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2. s/p

1. signs and symptoms

2. satus post (patient is being seen after an surgery)


1. Signs

2. Symptoms

3. SOA

1. Signs are what the clinician finds upon examination

2. Patients report symptoms (ex. sore throat)

3. Short of air


Traumatic Brain Injury

- TBI, insult to the brain that is not degenerative (progressive) or congenital nature (birth). Caused by an external force that may produce a diminished or altered state of conciousness. Can be caused by a shake, slap, fall, or bullet.


Epidemiology of TBI

- 1.5-1.9 million TBIs occur annually
-#1 cause of disability in kids and young adults
- Risk factors for TBI are determined by age, ethnicity, SES, gender, substance abuse, or recurrent TBI
- Myelin (lipoprotein) not complete until 25
-We care about infants and children with this because it inhibits their growth and learning.


Risk factors for TBI

-Increased risk for persons age 15-24y
-Males > Females; 2:1
-Race is too variable
-One study found that approximately 56% of persons with TBI had a high blood OH+ level (alcohol)
-Mayo Clinic found that risk for recurrent TBI increased 2.8-3.0x for a second TBI and 7.8-9.3x for a third TBI


Closed Head Injury

- CHI-Non-penetrating; Blunt Head Trauma
-Meninges remain intact
-Skull may be fractured-brain has not been exposed
-Associated with diffuse injury
-More common than OHI (children with shaking baby syndrome) damage is widespread


Open Head Injury

- OHI- Penetrating wound
-Coverings of the brain are ruptured due to tearing of the dura by skull fragments and/or other penetrating force
-Associated with focal injury; More common in wartime (specific location in the brain)


TBI Etiologies

- Falls are the most common cause of TBI per age overall
- MVA (motor vehicle accidents) acount for 50% of TBIs persons age 15-24
-Brain Injury (BI) impacts 1in5 households (KY)
-KY BIs are (2x) USA average
-1/3 of ED visits are due to BI
-A child's skull is 1/8th as strong as an adults
-KY has highest # of ATV fatalities


Brain Injury and Sports/Recreation

- BI is #1 cause of sports deaths.

- 65% of sports BI occur in ages 5-18y

- Activities that cause greatest # of ED visits are bicycling, football, playground activities, basketball, horseback riding, and riding ATVs

- < 13% of sports related BI are seen in ED

- number of concussion rates are rising in females and they sustain more than males in
sports played by both sexes

- Football players have a high occurrence of mTBI
- Concussions are mTBI


Primary Brain Damage

-Damage that happens at time of impact:Skull fracture
-Contusion (Bruise)
-Hematoma (Blood Clot- collection of blood)
-Laceration (cut)
-Nerve Damage (DAI- diffuse axonal injury- widespread)
-Part(s) of the brain damaged > than the size of the overall injury


Secondary Brain Damage

Damage that evolves over time following BI:
- Edema (swelling)
- Anemia
- Cardiac changes
- Increased ICP (intracranial pressure)
- Epilepsy- seizures
- Pulmonary changes
- Infection (especially with OHI)
- Hypo/Hyperthermia
- Nutritional changes
- Fever (febrile (low fever) )
- Abnormal Blood Coagulation (clotting issues)
- Other


Closed Head Injury

-BI that occurs secondary to impact causing deformation of the brain resulting in characteristic pathological changes
-MVAs, assaults, suicides, falling objects, and falls
-Leading cause of death under the age of 45y

-Accounts for 25-33% of all deaths related to trauma


Coup/Contrecoup injuries

brain acceleration vs. deceleration-deceleration of the brain- KNOW THIS- head and brain moves forward (hits the steering wheel and then the head slams back with the brain as it hits the chair)


Penetrating Head Injury

-Penetrating head injuries are less common than CHI (OHI)

-Occur secondary to the penetration of an object be it a: bullet, knife, bolt, shrapnel, nails, teeth, screwdriver, or the Eiffel Tower

-These injuries are often described as being: depressed, penetrating, or perforating

- Mortality rate appears lower for AP (anterior/posterior) wounds (25%) than lateral wounds (83%)


Depressed Head Injury

Object does not enter the cranial vault but causes a depressed fracture and cortical contusions


Penetrating Head Injury

Object enters the cranial cavity but does not pass through to the other side


Perforating Head Injury

Object traverses the cranial cavity and exits through a wound characteristically larger than the entry wound


TBI and the military

Recent warring activities in the Middle East, the US is now treating more TBIs than chest or abdominal wounds
As many as 1/3rd combat forces are at risk for TBI
In Iraq/Afghanistan, the ratio of wounded to fatalities is 16:1; while in Vietnam it was 2.6:1
TBI is separate from PTSD but both are co-related


Blast Injuries

-Explosion resulting in over-pressurization related trauma
-Blast-induced BI associated most frequently with high-power explosives
-There are four (+) basic mechanisms of blast injury labeled as:
-Psychological Trauma (PTSD)


Blast Injury Breakdown

-Primary: Occurs secondary to over-pressurization impulse created by a detonated high-explosive usually impacting the auditory, GI, and/or pulmonary systems- can cause rupture of tympanic membrane or abdomen
-Secondary: Injuries that occur secondary to flying objects
-Tertiary: Injuries sustained due to the person becoming airborne
-Quaternary: References burns and crushing injuries from falling objects
-Quinary: Chemical, biological, and/or radiological exposure



-Explosives are categorized as either high-order or low-order types

-High Order (HE): TNT, dynamite, ammonium nitrate

-Low Order (LE): Result in shrapnel-like injuries

-Improvised Explosive Devices (IEDs): Contain both HE and LE



-Concussion is an injury to the brain that is loosely defined as a “jarring” of the brain

-Concussion is the most common type of TBI

-Frequently occurs secondary to violent shaking, a direct blow to the head, or whiplash


Concussion Grading

1. Grade 1- no LOC
PTA< 30 mins

2. Grade 2- LOC< 5 mins
PTA (< 30 mins- PTA < 24 hours

3. Grade 3- LOC >5 mins
PTA > 24 hours


Pyramidal System

The pyramidal system is responsible for volitional motor control; Direct activation pathways


Extrapyramidal System

The extrapyramidal system is responsible for modulating and regulating motor movements; Indirect activation pathways.



