INTRO TO TBI
A.J. RUSH, MD
EPIDEMIOLOGY
• #1 cause of disability in US
• 12% of hospital admissions
US Annual ER Visits Hospitalizations Deaths
Total # 1.4m 275k 52k
#/100k 468 93 17
RISK FACTORS
• Age • Medical: Parkinson’s,
• 0-4, 15-24, >65 anticoagulants, diabetes,
dementia, arrhythmia,
depression, previous TBI
• Males
• Socioeconomic: Young, single,
minority males
• Alcohol
• Race: Very related to
socioeconomic status,
• Protective equipment
mechanism
SEVERITY
Mild Moderate Severe
24° GCS ≥13 9-12 ≤8
Post-traumatic amnesia 0-1 days 1-7 days >7 days
Alteration of consciousness <24° >24°
LOC <30’ 30’-24° >24°
Imaging Normal (DoD) Normal or abnormal
Normal or abnormal (CDC)
COGNITIVE RECOVERY SCALES
Rancho Braintree
I. Coma (same)
II. Vegetative (generalized response) (same)
III. Min responsive (localized response) (same)
IV. Confused, agitated
4. Confusional state
V. Confused, inappropriate
VI. Confused, appropriate 5. Post-confusional/
VII. Automatic, appropriate emerging independence
VIII. Purposeful, appropriate: stand-by assist
6. Social competence/
IX. Purposeful, appropriate: stand-by assistance on request
community re-entry
X. Purposeful, appropriate: modified independent
FUNCTIONAL OUTCOME SCALES:
DISABILITY RATING SCALE (DRS)
• 0 (normal)-30 (coma)
• Reverse GCS (0 good, 15 bad)
• Feeding, toileting & grooming
• Cognitive ability only, 0-3 points each
• Global assessment of functioning, employability
• Include physical limitations, 0-5 and –3 points, respectively
• Granular: 84% show improvement
• Very high reliability & validity
• Correlates -0.84 with FIM cognitive & -0.77 with FIM motor
FUNCTIONAL OUTCOME SCALES
• Glasgow Outcome Scale (GOS) • Extended Glasgow Outcome Scores
1. Death (GOSE)
2. Vegetative state 1. Death
3. Severe disability: follows commands 2. Vegetative state
but unable to live independently 3. 24° dependency at home
4. Moderate disability: lives 4. Independent for ≥8°
independently but no work/school
5. Independent but no work/school
5. Good recovery: returns to
6. Reduced capacity for former work
work/school
7. Resumption of former work but
• Insufficiently granular, only 33% show
interferes with daily activities
improvement
8. Complete recovery
FUNCTIONAL OUTCOME SCALES COMPARED
GOS GOSE DRS
1. Dead 1. (same) 29: Dead?
2. Vegetative 2. (same) 25-29: Extreme vegetative
22-24: Vegetative
3. Severe: Follows commands; 3. 24° dependent at home 17-21: Extremely severe
doesn’t live ind’ly 4. Independent for ≥8° 12-16: Severe
7-11: Moderately severe
4. Moderate: Lives ind’ly; 5. (same) 4-6: Moderate
doesn’t work
5. Good: Returns to work 6. Reduced capacity for former 2-3.5: Partial
work 1: Mild
7. Former work but daily 0: Normal
interference
8. Complete recovery
POOR PROGNOSTIC
FACTORS
• MRI
• Brainstem lesions: <7% of patient with
b/l brainstem lesions have GOS good
outcome
• DAI
• CT
• Traumatic SAH
• Midline shift
• Cisternal compression
• SDH
• EDH
POOR PROGNOSTIC FACTORS
• GCS
?
• No thresholds
• Length of coma
• <2 weeks: severe disability unlikely
• >4 weeks: good recovery unlikely
• PTA
• <2 months: severe disability unlikely
• >3 months: good recovery unlikely
• Age
• Good recovery unlikely >65 years
PATHOPHYSIOLOGY CATEGORIES
Diffuse Focal
Diffuse axonal injury (DAI Focal cortical contusion
Primary
Petechial white matter hemorrhage with Intracerebral hemorrhage
diffuse vascular injury
Extracerebral hemorrhage
Delayed neuronal injury
Secondary
Brain swelling
Ischemic injury
Hypoxic injury
Metabolic dysfunction
CONCUSSION
• Simple
• About 80% of patients who present to physician recover in 7-10 days
• “Brain rest”—no more than a couple days!!
