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TBI & Glasgow Coma Scale

TBI & Glasgow Coma Scale. Mandy Freeman March 2010. Aims. Highlight types of traumatic brain injuries (TBI) Highlight the importance of Glasgow Coma Scale. Aetiology. Annual incidence (US) – 180-220 cases per 100,000 i.e. 600,000 new cases per year (Tennant 1995) Fatal 10%

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TBI & Glasgow Coma Scale

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  1. TBI & Glasgow Coma Scale Mandy Freeman March 2010

  2. Aims • Highlight types of traumatic brain injuries (TBI) • Highlight the importance of Glasgow Coma Scale

  3. Aetiology • Annual incidence (US) – 180-220 cases per 100,000 i.e. 600,000 new cases per year (Tennant 1995) • Fatal 10% • GCS - Mild – 75-80 %, moderate – 10%, severe – 10% • Permanent disability • 100% in severe, 66% in moderate • Male to female ratio – 2:1 (Sosin et al 1996) • Age Range ?

  4. Most common causes?? • (Royal College of Surgeons of England 2007)

  5. Pathophysiology • Skull – rigid, inelastic container • = Vol (Brain) + Vol (CSF) + Vol (Blood) = 80% + 10% + 10% • Monro-Kellie Doctrine – states that total intracranial volume is fixed because of the inelastic nature of the skull • Intracranial compliance – change in the pressure due to the change in volume • Cushings Triad -Sign of ICP

  6. ºLaceration ºBOS # ºContusion ºAbrasion SKULL ºLaceration ºConcussion ºContusions ºEDH – ºSubdural: ºCranial # ºICH ºSAH

  7. EDH • Extradural hematomas • Between inner table of skull and dura • Biconvex • Arterial injury – enlarge rapidly • Venous in around 10% • Classic example – temporal EDH by fracture through course of middle meningeal artery • Lucid interval before deteriorating • If tackled early – good prognosis for isolated lesion

  8. SDH • Subdural hematoma • Between dura and brain • Outer edge – convex, inner – concave • Not limited by suture lines • Usually venous – bridging veins (cortex to dura) • In elderly brain more common due to cerebral atrophy

  9. Management • Mild Head Injury • 3% will progress to more serious injuries • Concussion – majority have concussion – physiological injury to brain without structural alteration • Monitored • Would require neurological observations • When discharged instructed to seek medical attention if severe headache, persistent nausea and vomiting, seizure, confusion, unusual behaviour, watery discharge from ear or nose

  10. Contusions • Most common and evident in minor and major head injuries • Can present with GCS 15/15 worsening over day 3 to 5 Strict fluid balance 2 litre restriction 4hrly Observations

  11. Diffuse Axonal Injury • Neuronal injury in subcortical gray matter or brain stem due to rotation or deceleration injury • Patients with severely depressed level of consciousness • CT – no significant injury • ICP – within reference range • Prognosis - poor

  12. GCS Severity of Head Injury • Mild head injury – GCS 15 - 13 • Moderate head injury – GCS 12 – 9 • Severe head injury – GCS 8 and below

  13. Developed by Jennett and Teasdale (1974) • Assess level of consciousness • 3 categories • Eye opening – E • Motor response – M • Verbal response – V

  14. Glasgow Coma Scale • Best Verbal response • 5 – oriented and converses • 4 – disoriented and converses • 3 – inappropriate words • 2 – incomprehensible sounds • 1 – No response Eye opening 4 – spontaneously 3 – to verbal commands 2 – to pain 1 – No response • Best Motor response • 6 – obeys commands • 5 – Localizes to pain • 4 – flexion withdrawal • 3 – abnormal flexion • 2 – extension • 1 – no response Best – 15 Worst - 3

  15. Poor Outcome • Age older than 60 years • GCS of <5 • Presence of fixed pupil • Prolonged hypotension or hypoxia • Presence of surgical treatable mass lesion

  16. NAI Children • Child with head injury – NAI must be excluded • HI is most common cause of morbidity and mortality in NAI • Multiple bilateral skull fractures, subdural hematomas of different ages, cortical contusions and shear injuries, cerebral ischaemia, retinal haemorrhages

  17. Dunn L, Henry J, Beard D. Social deprivation and adult head injury: a national study. (2003) J Neurol Neurosurg Psychiatry. 74:1060–1064 • National Institute for Clinical Excellence. (2007) Triage, assessment Investigation and early management of head injury in infants, children and adults Clinical Guidelines CG56. NICE; • Swann IJ, Walker A. (2001) Who cares for the patient with head injury now? Emerg Med.18:352–357. • Sosin DM, Sniezek JE, Thurman DJ. (1991) Incidence of mild and moderate brain injury in the United States. Brain Injury. 1996;10:47–54. • Thornhill S, Teasdale G, Murray GD, McEwen J, Yoy CW, Penny KI. Disability in young people and adults one year after head injury: prospective cohort study. BMJ.2000;320:1631–5

  18. Tennant A. Epidemiology of head injury. (1995) In: Chamberlain MA, Neumann VC, Tennant A, editor. Traumatic Brain Injury Rehabilitation: Services, treatments and outcomes. London: Chapman & Hall

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