Traumatic Brain Injury

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Traumatic brain injury (TBI) is a significant source of morbidity and mortality throughout the world. This article discusses the epidemiology, pathophysiology, and clinical presentations of minor, moderate, and severe TBI. Controversial topics, such as hypertonic saline for increased intracranial pressure, prehospital intubation of patients who have experienced TBI, and the use of recombinant factor VIIa, are addressed.

Section snippets

Physiology and pathophysiology of traumatic brain injury

A full discussion of the pathophysiology of TBI is beyond the scope of this article; however, major aspects of the physiology and pathophysiology of TBI must be understood because they form the basis of our clinical management. TBI is a dynamic process; a diagram of the contributing factors and cascading pathophysiologic events associated with TBI are shown in Fig. 3. For a more detailed description of brain physiology and pathophysiology following TBI, the reader is referred to several

Secondary brain insults and their relationship to outcome

At the time of head trauma, a series of destructive intracellular and extracellular pathologic processes begin, which include neurochemical, neuroanatomic, and neurophysiologic alterations. Secondary brain insults contribute to these devastating events. Secondary brain insults can be categorized as systemic or intracranial. Examples of systemic secondary brain insults include hypotension, hypoxia, anemia, and hyper- and hypocapnia. Intracranial secondary brain insults include severe

Minor head trauma

Minor head trauma is defined as isolated head injury producing a GCS score of 14 to 15 [23]. It is the most common degree of head injury in patients who present to EDs for evaluation. Most episodes of minor head trauma occur in the context of sports and other recreational activities.

By the time most patients with minor head trauma present to the ED, they are asymptomatic. When symptoms are present, headache is the most common complaint; however, nausea and emesis are common. Patients

Neuroimaging in patients who have minor head injuries

A key management decision for EPs is whether a head CT scan should be obtained on patients who have sustained minor head trauma. Many neurosurgical studies advocate for CT scanning of all patients who have sustained a minor head trauma who give a history of LOC or amnesia for the traumatic event [25], [26]; however, these studies undoubtedly suffer from selection bias, because neurosurgical consultation probably occurs only for a select, more injured population. Other authorities recommend

Concussions

A concussion is a transient brief interruption of neurologic function after minor head trauma, with or without an LOC, usually as a result of acceleration-deceleration forces to the head [30]. Although anyone can sustain a concussion, it is most often a consequence of a sports-related minor head injury. At least 300,000 sports-related concussions are reported yearly to the Centers for Disease Control and Prevention, and as many as 8% of United States high school and college football players

Disposition of patients with concussion

With regard to neuroimaging and disposition, the management decisions faced by the EP for patients with concussion are identical to those for patients with minor head injury. In addition, the EP may be encouraged by coaches, eager parents, and the concussed athletes themselves to allow return to play. From the ED standpoint, patients with a sports-related concussion probably should not be allowed to return to play from the ED even if they are symptom-free; if still symptom-free 1 week after the

Moderate traumatic brain injury: clinical features and acute management

Patients with moderate TBI have a GCS score of 9 to 13. Their clinical presentation can vary widely. Patients may have had LOC, a brief posttraumatic seizure, and be confused, but most patients can follow commands on arrival to the ED. Facial and other systematic trauma often is present. Patients may complain of a worsening headache and nausea. Focal neurologic deficits may be present.

The EP needs to be especially aware of one specific presentation of moderate TBI: the “talk-and-deteriorate”

Epidural hematoma

Epidural hematomas (EDHs) predominately are a result of a direct mechanical force that results in a skull fracture. Most often, this fracture occurs across the middle meningeal artery or a dural sinus. The temporoparietal region is the most likely site for an EDH. EDH is primarily a disease of the young and accounts for 0.5% to 1% of all patients who have experienced TBI [40]. Most often unilateral, the deterioration of a patient who has an EDH from arterial bleeding can be rapid and dramatic.

Prehospital intubations and traumatic brain injury

Controversy exists regarding prehospital intubations in patients with severe and moderate head injuries. It is unclear if field intubations truly improve neurologic outcome or survival. Unsuccessful attempts at field intubations may add to out-of-hospital time and increase the risk for aspiration or hypoxia.

It has long been a tenet in prehospital care that patients who have sustained a severe head injury need necessary airway interventions to prevent hypoxia. Hypoxia and hypotension have been

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