• Complex
• >7-10 days
• Treat the symptoms
• Post-concussion syndrome
• Presence of ≥3 typical symptoms at least 6-12 weeks post injury
• 99% eventually recover, the rest have premorbid psych issues
CONCUSSION & RETURN TO PLAY
• 1 concussion, full recovery, wait 10 days: risk for repeat almost down to general
population
• ≥3 concussions, full recovery, RR for repeat 3-4
• Don’t know how much of that is inherent risk versus risky style of play
• AAP
• Two concussions in a season and kid out for a season
• Younger kids higher risk than teens, who are higher risk than college/adult
• Sports are good for you
• Exercise, socialization…
• Even the NFL data indicates greater longevity and less health, including mental health, risks
• Rochester data: no increased risk of early death or neuro dz
TBI PHARMACOLOGY
A.J. RUSH, MD
RANCHO 1-2
• Seizure: Stop AEDs after 7 days if no seizures (immediate post-trauma seizures don’t
count, though almost ½ are assoc w/ bleed)
• Early sz 5%
• Late 4-7%
• BP: propranolol (see PSH presentation)
• DVT: Tanner 4 and up
• Dopamine depletion
• Start dopaminergic (amantadine, etc) to increase rate of emergence to Rancho 5
• Watch for agitation, hypertension
• Will not change eventual outcome, just rapidity of early stages
• Start now to eliminate benzos (except for seizures) and PRNs
• Check HR variability (see PSH)
RANCHO 3
• Paroxysmal Sympathetic Hyperactivity aka “Storming”
• Short answer: Disinhibited sympathetic tone in response to noxious
stimuli
• Long answer: See PSH talk
RANCHO 4
• Valproic acid & quetiapine are peanut butter & chocolate
• Start low, frequent doses (e.g. 50-100mg & 12.5-25mg, respectively, q1° PRN agitation in
adult)
• Let them self-titrate to necessary dose, then schedule it TID-QID
• Watch ammonia level (it’ll go up before LFTs), start levocarnitine if it starts to climb
• Plan B: Tegretol, Trileptal
• Plan C: Lamotrigine
• Testosterone (and to lesser extent, estrogen) and TBI don’t go well together
• In teens and adults in 20s-30s, strongly consider Depo-Provera 150mg IMx1 as soon as
they seem violent or hypersexual.
RANCHO 5+
• Stop dopaminergics: No evidence of further benefit
• Fatigue/ADHD
• Caffeine
• Amantadine
• Amphetamines/methylphenidate
• MAOIs
• Modafinil
• Depression/anxiety
• Default: SSRI or SNRI
• Look for synergies: mirtazapine if anorexia or insomnia, etc
• Sleep
FATIGUE
• 9-28% severe TBI • TBI does not vaccinate vs mono,
Lyme, chronic pancreatitis, hepatitis,
HIV, TB…
• Rule out • Insomnia
• Iatrogenic
• AEDs, mood stabilizers • Meds
• Depression • Caffeine
• Cardio • Psychostimulants
• Endo
• Infectious
PAIN MEDS
• Don’t forget they • Causes
can’t express • Neuropathic/central
themselves • CRPS
• Occult fracture
• Soft tissue
• UTI
• Schedule • Yeast infection
• Constipation
• Spasticit
• Skin
• Headache
• Visual disturbance
SLEEP
• Abnormal sleep study 39% • Insomnia 30% (full ICD-10, more
• OSA 23% reported in mild TBI)
• Initiation
• Hypersomnia 3%
• Zolpidem
• Narcolepsy 5%
• Maintenance
• Periodic limb movements in sleep • Zolpidem CR, TCA
(PLMS) 7% • Both
• Excessive daytime sleepiness 12% • Trazodone
(≠ fatigue) • Circadian disruption
• Bright lights
• Melatonin
OTHER
• Traches • HO
• Downsize • Dx: XR, ESR, triple-phase
• Remove • Indocin, Didronel
• Secretions • Surgery: not as important to wait as
we once thought
• Systemic vs local anticholinergics
• Dizziness
• Urinary retention
• Antihistamines (meclizine—also
• Polypharmacy
antichol—works but limits habituation)
• Constipation
• Anticholinergics (orthostatic
• Neurogenic hypotension)
• GI • Benzos (cognitive)
CHANGE IN MS
• Hydrocephalus
• WWW: Wet, Wobbly, Weird
• Imaging says 30-89%
• Seizure
• Bleed/CVA
ENDO
• SIADH > CSW > DI • 21-25% hypopituitarism
• Can have 2/3 (in my experience, • When to screen?
frequently occurs, but probably • During hospitalization if suspicious
observer bias) • Again at 6 months
• P 398 • What?
• Cortisol
• Free T4, TSH
• IGF-1
• FSH, LH
• Testosterone or estradiol
• Prolactin
SX OF CRANIOTOMY
• HA
• Apathy
• HP
• Midbrain syndrome
• Tremor
• Gait
• Cognitive function
• Early cranioplasty helps
PSEUDOBULBAR AFFECT/PATHOLOGICAL
LAUGHING & CRYING
• 5-11% in 1st year
• SSRI/SNRI
• TCA
• Dopaminergics
• NMDA antagonists
• Dextromethorphan/quinidine
• AEDs
