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Traumatic Brain Injury

Traumatic Brain Injury . Linda Wilkinson, MSN, ACNP, LMT Nurse Practitioner -Trauma Vanderbilt University Medical Center. Traumatic Brain Injury . Linda Wilkinson, MSN, ACNP, LMT Nurse Practitioner -Trauma Vanderbilt University Medical Center. Objectives. Define TBI Overview of TBI

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Traumatic Brain Injury

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  1. Traumatic Brain Injury Linda Wilkinson, MSN, ACNP, LMT Nurse Practitioner -Trauma Vanderbilt University Medical Center

  2. Traumatic Brain Injury Linda Wilkinson, MSN, ACNP, LMT Nurse Practitioner -Trauma Vanderbilt University Medical Center

  3. Objectives • Define TBI • Overview of TBI • Look at Statistics • Review of types of TBI • Discuss Long Term issues • Acute Care Management • Post Acute Care Considerations

  4. What is Traumatic Brain Injury? • “… a nondegenerative, noncongenital insult to the brain from an external mechanical force, possibly leading to permanent or temporary impairments of cognitive, physical and psychosocial functions with an associated diminished or altered state of consciousness”

  5. How Big a Problem?Incidence • 1.4 million people sustain TBI annually • Does not include • non-diagnosed • military • sports-related • $56 billion direct/indirect costs • 50,000 die annually • Approximately 100,000 long-term disability • Over 5 million TBI-related patients CDC, Report to Congress TBI, 2003

  6. http://www.cdc.gov/traumaticbraininjury/pdf/blue_book.pdf

  7. How Much Does it Cost?Financial Impact • Costs: • Acute care: $8000/day • Rehabilitation: $2500/day • Employment: • Approx 60% at time of injury • 28% post-injury • 34% are unable to return to work rapidly • Majority require up to 3-6 months • 25% over one year Rimel Neurosurgery 1981, Boake Neurosurgery 2005, Max JHTR 1991

  8. Why Is It Important? • Traumatic Brain Injury (TBI) • Accounts for 51.6% of mortality amongst trauma patients Dutton. J Trauma. 2010. • Progression of Intracranial Hemorrhagic Injury (IHI) • Longer hospitalizations (14.4 d vs. 9.7 d, p <0.01) • Increased mortality (24% vs. 3%, p <0.01) Thomas. J Am Coll Surg. 2010.

  9. Who’s Involved? Demographics • Traumatic brain injury effects all levels of society • TBI affects all ages • Majority (75 to 90%) recover quickly • “Mild” = 90% • 10 to 25% have long-term deficit • 2% of Americans living with TBI-related disabilities • (313.9 Million x .02 =6.3 Million) 2012 census • The ‘Hidden’ TBI patient • Emotional distress/cognitive issues

  10. “At Risk” Groups • Males are more likely to incur TBI compared to females. (3.4:1) • GSW 6:1 • MVC 2.4:1 • Highest rate of injury: 15-24 years old. • Also at higher risk: • Children <5 years old • Elderly > 75 years old

  11. Trauma Centers are the epicenter of major TBI • Hospitalizations increasing 10% per year • EARLY identification improves outcomes • Appropriate in-patient management important • Post-hospital rehab improves outcomes • Collaborative efforts through multi-discipline teams

  12. What Happened?Mechanism of Injury (Blunt) • Leading causes of TBI: • Falls: 35% • Half of children (<14 yrs) eval in ED • Two-thirds >65y • MVC: 17% • Leading cause of TBI-death (32%) • Struck (auto-ped): 17% • Assault: 10%

  13. Traumatic Brain Injury • Concussion • Epidural Hematoma • Subdural Hematoma • Subarachnoid hemorrhage • Intracerebral Hematoma • Intraventricular hemorrhage • Shear injury / diffuse axonal injury

  14. Normal Anatomy • Scalp • Skull • Epidural Space • Dura • Subdural Space • Arachnoid • Subarachnoid Space • CSF • Brain

  15. Concussion • A clinical syndrome characterized by immediate and transient alteration in brain function, including alteration of mental status and level of consciousness, resulting from mechanical force or trauma.

