TBI(Compressed)

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Traumatic Brain Injury



Definition

Traumatic Brain Injury (TBI)

Any head injury with evidence of brain

involvement.

This term is preferred because it clearly

denotes that injury to the brain is the major

cause of morbidity and mortality and that

injury is caused by external forces.



Other terms

Craniocerebral trauma

Head injury / head trauma



TBI is one subset of Acquired Brain

Injuries (ABI)

ABI are any injury to the brain acquired after

birth.

The other subset is Non-traumatic Brain

Injury.



Classification

As to severity:

Mild GCS 13-15

Loss of consciousness < 20 min No TBI related abnormalities on neurological

examination and normal CT of the brain If positive, classify patient as moderate TBI or mild TBI

with complications

Moderate GCS 9-12

Severe

GCS 3-8



Glasgow Coma Scale (GCS)

Consists of:

Eye Opening (E)

Best Motor Response (M)

Verbal Response (V)

GCS=E+M+V




Eye Opening (E)

(4) Spontaneous

(3) To loud voice

(2) To pain

(1) Nil




Best Motor Response (M)

(6) Obeys

(5) Localizes

(4) Withdraws (flexion)

(3) Abnormal flexion posturing

(2) Extension posturing (1) Nil




Verbal Response (V)

(5) Oriented

(4) Confused, disoriented

(3) Inappropriate words

(2) Incomprehensible sounds

(1) Nil





As to Primary Injury

Closed

Open

Piercing




Closed

Concussion

Contusion

Local brain damage

Coup-contrecoup injury

Polar brain damage

Diffuse axonal injury










Open

Piercing

Stab

Missile



As to Secondary Injury

Hypoxic-Ischemic Injury (HII)

Late-occurring Intracranial Hematomas

Increased Intracranial Pressure (ICP)

Intracranial Infection

Cerebral Artery Vasospasm

Tumors

Obstructive Hydrocephalus

Post-traumatic Epilepsy

Neurochemical Changes







Types as to Affectation:

Focal

Diffuse

Types as to Trauma Velocity:

High-velocity impact

Low-velocity impact



Epidemiology

Worldwide (1996 data):

Of all types of injury, those to the brain are

among the most likely to result in death or

permanent disability. The leading cause of death and disability.

Traumatic brain injury is the leading cause of

seizure disorders. Closed head injury with or without skull

fracture constitutes the majority of cases.



Etiology

Motor Vehicle Accidents (MVA) – 50%

Falls – 21%

Violence, Assaults, Gunshot wounds – 12%

Sports, athletic events – 10%



Pathophysiology/Pathomechanics

Pathomechanics

Types as to Primary Injury

Pathophysiology

Types as to Secondary Injury



Clinical Manifestation

Signs/Symptoms:

Loss of consciousness

Signs of increased ICP

Brainstem damage

Localizing symptoms



Direct Impairments

Cognitive

Neuromuscular

Visual – Perceptual

Swallowing

Behavioral



Nature of Residual Disabilities:

Permanent neuromuscular deficit

Seizures

Cognitive and behavioral problems

Resolution of neurologic signs may

continue as long as 3 years post-trauma.



Complications

Sequelae of Head Injuries

Secondary injuries

Infection – meningitis, abscess

Extradural infection

Meningitis

Brain abscess

Focal cerebral lesions



Indirect Impairments

Contractures

Mobility deficits

Skin breakdown

Heterotopic ossification

Decreased endurance

Infection

Pneumonia

Impaired speech (if with tracheostomy)

DVT



Diagnosis

CT Scan

MRI

Positron emission tomography (PET)scan

Standard EMG/NCV

Electroencephalograms (EEG) andEvoked Potentials

Clinical Rating Scales



Clinical rating scales


Glasgow Outcome Scale (GOS)

Ranchos Los Amigos Level of Cognitive

Functioning

Rappaport’s Disability Rating Scale (DRS)







Differential Diagnosis

Non-traumatic Brain Injury

Cerebral Palsy



Prognosis

Prognostic Factors:

Patient’s age

Extracranial injuries

Availability of family support





Medical/Surgical Management

Early medical management focuses on

determination of the severity of injury,

preservation of life and prevention of

further damage. LOC determined by GCS-neurologic exam

radiographic exam of the skull and cervical

spine



ICP monitoring via catheter in lateral ventricle

if ICP is over main value of 25 mmHg, decrease it

if ICP is below 25 mmHg value for 24 hours

consistent, system can be discontinued.



Pharmacologic Management

Elavil

Tofrani

Ritalin

Phenobarbital

Tegretol

Dantrium

Lioresal (Baclofen)

Valium



PT Assessment

Major focus is on

Communication Ability, Affect, Cognition,

Language, and Learning Style

Neurologic Assessment

Musculoskeletal Assessment

Functional Assessment

Other things to assess All other objective data (only when affected)



If purely TBI without associated injuries,

usual diagnostic classification is:

Impaired arousal, range of motion, and motor

control associated with coma, near coma, orvegetative state



PT Management

Acute Management

Prevention of complication: e.g. respiratory

distress, contracture development, skin

breakdown Frequent position changes will assist

pulmonary hygiene and skin integrity

Postural drainage, percussion, and vibrationare used to keep the patient’s lung clear

PROM should be performed regularly but may

not be enough to prevent development of

deformities



Other management

Use of splints or prophylactic short leg casts

and passive standing on a tilt table

Functional mobility training may begin whenhe patient’s medical status is stable

Initial goals:

Patient tolerance to upright positioning Increase patient’s active movement capabilities



Rehabilitative management

Goal: Returning the patient to society at the

highest possible level of function



Issues that cross all levels

ROM – must be continued at all levels of

rehabilitation

Mobility – important to encourage activemobility ASAP



Management based on RLASOCF

Low

Mid

High



Thank You

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