TRAUMATIC BRAIN INJURY AND GLASGOW COMA SCALE.DR. DAMIAN LASTRA COPELLO..pdf

Traumatic Brain Injury (TBI) is defined as a sudden exchange of mechanical energy caused by an external force, which could results in an alteration at the anatomical and functional level of the brain and its meningeal envelopes (dura mater, arachnoid and pia mater), the cranial vault that protects it and the epicranial soft tissues (scalp), in a permanent or temporary way.

1. TRAUMATIC BRAIN
INJURY AND GLASGOW
COMA SCALE
REPUBLIC OF THE GAMBIA
SHARAB MEDICAL CENTER
Dr.DamianLastra Copello. Senior Consultant
Neurosurgeon. Emergency and Critical
Care Fellowship. Spine Surgery and Neuro-
Oncology Training. Lecturer. Researcher.

2. “…A task may
seem impossible
until it is
done…”
Nelson Mandela

3. Conference objective
1.Identifythemainsignsandsymptomsthatwecanseeina
patientaftersufferaTraumaticBrainInjury
2.Specifythetherapeuticoptionsandthestandard
treatmentprotocolforpatientswhosufferasimple,
moderateorseveretraumaticbraininjury
3.InterpretationoftheGlasgowComaScaleand
establishingitsuseforClinicalMonitoringinPatients
admittedbyNeurosurgeryServiceinourcenter

4. Summary:
Epidemiology, Historical Perspective and
Concept
Classification.
Clinical manifestations.
Neuro -imaging and others Investigations
Assistance, (GCS) –Clinical-neurological
monitoring and Standard Treatment Protocol

5. Traumatic brain injuries (TBI) represent a
serious health problem
In general, the incidence has been
estimated at 200 cases per 100,000
people around the world.
62% of TBI are caused by traffic accidents
Epidemiology

6. EPIDEMIOLOGY
INCIDENCE
200/100,000 citizens
(470,000 new cases per year)
This health problem is classified in the
scientific world as the pandemic of
silent death.

7. Traumatic Brain Injury From
Historical Perspective

8. The first information about Brain Trauma was
founded in an ancient text, called The
Surgical Papyrus of Edwin Smith, written
around more than1550 BC.

9. TBI -HISTORY
-Sir Victor Horsley (1857-1916) London.UK was the first neurosurgeon
appointed to the National Hospital Queen Square, and was known
worldwide as the 'Father of Neurosurgery'. Began to develop first
Concepts on Cranial Trauma, continuing this sphere with greater depth
and development of his student
Dr. Wilfred Trotter (3 November 1872 –25 November 1939)was an
English surgeon, a pioneer in neurosurgery

10. DR. Harvey Williams Cushing, invited by Professor
William Williams Keen, wrote a chapter in the book
“Surgery. Theoretical-practical treatise on surgical
pathology and clinic”. 1912
The proposed classification of skull
fractures according to the mechanism
of production is analyzed.

11. Concept:
TraumaticBrainInjury(TBI)isdefinedasasuddenexchangeof
mechanicalenergycausedbyanexternalforce,whichcould
resultsinanalterationattheanatomicalandfunctionallevelof
thebrainanditsmeningealenvelopes(duramater,arachnoidand
piamater),thecranialvaultthatprotectsitandtheepicranialsoft
tissues(scalp),inapermanentortemporaryway.

12. CLASSIFICATION
There are multiple classifications
based on different criteria:
Pathophysiological
Trauma Mechanism
Anatomo-pathological
Clinical
According to severity of the Trauma
(Glasgow Scale)
?
?

13. Pathophysiology.
TheTBIoccursin2phases:
Primaryinjury(firstphase):mechanicaldamagecausedat
thetimetheinjuryoccurred.
Secondaryinjury(secondaryphase):hypoxia,ischemiaor
elevatedintracranialpressure.

14. CLASSIFICATION
TRAUMA MECHANISM
Impact and Deceleration
Acceleration Deceleration
Compression and Crushing

15. ANATOMOPATHOLOGICAL CLASSIFICATION
Softpartsof theHead:
-Wounds, bruises, sub-galial
hematoma, :

16. ANATOMOPATHOLOGICAL CLASSIFICATION
SKULL:
We can find:
-Vault Fracture (70%)
-Linear, depressed, comminuted and
ping-pong fractures (COMMON IN PEDIATRIC
PATIENTS UNDER 3 YEARS OLD)
-Skull Base fractures (30%)
-Anterior Cranial Fossa
-Middle Cranial Fossa
-Posterior Cranial Fossa

17. ANATOMOPATHOLOGICAL CLASSIFICATION
Meninges:
WHEN THE DURA MATTER OF THE BRAIN IS
EXPOSED, the trauma is considered
open.
If the bone fragment breaks the dura
mater, it is called Penetrating Fracture.
There may be JUXTADURALblood
collections:
-Epidural HEMATOMA
-Subdural HEMATOMA
-Subarachnoid HEMORRHAGE

18. ANATOMOPATHOLOGICAL CLASSIFICATION
Brain:
-Edema.
-Epidural hematoma
-Subdural hematoma.
-Intraparenchymalhematoma.
-Subarachnoidhemorrhage.
-intraventricularHemorrhage
-Focal concussion

19. CLINICAL CLASSIFICATION

20. -Simple SkullTrauma
-Transientconcussion
-Focal brainconcussion
-BRAIN COMPRESSION

21. BRAIN COMPRESSION
Post-traumatic conditionthatisclinically
characterizedbyAcuteIntracranialHypertension
Syndrome:(CUSHING'STRIAD)

