Traumatic Brain Injury 1

What can be done to prevent reinjury in a teenager who sustained TBI?
• Decrease fatality of MVA: airbags and seatbelts reduce fatalities by 50%
• Use of helmet in motorcycle
• Discourage drugs and alcohol
• Prevention of falls (more important in elderly) by decreasing polypharmacy, minimizing sedating medications, and addressing postural hypotension and addressing gait/balance abnormalities.

What are important prognostic factors after severe TBI?
• Avoid telling family percentages
• Initial GCS score
• Length of coma (time until following commands)
• Duration of PTA*: measured by Galveston Orientation and Amnesia Test. The GOAT is a standard technique for assessing PTA, involving orientation questions and memory. It is scored out of 100 pts and 75 is normal. A score of >75 on 2 days in a row marks the end of PTA. 5-10 minutes PTA is mild, 1-24hrs is moderate, 1-7 days is severe, 1-4weeks is very severe, greater than 4 weeks is extremely severe. For moderate severity or less, a quick and full recovery should be expected. For a severe injury, residual deficits are expected.
• Results of early MRI/CT
• Age
• Pupillary reaction to light
• Time since injury (recovery less likely after 6 months)

Why might a teenager with a CT-negative TBI still remain unresponsive 1 week after injury?
• Diffuse axonal injury: can be primary or secondary
• Systemic hypoxia
• Poor cerebral circulation
• Excitotoxicity

What are the national guidelines for early management of severe TBI?
• IVC to monitor intracranial pressure if needed
• Avoid prophylactic hypoventilation
• Use of steroids not recommended (increases mortality)
• Mannitol and saline solution are not TBI treatment standards, but can be used
• Recommend maintenance of Cerebral Perfusion Pressure at > 60 mmHg