  16. Concussion Symptoms Memory loss Ringing ears Difficulty concentrating Sensitivity to light Sensitivity to sound Loss of smell or taste Sleep disturbances Repetitive questioning • Prolonged headache • Vision disturbances • Dizziness / “fogginess” • Nausea or vomiting • Impaired balance • Confusion • Irritability • Labile / exaggerated emotions

  17. Post Concussive Syndrome • May last for weeks or months. • Symptoms include memory and concentration problems, mood swings, personality changes, headache, fatigue, dizziness, insomnia and excessive drowsiness. • Patients with postconcussive syndrome should avoid activities that put them at risk for a repeated concussion.

  18. Normal Head CT

  19. Epidural Hematoma • Collection of blood between the skull and the dura • Often caused by laceration of middle meningeal artery by parietal skull fracture • Classic: + LOC, lucid interval, neurologic decline (signs of ^ ICP) • Biconcave on CT • Most common in temporal area • Often little or no contusion • May be surgically evacuated (>1 cm)

  20. EDH – Signs / Symptoms • Lucid period then decreased LOC • Headache • Vomiting • Seizure • Unilateral babinski • Contralateral hemiparesis • Ipsilateral pupil dilation • Mortality 20-55%

  21. Subdural Hematoma • collection of blood below the dural membrane • usually venous • may develop more slowly (venous vs. arterial bleeding) • may spread over wider surface (not restrained by dura) • often associated with cerebral contusion and edema • May occur spontaneously in alcoholics and elderly (atrophy) • Crescent shaped on CT • May be surgically evacuated if large mass effect. (>1 cm)

  22. SDH - Signs / Symptoms • Headache • Decreased level of consciousness • Abnormal cortical function

  23. Subarachnoid Hemorrhage • Collection of blood between arachnoid membrane and brain • Often little “mass effect”, due to diffuse spread • Irritating to brain

  24. SAH – Signs / Symptoms • “worst headache of my life” • Hypertension • Obtunded • Nuchal rigidity

  25. Intraparenchymal Hemorrhage • Bleeding into the tissue of the brain • Symptoms dependent on area of brain affected

  26. Intraparenchymal Hemorrhage • Symptoms vary depending on size and location of bleed. • May require surgical intervention / craniotomy

  27. Diffuse Axonal / Shear Injury • Usually occur with sudden rotation of the head • Shearing forces “stretch” axons. • If axon injured but not severed, may recover without secondary injury.

  28. DAI Symptoms • Headache • Vary depending on • Location • Number • Size • May be asymptomatic • Rarely fatal • May result in ‘persistent vegetative state’

  29. Injury Severity • Concussion • - Less than 30 min • - Greater than 30 min • Post-traumatic amnesia • Intracranial Hemorrhage (ICH) • Glasgow Coma Score (GCS) • Mild 13-15 • Moderate 9-12 • Severe 3-8

  30. Glascow Coma Scale Motor 6- Follows commands 5- Localizes to pain 4- Withdraws to pain 3- Flexion 2- Extension 1- No movement Verbal 5- Oriented/Conversant 4- Confused 3- Inappropriate 2- Incomprehensible 1- None • Eyes • 4- Opens Spontaneously • 3- Opens to voice • 2- Opens to pain • 1- None Teasdale, Lancet, 1976

  31. What Do We Do?Management • Immediate • “Time is brain” • Short-term: Intensive care / Acute Care • Monitors • Surveillance • Management • Long-term: Post-discharge

  32. Immediate • Trauma Team: Manage Resuscitation • Protection • Anoxia • Hypotension • 25% Increased Mortality • Individually • 75% Increased Mortality • Combined

  33. Acute Care Management • CT scans? • Head up • Sedation • ICP/CPP management • Osmolar therapy • Hypertonic saline • Decompressive craniotomy • Induced coma • Hypothermia

  34. Repeat head CT scans • Beneficial in setting of neurological deterioration Brown. J Trauma. 2007. Kaups. J Trauma. 2004. • Debated for patients with normal or stable clinical exams Wang. J Trauma. 2006. Sifri. J Trauma. 2006.

