1. Wayne Triner, DO, MPH, FACEP
Professor, Emergency Medicine
Albany Medical College &
State University at Albany

2.  All TBI 790
/ 100,000 py
 Mod to Severe 41
/ 100,000 py
 1.2 x risk Maori
 2-5 x risk in rural
the incidence of TBI per 100 000 people
per year (790 cases), especially mild TBI
(749 cases), in New Zealand was
substantially greater than in other high-
income countries. in Europe (47–453
cases) and North America (51–618
cases).

4.  Primary
 Direct tissue injury
 Secondary
 Cerebral perfusion/edema
 Vasoregulation
 Tissue ischemia
 Herniation

5.  Cerebral Blood Flow
CBF ~ CPP – CVP
 Cerebral Perfusion Pressure
CPP = MAP – ICP
CBF ~ (MAP – ICP) - CVP

6.  Mild
 GCS > 12
 Moderate
 GCS 12-8
 Severe
 GCS < 8

7. Eye Opening  Mild
 4=Spontaneous
 GCS > 12
 3=To voice
 2=To pain  Moderate
 1=None  GCS 12-8
 Severe
Verbal  GCS < 8
 5=Normal conversation
 4=Disoriented conversation
 3=Words, but not coherent
 2=No words......only sounds
 1=None
Motor
 6=Normal
 5=Localizes to pain
 4=Withdraws to pain
 3=Decorticate posture
 2=Decerebrate
 1=None

8.  GCS 13-15
 < 30 minute LOC
 Non-focal exam

9.  Short term  Long term
 Mood and cognitive  Depression
disturbances  Dementia
 Validation  Parkinson’s
 Variable rate of CT  Cognitive deficits
abnormalities

10. The goal being identification of significant
conditions amenable to intervention

11. LEVEL I RECOMMENDATION LEVEL II RECOMMENDATION
A noncontrast head CT is indicated A noncontrast head CT should be
in head trauma patients with loss of considered in head trauma patients
consciousness or pos- traumatic with no loss of consciousness or
amnesia only if one of the post-traumatic amnesia if there is
following is present: focal deficit, vomiting, severe
headache, vomiting, age > 60 headache, age > 65 years, signs of
years, drug or alcohol basilar skull Fx, GCS < 15,
intoxication, deficits in short-term coagulopathy or dangerous
memory, physical evidence of mechanism (ejection from vehicle,
trauma above the pedestrian struck, fall of more than
clavicle, posttraumatic seizure, GCS 3 ft or 5 stairs)
< 15, focal deficit or coagulopathy.
Clinical Policy:
Neuroimaging and Decisionmaking in Adult Mild Traumatic Brain Injury in the Acute Setting
ACEP 2008

12.  Understand the risk factors
 Age
 Small brains
 Inability to fully evaluate
 Propensity for bleeding
 Mechanism and evidence of trauma
 Recognize neurological abnormalities
 HA, vomiting, focal deficits

13.  Recommendations
 “Neuro rest”
 Proven
 ?????

15.  ABCs
 Limit secondary brain injury
 Preservation of CBF
 Issues of coagulation
 Reversal of coagulopathies
▪ F VIIa
▪ Prothrombin complex concentrate
▪ Vit K and FFP

16.  “Evidence based”
 Standards, Guidelines and Options
• Preserve oxygenation
(at all costs)
• Avoidance of hypotension
(SBP < 90)
• Euventilation

17. Rapid reduction in ICP
 3 compartment
model
 Below pCO2 < 23,
CBF < 20
ml/100g/min

18.  Preserve oxygenation (at all costs)
 Issues of airway management
▪ Pre-hospital ETT
▪ Neuro-protective RSI
▪ Laryngeal manipulation
▪ Hypotension
▪ ICP management

19.  Avoidance of hypotension (SBP < 90)
 Preserve CBF
 Control of cerebral edema
▪ Brief hyperventilation
 Hyperosmolar therapy

20.  Recommendations;
 Level II
▪ Mannitol is effective for the control of raised
intracranial pressure at doses of 0.25 to 1 g/kg.
Hypotension (SBP < 90) should be avoided
 Level III
▪ Restrict mannitol use prior to ICP monitoring to
patients with signs of transtentorial herniation or
deteriorating mental status not attributable to other
causes
 Mechanism of Action
 Blood rheology
▪ immediate plasma volume expansion
 Osmotic redistribution
 Hypertonic Saline
 23.4% 50 ml

21.  Typically uncus herniating across tentorum
 CN III compression
▪ pupillary dilitation
▪ 80% ipsilateral to side of structural lesion
 Pyramidal tract compression
▪ Contralateral weakness
▪ 80% contralateral to side of structural lesion
 Rapid deterioration of mental status
 Cushing’s reflex

22.  No Level I or II recommendations
 Level III:
 No change in all-cause mortality
 46% improved chance of favorable outcome (GOS
4-5)
 Some evidence of improved outcome with > 48
hours of cooling

23.  Most common CT finding
in TBI
 Often occurs in concert
with other imaging
abnormalities
 Neuro deficits reflect
parenchymal injury and
generally not a vascular
insult

24.  High Mortality Rate
 Association with Skull Fracture

25.  Acute
 Higher Mortality Rate
Than EDH
 underlying brain injury
 co-morbidity
 Chronic
 Subacute

26.  Presence of
contusion does not
independently
predict outcome

27. • Cisterns
• Gray – White
Interface

28.  Decompressable lesion with neuro findings
 SDH, EDH, very few contusions
 Traumatic SAH is not decompressable and not an
indication for aneurysm screening
 Indications of increasing ICP
 Deteriorating mental status
 Herniation syndromes
 Decompressive craniectomy

29.  Cerebral edema  ICP determination
 Monitoring  early detection of mass
 GCS < 8 and Abnormal lesions
Head CT  limit potentially harmful
 GCS < 8 and Normal therapies
Head CT with...  determination of
▪ age > 40 prognosis
▪ posturing  CSF drainage*
▪ hypotension

30.  All about GCS
 GSW injury reflect patterns of ballistics

31.  Issues in
management
 Hearing
 Antibiotics
 Disposition

32. 1 Fearnside MR, Cook RJ, McDougall P, et al.: The Westmead Head Injury Project outcome in severe head injury. A comparative analysis of pre-
hospital, clinical, and CT variables. Br J Neurosurg 7:267-279, 1993.
2 Braakman R: Interactions between factors determining prognosis in populations of patients with severe head injury. In Frowein RA, Wilcke O,
Karimi-Nejad A, et al. Advances in Neurosurgery: Head Injuries-Tumors of the Cerebellar Region. Springer-Verlag, Berlin: 12-15, 1978.
3 Phuenpathom N, Choomuang M, Ratanalert S: Outcome and outcome prediction in acute subdural hematoma. Surg Neurol 40:22-25, 1993

33.  Strong factor in determining outcome from
severe TBI
 This holds true even after correcting for co-
morbid conditions.

34.  TBI Biomarkers
 Need for imaging
 Validation
 Prognostication
 Intervention
 Hypothermia
 Progesterone
 Reduction of oxidative stress