The cerebellum does not initiate movement, rather it works in tandem with the EPS to maintain balance/posture and coordination of motor movements; includes motor learning


Dementia Pugilistica

-Punch-Drunk Syndrome or Chronic Traumatic Encephalopathy- common in boxers

-Occurs secondary to repeated concussive blows to the head- could be repeated grade 1 concussions

-Estimated that 10-25% of boxers ultimately develop post-boxing neurological syndrome characterized by cerebral atrophy, cellular loss in the cerebellum, and increased cortical and subcortical neurofibrillary tangles
s/s may begin to appear 12-16y post initiation of boxing career

-Occurs in both professionals and amateurs; NOT JUST BOXING


Dementia Pugilistic Stages

1. Stage 1- affective disorder (mood or attention), mild incoordination

2. Aphasia, apraxia, agnosia (sensory), apathy (indifferent), flat affect, neuro s/s

3. Global cognitive decline and parkinsonism


Second Impact Syndrome

-Occurs when a second TBI occurs prior to the initial one healing
-causes edema and diffuse damage
- LOC does not have to be present


Long term implications of Second Impact Syndrome

- Increased muscle tone (spasticity)
- Rapidly changing emotions
- Muscle spasms
- Hallucinations
- Difficulty thinking and learning


TBI infancy and childhood

-Mean incidence under 15 is 180 per 100K (thousand)
- Fracture of skull is seen in 20-40% of cases
- Abusive head trauma (25% of children <2y)
-Names for abusive head trauma:
Non-Accidental Trauma, Shaken Baby Syndrome, Child Maltreatment, Child Abuse (all used)
-SDH is the most common intracranial injury following abuse


Children with TBI: Symptoms

-Children with TBI may lack the communication skills to report headaches, sensory problems, confusion, and/or similar symptoms:
- Refusing to eat
- Appear listless and cranky
- Altered sleep patterns
- Changes in school performance
- Loss of interest in preferred activities


Abusive head trauma

- Improper name-nonaccidental trauma and shaking baby syndrome
SBS is the leading cause of child abuse deaths in the USA
-KY is #1
-Babies (newborn to 4m) are at greatest risk of shaking
-Inconsolable crying is the #1 trigger for shaking a baby
-1 in 4 babies that are shaken will die
-It is rare that a single instance of noted injury present in the ED is the first occurrence; there is usually a chronic history of abuse


Possible Abusive Head Trauma

-Glassy-Eyed; Fixed Pupils; Fixed Stare
-Somnolence (Sleepiness); Inactivity
- Choking
- Seizures
- Resp. problems
- Inability to lift head/ turn head to the side
- Decreased appetite
- Lethargy and irritability
- Vomiting
- Retinal Hemorrhage
- Bluish Color


Diffuse Axonal Injury

-DAI references the neuropathological changes that occur at the axonal level following trauma
-Damage results from twisting, tearing, and/or shearing of the axon
-Occurs as a person is shaken, and the brain is sloshed around, axons shift or tear, diffuse and happens in greater clumps.


Cerebral Edema

- Brain swelling
-Frequently follows trauma; appears to be more of a secondary injury than a primary injury
-Focal edema is more common in adults whereas diffuse edema is more common in pediatrics
-Cerebral edema results in increased cranial pressure or ICP


Intracranial Pressure

-ICP should be <20mmHg
(millimeters of Mercury) when exceeded, neurosurgical intervention is necessary
-There are at least three mechanisms by which intracranial pressure can be monitored:
1. EVD- extraventricular drain (or intraventricular catheter); thin, flexible tube threaded into one of the two lateral ventricles
2. Screw/bolt- placed into the space between arachnoid membrane and cortex (subarachnoid bolt/screw)
3. Epidural Sensor- placed in the epidural space below skull

EVD and Screw Bolt are more common



-Baby's soft spot. Allows for a greater amount of movement for cerebral edema.

- Bulging fontanelle- increased CSF in the brain (hydrocephalus) and causes craniocinaosis- abnormal head shape


Monroe-Kellie Hypothesis

-The MKH states that the cranial compartment is incompressible; meaning, the volume is fixed and should not change

-The skull, CSF, and brain tissue create a volume equilibrium such that any increase in volume of one of the cranial constituents must be compensated by a decrease in the volume of another

Tumor is a violation of this hypothesis, also a hematoma


Brain shift and herniation

If a hematoma continues to enlarge or focal edema of adjacent brain tissue increases, the brain may be shifted away from the growing mass, and structures that normally lie in the midline may be displaced


Cushing's Triad

-Significant sign of intracranial HTN
-Precursor to herniation
Comprised of three components:
1. Hypertension- high blood pressure (33% chance of herniation)
2. Bradycardia- slow heart beat
3. Resp. irregularity