traumatic brain injury

traumatic brain injury

Traumatic brain injury (TBI) – damage to the mechanical energy of the skull, and intracranial contents (brain, meninges, blood vessels, cranial nerves). The concept of TBI includes not only the clinical picture that develops in the first hours and days after the injury, but also a complex of physiological and clinical manifestations inherent in the recovery period (sometimes lasting for years). Frequency

• • In Russia, brain damage occurs annually in more than 1,200,000 people
  • Leading underlying cause of death in men under 35
  • Most often occurs in traffic accidents (in 50% of cases), falls, fights, sports (with an increased risk of head injury).

Classification

t By the nature of TBI

• • Closed and open. Criterion – violation of the integrity of soft tissues, including tendon aponeurosis
  • Non-penetrating and penetrating. The criterion for penetrating TBI is damage to the meninges, CSF leakage.
  • According to the extent of damage
  • Focal (brain contusion, intracerebral hematomas)
  • Diffuse (concussion, diffuse axonal damage).
  • Associated injuries
  • Isolated – damage only to the head (due to mechanical impact)
  • Combined – TBI in combination with traumatic injury to other parts of the body (facial skeleton, internal organs, limbs)
  • Combined – TBI (lesion as a result of exposure to a mechanical factor) in combination with burns, radiation damage, etc.
  • according to the clinical form
  • Brain concussion
  • Focal brain contusion (mild, moderate, severe)
  • Diffuse axonal injury
  • Brain compression.
  • By severity
  • Mild degree – concussion, mild contusion of the brain
  • Moderate degree – brain contusion of moderate severity
  • Severe degree – severe brain contusion, increasing compression of the brain.

Clinical signs

• • Loss of consciousness
  • Signs of head soft tissue injury
  • Cerebral symptoms occur with increased ICP – with cerebral edema, additional volumes in the cranial cavity (for example, hematomas). See Cerebral edema, Brain compression
  • Focal neurological symptoms (depending on location)
  • Signs of increasing compression of the brain: depression of consciousness, an increase in symptoms of damage to the cerebral hemispheres, the appearance of clinical signs of brain stem dysfunction
  • Post-traumatic amnesia (duration depends on the severity of the injury).

Diagnostic tactics

• • Consistent assessment of vital functions (the question of the need to involve resuscitators), level of consciousness, severity of the condition on the Glasgow scale and assessment of focal neurological disorders
  • Plain radiography of the skull in frontal and lateral projections, echoencephalography (detection of displacement of median structures), dynamic observation, CT/MRI
  • CT/MRI is recommended for all patients who are unconscious for more than 2 hours, as well as for all patients with focal neurological symptoms.
  • X-ray examination of the cervical spine – in 5% of patients with severe TBI, a concomitant fracture of the cervical vertebrae is observed.

Differential diagnosis – coma of various etiologies (diabetes mellitus, cerebrovascular accident [fall may be the result of a stroke], alcohol intoxication, drug overdose).

Treatment:

Diet. In the unconscious state – parenteral nutrition, in the semi-conscious state – diet number 0. Management tactics

• • Mild TBI – there is no need for specific therapy. Hospitalization, dynamic observation and symptomatic treatment are indicated.
  • TBI of moderate and severe degrees
  • Immediately after the restoration of airway patency (if necessary, intubation), the victim is immobilized and transported to a specialized medical facility
  • Transportation: in the supine position on a rigid plane, the use of immobilization splints in case of suspected concomitant limb injuries
  • With combined and combined TBI, treatment of concomitant emergencies will be necessary.

Surgery

• • In many situations, the only way to save the patient
  • With open TBI, primary surgical treatment of soft tissue wounds is necessary.
  • The indication for trepanation and intervention in the cranial cavity is compression and dislocation of the brain. Conservative therapy
  • Maintenance of vital functions, if necessary – resuscitation.
  • Treatment of cerebral edema
  • Osmotic diuretics: mannitol (mannitol) – 1 g / kg IV every 8 hours
  • Furosemide up to 20 mg IV
  • Hyperventilation (IVL with pCO2 30 mm Hg) – an increase in the oxygen content in the blood, which leads to a narrowing of the vessels of the brain and a decrease in its volume
  • The introduction of large doses of glucocorticoids to reduce cerebral edema in TBI is not recommended.
  • Analgesics, incl. narcotic (for example, morphine hydrochloride 4-12 mg every 2-4 hours) – if necessary.
  • Anticonvulsants, such as carbamazepine, for convulsions.
  • Chlorpromazine (chlorpromazine) 50 mg intravenously, haloperidol 2-5 mg intramuscularly – with severe motor restlessness.
  • With open TBI, as well as in the postoperative period – broad-spectrum antibiotics.
  • Means that improve cerebral circulation, regulate metabolic processes (dimephosphone, sermion [nicegoline], nootropil, reopoliglyukin, pentoxifylline, cerebrolysin, aminalon, encephabol).
  • Protease inhibitors (gordox, contrical, trasylol).

Complications

• • Pyoinflammatory (meningitis, encephalitis, brain abscess, subdural empyema, osteomyelitis of the skull bones)
  • Neurovegetative (changes in peripheral and central hemodynamics, thermoregulation)
  • Psychopathological. Course and forecast
  • The milder the severity of TBI, the better the prognosis
  • TBI is more severe with alcohol abuse, the presence of previous TBI
  • TBI prognosis depends on age
  • Adults: positive dynamics is best expressed during the first 6 months after TBI, after 2 years there is no further improvement in the condition
  • Children: the prognosis for functional recovery is more favorable. Babies are less likely to develop intracranial hematoma, which is more common in adults.
  • Elderly: tendency to worsen the prognosis of the disease with increasing age of the patient. Subdural hematomas often develop with a blurred clinical picture.
  • Mortality in severe TBI reaches 50%
  • If consciousness begins to clear within 1 week after a severe TBI, the prognosis is favorable
  • Signs of primary brainstem damage (coma, irregular breathing, lack of response to light, loss of oculocephalic and oculovestibular reflexes, diffuse muscle hypotension) almost always imply severe TBI and poor prognosis
  • The most severe form of TBI is an injury that causes an almost complete disruption of the functions of the cerebral cortex while preserving the brain stem. Survivors remain in a vegetative state for a long time, lasting several years with adequate care. Most often, recovery from a vegetative state occurs within 3 months, and after 6 months, recovery is extremely unlikely.

Exodus

• • Almost complete recovery
  • Moderate disability
  • Gross disability
  • Vegetative state
  • Death.

See also Subdural hematoma, Epidural hematoma, Traumatic brain injury disorders, Brain compression, Concussion, ICD cerebral contusion

• S06 Intracranial injury
• T90.5 Sequelae of intracranial injury