THENAN - DANIAL - AINA

Definition
Epidemiology
Classification
Thenan A/L Sankar 132865
 Definition
Traumatic brain injury (TBI) as blunt and/or penetrating injury to the head (above
the neck) and/or brain due to external force with temporary or permanent
impairment in brain function which may or may not result in underlying structural
changes in the brain.

Epidemiology
Injury was the fifth (7.86%) commonest cause of hospitalization
age group between 15-34 years (56.6%) was at the highest risk of major trauma
Road traffic accident was the commonest cause of injury related hospitalisations
Head injury was the commonest diagnosis leading to intensive care unit (ICU) admission
blunt trauma made up 96% of injury
Road trauma accounted for 75% of cases with motorcyclists being most commonly injured.
High proportion 86% of major trauma patients had injuries to the head and neck with AIS >3.85%
of all trauma patients with head injury have some form of intracranial injury.
Based on the World Health Organization Global status report on road safety 2013 , the road traffic
fatality rate was higher than global road traffic fatality rate (25 vs 18 per 100 000 population).
Brain Injury

• To define head injury, three criteria must be present

I. mechanism - presence of external force*

II. anatomical - scalp and/or face and/or skull with or without brain injury
(internal and external)

III. physiological - alteration in physiology of the brain such as LOC or amnesia

 Classification of TBI
1. Glasgow coma scale

Severity GCS score

Mild 13-15

Moderate 9-12

Severe 3-8
Peads GCS
2. Morphology
 3. Imaging
ROTTERDAM CT SCORE

MARSHALL CT CLASSIFICATION OF TBI

Grade 1 = Normal CT scan (9.6% mortality)

Grade 2 = Cisterns present, shift <5mm (13.5% mortality)
Grade 3 = Cistern compressed, shift <5mm (34% mortality)
Grade 4 = Shift >5mm (56.2% mortality)
Monro-Kellie Doctrine

Doctrine states that :

1. Total volume of intracranial contents must
remain constant because cranium is a rigid
container in capable of expanding.
2. Venous blood and CSF can be compressed out
of the container, providing degree of pressure
buffering
-Thus, very early after injury, mass such as
blood clot can enlarged while ICP remains
constant. However, once the limit of
displacement of CSF and intravascular
blood has reached, ICP rapidly increases.
MANAGEMENT OF
TBI
Thenan A/L Sankar 132865
 Referral or Discharge at Primary Care
Setting
Referral of patients with mild head injury to the nearest hospital should be considered if they have the
following factors:

• Glasgow Coma Scale (GCS) of 15 but symptomatic such as

• Amnesia
• Headache
• vomiting
• restlessness
• Age >65 years old
• patients treated with antiplatelets or anticoagulants
• declining GCS score
• alcohol intoxication and substance misuse
• focal temporal blow
• social issues such as transport, communication problem or no supervision by a responsible adult
• other criteria that fulfil indication for CT scan as mention in Algorithm 3 on Selection of Patient for Head CT
 SAFE TRANSFER
Criteria for rapid transfer to hospital
• deterioration in patient’s condition
GCS <15
• focal neurological deficit
• seizure
• suspected skull fracture or penetrating
head injury
• high impact head injury suspected
neck injury
General principles of safe transfer are:
• Ensure haemodynamic stabilisation
• Secure of bleeding prior to transfer e.g. applying
haemostatic suturing for bleeding scalp wound and applying
splint for long bone fractures. intubation if required)
• Total spinal immobilisation (e.g. combination of cervical
collar, head immobiliser, spinal board or stretcher)
• If spinal injury has not been ruled out, the transfer team
should be trained in neuro-trauma management
• Reliable communication equipment between the transfer
team with their hospital and the neurosurgical team
Neurosurgery centres
• HKL
• Hospital Pulau Pinang
• Hospital Raja Permaisuri Bainun , Ipoh , Perak
• Hospital Sungai Buloh , Selangor
• Hospital Sultanah Aminah , Johor
• Hospital Queen Elizabeth , Kota Kinabalu , Sabah
• Hospital Umum Sarawak , Kuching , Sarawak
• PPUM
• HUSM
• HUKM
• Hospital Sultanah Bahlyah , Alor setar , Kedah
• Hospital Tengku Ampuan Afzan , Kuantan, Pahang
Cervical-spine radiography is indicated
for patients with trauma unless they
meet all of the following criteria:
• No posterior midline cervical-spine
tenderness
• No evidence of intoxication
• A normal level of alertnessc
• No focal neurologic deficitd
• No painful distracting injuries
The following parameters should be
used for observation of patients with
head injury:
a) Glasgow Coma Scale and Score
b) Vital signs : Respiratory rate, oxygen
saturation,pulse rate,blood
pressure,pain score,temperature
c) Neurological deficits : Pupil size and
reactivity, limb movement,unusual
behaviour, temperament or speech
impairment
d) Other symptoms such as persistent
vomiting, seizure, amnesia and
diffuse headache
Patients with mild head injury who have been observed for six hours in emergency
department should be admitted if they have
• clinical significant abnormalities on head CT imaging if it is performed
• Glasgow Coma Scale Score <15
• Worrying signs (e.g. vomit >2 times, seizure, diffuse headache, amnesia,
abnormal behavior or neurological deficit)
• Other body system injuries requiring admission
• Social problems or no supervision by a responsible adult

