP that lasts longer. Hypertonic saline is preferred for refractory cerebral hypertension.
Seizure prevention has little effect on mortality or morbidity. For patients with early seizures, dural-penetrating injuries, multiple contusions, and/or subdural hematomas needing evacuation, consider phenytoin or levetiracetam for 1 week postinjury or longer.

The First Line of Medicine
In individuals with TBIs, pain management is crucial. There are scales, such the Nociception Coma Scale (NCS), that can be used on people with severe brain injuries who are unable to communicate.
Enhanced ICP
The preferred treatment is hypertonic saline: 2 mL/kg IV reduces ICP without affecting hemodynamic status.
Mannitol: Patients with sufficient renal function should receive 0.25 to 2.00 g/kg (0.25 to 1.00 g/kg in children) over the course of 30 to 60 minutes. Use as a preventative is linked to negative consequences.
Propofol is preferred for sedation because of its rapid onset of action. To prevent propofol infusion syndrome, avoid large doses. When taken with morphine, it can also significantly lower ICP and reduce the need for additional medications.
Midazolam may produce hypotension but has sedative effects similar to those of propofol. In critically ill people with severe TBI, a comprehensive review found that no sedative is more effective than the others for improving patient-centered outcomes, ICP, or CPP.
Phenytoin (Dilantin) 15 mg/kg IV (1 mg/kg/min IV, not to exceed 50 mg/min) is used to treat seizures. If the QT interval rises by more than 50%, stop the infusion.



Caution
Use of corticosteroids should be avoided since they raise mortality rates and the possibility of late-onset seizures.


Consult neurosurgery if you have any penetrating head trauma or if your head CT scan is abnormal.

Further Treatments

Emerging treatments with scant but encouraging data include amantadine, zolpidem, and levodopa/carbidopa for coma arousal and bromocriptine for post-coma treatment.
Therapeutic hypothermia with established physiologic parameters yielded variable results.
TXA was found to have a similar incidence of thromboembolic events (1.7% in TXA vs. 1.4% in the placebo group) in a systematic review and meta-analysis (12)[A]. It showed a decrease in fatalities in the population with TBI.

Surgical Technique

Early removal of intracranial hematoma caused by trauma reduces mortality, especially when there is GCS 6 and CT evidence of hematoma, cerebral edema, or herniation.
CSF leakage frequently cures in 24 hours with bed rest, but if not, may need surgical correction. CSF draining lowers ICP, but it has not been shown to have long-term benefits.


additional medication
In TBI patients who are comatose, music treatment combined with multimodal stimulation enhances awareness.


Those behind admission
GCS or CT abnormalities

 Patient without a competent adult at home for surveillance; persistent neurologic impairments (e.g., disorientation, somnolence); Potentially admit: LOC, amnesia, patients taking anticoagulants with a negative CT
Use normal saline as resuscitation fluid; consider C-spine immobilization in all cases of head trauma; discharge requirements include a normal CT, a return to normal mental status, and a competent adult to supervise the patient at home.

Establish a weekly follow-up appointment to decide when you can resume your normal activities.
Following a serious acute injury, rehabilitation was recommended. Set attainable objectives.
Resuming medication after discharge has a net benefit for patients taking anticoagulants despite a higher risk of bleeding.
 

patient observation

With specific instructions on the indications and symptoms that call for quick evaluation (such as altered mental state, worsening headache, focused findings, or any indicators of distress), the patient should be released to the care of an adult who is competent. Patients should be watched over but not roused from their sleep.
EAT AS TOLERATED; keep an eye out for nausea symptoms.

Patient Education

It's crucial to receive the right therapy, control your symptoms, and gradually resume your regular activities.


The mortality rate for TBI in the United States is 30 per 100,000 per year. Poor prognostic variables include poor GCS at admission, nonreactive pupils, senior age, comorbidities, midline shift, and nonambulatory.
50% of individuals with mild TBI return to work after one month of injury, and over 80% do so within six months.


Complications
Chronic subdural hematoma, which can occur after even "mild" head trauma, is especially common in the elderly and frequently manifests as headache and memory loss.
Seizures: Over a 30-year period, the incidence of late seizures following a traumatic brain injury is 2% for mild injuries, 4% for moderate injuries, and over 15% for severe injuries; 5% of hospitalized patients experience late seizures.
Post concussion syndrome, which might include headaches, dizziness, exhaustion, and minor cognitive or affective alterations, can occur after a mild head injury without LOC.
Second-impact syndrome develops when the CNS is unable to maintain autoregulation. When a person with a mild head injury returns to a contact sport, even a small injury (such as whiplash), the patient loses consciousness and may herniate fast, with a 50% death rate. In youngsters, even a little injury might result in a condition comparable to malignant edema.