  35. ICP Monitoring – when? • Intracranial Pressure Monitoring • All ‘salvageable’ severe TBI patients • GCS <8 • CT scan with pathology • ICH • Swelling • Herniation • Normal CT scan • Age >40 • Posturing • Sys BP <90mmHG

  36. TBI GCS<9 Protocol

  37. Hyperosmolar Therapy • Hyperosmolar Therapy • Mannitol to maintain ICPs <20mmHg • Early okay • Late not much data • Hypertonic Saline-no current evidence to support the use/disuse • Does decrease ICPs • No change in outcomes Shackford, JoT, 1998 Himmelseher, Cur Op An, 2007

  38. Antiseizure Prophylaxis • Decrease incidence of EARLY seizures (<7d) • Dilantin, maybe Valproate • NO prevention of LATE seizures (PTS) • Steroids • No use • Hyperventilation • No use

  39. Sedation/Induced Coma - EEG burst suppression • Prophylactically not recommended • Refractory elevated ICP after med mgmt: YES • Criteria: • Refractory intracranial hypertension • Na 145-155 (but < 160), Osm 320-330 • Repeat Head CT without surgically treatable lesion • Nsgy eval recommends non surgical treatment Jiang, Neursurg, 2000

  40. Pentobarbitol Coma Protocol • 10mg/kg bolus over 30 minutes • 5mg/kg/hr continuous infusion x 3 hours • Then 1mg/kg/hr • Titrate based on EEG burst suppression (2-5/min) • Continue for at least 72 hours, then wean to keep ICP<20 Failure • ICP 21-35 > 4 hrs, 36-40 for 1 hr, or > 40 for 5 minutes • ICP not <20 in 7 days without pentobarital • Brain death/herniation • Side effect requiring discontinuation (hypotension, sepsis, etc)

  41. Decompressive Craniotomy • Indications: elevated ICP refractory to medical management • Aims to decrease ICP / increase perfusion, by opening a closed system, allowing room for swelling /expansion • Some studies show: decrease ICP, decreased LOS, worse outcome • - problematic study: Bad patient selection, Bad operative intervention • Intervention period too long, ICP elevation too low, Poor oxygenation remains a problem, No measure of cerebral blood flow Cooper, NEJM, 2011 Editorial Reply, NEJM, 2011

  42. Prophylactic Hypothermia • Not significant data • Early work suggests mortality benefit Abiki, Br Inj, 2000

  43. Other issues – Ongoing Study: • Beta-blockade of adrenergic/sympathetic surge • Alpha agents for adrenergic/sympathetic surge • Progesterone for early TBI

  44. Sympathetic Storming • Most commonly seen in Severe TBI (GCS 4-8) • Periods of unmodulated sympathetic activity • Symptoms:alterations in level of consciousness, increased posturing, dystonia, hypertension, hyperthermia, tachycardia, tachypnea, diaphoresis, and agitation. • Must rule out other causes (infection, pain, etc)

  45. DASH

  46. What do we see?Presentation (Mild, Moderate, Severe) • Physical • Cognitive • Behavioral

  47. Physical Impairments   Speech, vision, hearing, other sensory impairments  Headaches  Lack of coordination  Muscle spasticity  Paralysis  Seizure disorders  Problems with sleep  Dysphagia  Dysarthria (articulation and muscular/motor control of speech)

  48. Cognitive Impairments • Short- and long-term memory deficits • Slowness of thinking • Problems with reading and writing skills • Difficulty maintaining attention / concentration • Impairments of perception, communication, reasoning, problem solving, planning, sequencing and judgment • Lack of motivation or inability to initiate activities

  49. Behavioral Impairments • Mood swings • Denial • Depression and/or anxiety • Lowered self esteem • Sexual dysfunction • Restlessness and/or impatience • Inability to self-monitor, inappropriate social responses • Difficulty with emotional control and anger management • Inability to cope • Excessive laughing or crying • Difficulty relating to others • Irritability and/or anger • Agitation • Abrupt and unexpected acts of violence • Delusions, paranoia, mania

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