*Patients should have a head CT before admission*

 MEDICATIONS FOR INITIAL
MANAGEMENT
1. Analgesic/ sedation
2. Iv fluids
3. Diuretics
4. Anti-convulsant
1. ANALGESIC
• Analgesic and sedative should be used in severe
head injury patients who are intubated and
ventilated.
• In mild to moderate head injury:
• Analgesia used to control pain
• Short-acting sedative agent may be offered in
titrated dose to control agitation/restlessness
• Indication
• To induce anxiolysis
• To control agitation/ restlessness
• To control pain
• To facilitate mechanical ventilation
• To improve ICP and cerebral perfusion
pressure (CPP)
• Naloxone may be used as opioid reversal in TBI.
2. INTRAVENOUS FLUID 3. DIURETICS

Important in restoration
and maintenances of the
systemic and cerebral
perfusion.
2. Intravenous
fluids
Isotonic crystalloid is a
preferred choice of IV fluid
in head injury.
 4. ANTICONVULSANT
Post traumatic seizure (PTS) defined as recurrent seizure
disorder due to TBI

Can be divided into 3 groups :

• Immediate seizure (occurring within 24 hours)
• Early seizure ( within 7 days of injury)
• Late seizure (>7 days after injury)

Phenytoin should be given as prophylaxis against early

post-traumatic seizure in head injury with risk factors

In a systematic review, IV prophylactic phenytoin

administered within eight hours of injury (ideally in the
first one hour) was efficacious in reducing the incidence
of early PTS in moderate to severe head injury
 The risk factors for PTS include:
• GCS score <10/15
• cortical contusions
• depressed skull fractures
• early intracranial haematoma (ICH)
• wounds with dural penetration (epidural or subdural)
• prolonged length of coma (>24 hours)
• prolonged length of post-traumatic amnesia (>24 hours)
• damage in the region adjacent to the temporal sulcus

Reference:
1. CPG on Early Managment of Head Injury in Adult 2015
Traumatic Surgical Interventions
• Emergency surgery may be needed to minimize additional damage to brain tissues.
Surgery may be used to address the following problems:
• Removing clotted blood (hematomas). Bleeding outside or within the brain can
result in a collection of clotted blood (hematoma) that puts pressure on the brain
and damages brain tissue.
• Repairing skull fractures. Surgery may be needed to repair severe skull fractures or
to remove pieces of skull in the brain.
• Bleeding in the brain. Head injuries that cause bleeding in the brain may need
surgery to stop the bleeding.
• Opening a window in the skull. Surgery may be used to relieve pressure inside the
skull by draining accumulated cerebral spinal fluid or creating a window in the skull
that provides more room for swollen tissues.
• Indications

• aEDH : >30cm3 should be evacuated regardless of the patient’s GCS score

An EDH <30 cm3 and with <5-mm midline shift in patients with a GCS score >8
without focal deficit can be managed nonoperatively with serial computed
tomographic (CT) scanning and close neurological observation in a neurosurgical
center.
• aSDH : midline shift >5mm should undergo surgical evacuation regardless of
GCS score
• Focal Traumatic Parenchymal Lesion :
Progressive neurological deterioration , medically refractory intracranial
hypertension or signs of mass effect on CT should be considered for surgical
evacuation.
Patients with GCS 6-8 with frontal or temporal contusions >20cm3 in volume with
>5mm of midline shift and/or cisternal compression on CT scan, as well as,
patients with any lesion >50 cm3 in size
• Traumatic posterior fossa mass lesions :
Mass effect or with neurological dysfunction or deterioration 
mass effect = distortion, dislocation, or obliteration of the fourth ventricle;
compression or loss of visualization of the basal cisterns, or the presence of
obstructive hydrocephalus
• Depressed cranium fracture :
Open (compound) cranial fractures depressed greater than the thickness of
the cranium should undergo operative intervention to prevent infection.
Open (compound) depressed cranial fractures may be treated
nonoperatively if there is no evidence of dural penetration, significant
intracranial hematoma, depression greater than 1 cm, frontal sinus
involvement, gross cosmetic deformity, wound infection, pneumocephalus,
or gross wound contamination.
Craniotomy and Craniectomy
Thank you