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StatPearls
Continuing Education Activity
Traumatic Brain Injury is a significant cause of morbidity và mortality in the United States, with an annual occurrence of more than 1.5 million. Falls are the most comtháng cause of traumatic brain injury, & motor vehicle-related incidents are the second leading cause. Blunt head trauma is classified as mild, moderate, or severe traumatic brain injury. This activity describes the etiology, classification, pathophysiology, evaluation, and management of blunt head trauma và highlights the role of interprofessional teams in improving outcomes for such patients.
Objectives:
Describe the etiology, epidemiology, pathophysiology, và classification of patients with blunt head trauma.
đánh giá the conservative sầu & surgical treatment options available for patients with blunt head trauma.
Explain interprofessional team strategies for enhancing care coordination lớn facilitate rapid diagnosis và targeted management of patients with blunt head trauma.
Introduction
Traumatic Brain Injury (TBI) is a significant cause of morbidity và mortality in the United States, with an annual occurrence of more than 1.5 million. Patients with moderate & severe TBI comprise about 20% of TBI, and those with moderate TBI have sầu a mortality of about 15% while those with severe TBI have sầu associated mortality approaching 40%. The majority (approximately 80%) of patients with TBI have mild TBI which is associated with a less than 0.5% mortality, but about 25% experience extended post-concussive symptoms including a headache, dizziness, difficulty concentrating, and depression. <1><2><3>
Etiology
Falls are the most comtháng cause of TBI, & motor vehicle-related incidents are the second leading cause of TBI. Motor vehicle-related TBI includes autoSmartphone, motorcycle, và bicycle accidents và pedestrians struchồng by those vehicles. Sports, recreation, & work-related injuries are the third leading cause of TBI, và assaults are the fourth leading cause of TBI. Blast injuries are the leading cause of TBI in active duty military personnel in war zones.
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<4><5><6>Epidemiology
TBI is the most comtháng cause of death in people younger than the age of 25. The majority of fatal TBI is due khổng lồ motor vehicle-related incidents, falls, and assaults. Mortality due to motor vehicle accidents is greakiểm tra in the young-adult age group attributed khổng lồ alcohol use and excessive speed. Mortality due khổng lồ falls is greademo in patients over age 65, which is also the age group with the highest mortality in any TBI. Neurosurgical intervention such as craniotomy, elevation of skull fracture, intracranial pressure (ICP) monitor, or ventriculostomy is required in about 40% of patients with severe TBI and about 10% of patients with moderate TBI. <7><8>
Pathophysiology
Most patients with moderate to lớn severe TBI have sầu a combination of intracranial injuries. The majority of patients with moderate to severe TBI have sầu related diffuse axonal injury khổng lồ some degree. The diffuse axonal injury typically is caused by a rapid rotational or deceleration force that causes stretching & tearing of neurons, leading to focal areas of hemorrhage and edema that are not always detected on the initial computed tomogram (CT) scan. Subarachnoid hemorrhage (SAH) is the most comtháng CT finding in TBI và is caused by tears in the pial vessels. Subdural và epidural hematomas are the most frequent type of mass lesion identified in TBI. Cerebral contusions occur in about a third of patients with moderate to lớn severe TBI, caused by direct impact or acceleration-deceleration forces that cause the brain khổng lồ strike the frontal or temporal regions of the skull. Intracerebral bleeding or hematoma, caused by coalescence of contusions or a tear in a parenchymal vessel, occurring in up to a third of patients with moderate khổng lồ severe TBI. <9><10>
History và Physical
The majority of patients with TBI have sầu a straightforward clinical presentation, but it is also important khổng lồ solicit the mechanism of injury, current anticoagulation use, symptoms of the head or neck pain, post-traumatic seizure, and any history of repeat head injury or past central nervous system surgeries.
The initial resuscitation should proceed in a step-wise fashion lớn identify all injuries and optimize cerebral perfusion by maintaining hemodynamic stabilization và oxygenation. The initial survey also should include a brief, focused neurological examination with attention khổng lồ the Glasgow Coma Scale (GCS), pupillary examination, and motor function.
After addressing any airway or circulatory deficits, a thorough head-to-toe physical examination must be performed with vigilance for occult injuries & careful attention khổng lồ detect any of the following warning signs<11>:
Fundoscopic examination for retinal hemorrhage (a potential sign of abuse in children) & papilledema (a sign of increased ICP)
Optic nerve sheath diameter of greater than 5 milimet on ultrasound has been shown khổng lồ correlate well with increased intracranial pressure in patients with TBI
Palpation of the scalp for hematoma, crepitus, laceration, và bony deformity (markers of skull fractures)
Auscultation for carotid bruits, painful Horner syndrome or facial/neck hyperesthesia (markers of carotid or vertebral dissection)
Evaluation for cervical spine tenderness, paresthesias, incontinence, extremity weakness, priapism (signs of spinal cord injury)
Evaluation
Non-contrast cranial CT is the imaging modality of choice for patients with TBI. CT findings associated with a poor outcome in TBI include midline shift, subarachnoid hemorrhage inkhổng lồ the verticals, and compression of the basal cisterns. Magnetic Resonance Imaging scan may be indicated when the clinical picture remains unclear after a CT khổng lồ identify more subtle lesions.<13><14>
Treatment / Management
Airway adjuncts are indicated in patients not able to lớn maintain an open airway or maintain more than 90% oxygen saturation with supplementary oxyren. Oxygenation parameters should be monitored using continuous pulse oximetry with a target of more than 90% oxyren saturation. Ventilation should be monitored with continuous capnography with an end-tidal CO2 target of 35 mmHg to 40 mmHg. Placement of a definitive sầu airway is recommended in the patient with a Glasgow Coma Scale (GCS) score of less than 9. <15>
Systemic hypotension negatively impacts the outcome in the setting of TBI, & current studies have sầu demonstrated improved outcomes in patients with systolic blood pressure (BP) greater than or equal khổng lồ 1đôi mươi mmHg. Isotonic crystalloids should be used khổng lồ prevent và correct hypotension; colloidal solutions have sầu not been shown khổng lồ improve outcomes.
Serial neurological examinations allow for early identification of patients with elevated ICP.., & subsequent implementation of primary bedside interventions lớn improve sầu venous outflow và reduce metabolic demands. Initial bedside approaches to lớn increase ICPhường. include elevating the head of the patient"s bed 30 degrees, ascertaining that the cervical collar is not impeding venous outflow, & appropriate analgesics and sedation.
Routine hyperventilation should be avoided during the first 24 hours, & should only be used as a temporizing measure in the setting of impending herniation. Hyperosmolar therapy such as mannitol or hypertonic saline can further reduce intracerebral volume. ICPhường monitoring is indicated in patients with TBI when they have a GCS score of less than 9, an abnormal CT, và the approach to lớn refractory elevated intracranial pressure includes high-dose barbiturates & possibly a decompressive hemicraniectomy.<16>
