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Traumatic Brain Injury

AHMAD SETYADI

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Definition of TBI

  • Traumatic brain injury (TBI) is an insult to the brain from an external mechanical force, possibly leading to permanent or temporary impairment of cognitive, physical, and psychosocial functions, with an associated diminished or altered state of consciousness.

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Incidence Rates

  • Sixty-nine million individuals are estimated to suffer TBI from all causes each year
  • 1.5 million Americans sustain a TBI each year
  • More than 50,000 people die each year from TBI (22% of people with TBI)
  • The risk of TBI in men is twice the risk in women
  • Based on Riskesdas 2018, TBI was the third cases of injury with 11.9% rate after lower extremity and upper extremity injury.

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Classification

  • Primary Injury
    • Contusion
    • Hematoma (EDH, SDH, SAH, IVH, ICH)
    • Diffuse axonal injury (stress or damage to axons)
  • Secondary injury
    • Systemic hypotension
    • Hypoxia
    • Increase in ICP

EDH

SDH

SAH

ICH

IVH

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Diagnosis

  • Anamnesis: mnemonic AMPLE
  • Physical examination:
    • GCS (severity of TBI)
    • Pupillary Response/Limb weakness
    • Scalp lacerations / bruising-CSF leak,herniation of brain matter
    • Evidence of base skull fracture: racoon eyes, battle’s sign, otorrhea, rhinorrhea
  • Imaging: laboratory study, plain x-ray, CT scan, MRI

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Levels of TBI

  • Mild TBI
    • Glascow Coma Scale score 13-15

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  • Moderate TBI
    • Glascow Coma Scale score 9-12

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  • Severe TBI
    • Glascow Coma Scale score 8 or less

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Management

  • Primary Survey
    • Airway and restriction of cervical spine motion
    • Breathing and ventilation
    • Circulation with hemorrhage control
    • Disability
    • Exposure
  • Secondary Survey
    • History (mnemonic AMPLE)
    • Physical examination
    • Perform serial examinations (note GCS score, lateralizing signs, and pupillary reaction) to detect neurological deterioration as early as possible.

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Management

  • Medication
    • IV fluid RL and normal saline
    • Hyperventilation
    • Mannitol
    • Barbiturate
    • Anticonvulsant
  • Surgical management
    • Burr hole craniotomy
    • Decompression craniectomy

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Prognosis

  • The outcomes after head trauma depend on many factors.
  • Patients with a GCS of less than 8 at presentation have high mortality.
  • Advanced age, comorbidity, respiratory distress, and a comatose state are also associated with poor outcomes.

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