22. GLASGOW COMA SCALE
(SEVERITY AND STATE OF CONSCIOUSNESS)
GLASGOW CITY. SCOTLAND

23. GCS
DR.GRAHAM TEASDALE.
AMERICAN NEUROLOGIST
1974
DR.BRYAN JENNET.
BRITISH NEUROSURGEON

24. GCS

25. CLINICAL CRITERIA FOR DIAGNOSIS OF
SEVERE HEAD-BRAIN TRAUMA
-An-isochoric pupil (unilateral pupillary dilation)
caused by Brain Compression
-Brain tissue exposure
-GCS equal to or less than 8 points
-Hemodynamic instability (brain stem injury -Cushing's
Triad)

27. These patients require dynamic,
continuous and coordinated treatment.
All factors of the multidisciplinary team in
Emergency Service must intervene ON
PATIENT TREATMENT
Intervention and Nursing
Procedures in patients with TBI

28. A Airway
B Breathing
C Circulation
D Neurological Deficiency
E Exposure or Exposition
PolytraumatizedPatient with
CranioencephalicPredominance

29. URGENT
INVESTIGATIONS(mandatory)
SKULL X RAY ,CERVICAL SPINE X RAY, SIMPLE CHEST X RAY
AND ANOTHER INTEREST BONE STRUCTURE ( PELVIC BONE)
RBS, FBC, ELECTROLYTES
BRAIN CT SCAN, CERVICAL SPINE CT SCAN

30. CONDUCT TO FOLLOW MODERATE AND SEVERE TBI
Initial priorities…
-PERMEAVILIZATION of Airways WITH CONTROL OF
CERVICAL SPINE (Philadelphia Collar)
-Maintain pump function and cardiovascular
volume.
-Prevent external bleeding.
-Prevent and treat intracranial hypertension

31. Cervical Spine Control (Philadelphia Collar)
Checking peripheral pulses and blood pressure figures
Initial intermittent supplemental oxygen support by nasal
catheter at rate of 3 L/min or mask at rate of 5 L/min until
evaluation by NS or ICU Specialist
Place Peripheral Vein cannula or Central Vein Catheter,
(failing that 2 peripheral veins cannula-never in lower
limbs)
Place urinary catheter (Foley or Nelaton )
COMPRESSION BANDAGE OF WOUNDS OR SUTURING OF
WOUNDS
Admission, Recognitionand
Transportation. Moderateand Severe
TraumaticBrainInjury(STANDARD
PROTOCOL)

32. PATIENT WITH SCORE ON GLASGOW
COMA SCALE EQUAL TO /-OR
LOWER THAN 8 POINTS REQUIRES
OROTRACHEAL INTUBATION AND
INVASIVE MECHANICAL
VENTILATION

33. Normal Saline 0.9% 500 ml + Magnesium Sulfate 10%, 1ml +
Potassium Chloride K CL 25.6 meq ½ amp + Ca Gluconate 10% or
87.3 meq ½ amp.
Physiological Glucose Solution. (Normal Saline 0.9% 500 ml plus
Hypertonic Dextrose 20% 1 amp. (Only if blood glucose values
have been found in emergency laboratory results lower than
permissible limit, otherwise it is not recommended to administer
glucose solutions)
Volume contribution Running 1
hour. (Until evaluation by
Neurosurgery or ICU Specialist)

34. USE OF BRAIN DEHYDRANTS
AND CRITERIA FOR TRANSPORTATION AND REFERRAL
The patient must be transported with a therapy that treats
the initial reaction of the brain to the trauma, which is
cerebral edema, with specific medications such as:
-Mannitol (1.5 to 2g X Kg of body weight)
Maintenance-0.25 to 0.50 g/kg/30min –every 4 hours
-Furosemide 1 -2mg /kg-Start Dose
Maintenance (0.30 to 0.60 mg x kg body weight or 40 mg
TDS or BD

35. Follow Central Venous Pressure
Follow a Hydromineral Balance Sheet
Follow Hourly Diuresis
Continuous clinical monitoring every 2
hours of vital signs and neurological state
ICU

36. Administer Dextrose
Transport patients without cervical spine stability, in
addition to compressive bandage and
hemorrhage control.
Transport patients without a patent venous
catheter and without a urinary catheter
What should not be
done

37. -Patel HC, Menon DK, TebbsS, Hawker R, Hutchinson PJ, Kirkpatrick PJ.
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Long-term follow-up of patients with mild traumatic brain injury: a mixed-
method study. J RehabilMed. 2017;45(8):758-64.
-2012; 22:341–353. 43. Thompson HJ, DikmenS, TemkinN. Prevalence of
comorbidity and its association with traumatic brain injury and outcomes in
older adults. Res GerontolNurs. 2012;5(1):17-24. 44.
-Bratton SL, Chestnut RM, GhajarJ, McconnellHammond FF, Harris OA, Hartl
R, et al. VI. Indications for intracranial pressure monitoring. J Neurotrauma
[Internet]. 2017 [citado2 Mar 2018]; 24(Suppl1):37-44. Di
-http://online.liebertpub.com/doi/pdf/10.1089/neu.2015.9990. 45. ----
DeardenM, TeandaleGM, BraakmanR, CohadonF, IonnottiF, KorimiA,
et al. EBIC-Guidelines for Manaagement of Severe Head Injury in Adults.
ActaNeuroenir(wient) 1997 139: 286-94. 46.
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depicted on multidetectorcomputed tomography angiography predicts
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40. THANK YOU SO MUCH