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18.2 Traumatic Brain Injuries (TBI)

Table of Contents

It is any episode of trauma to the head (brain). Mortality is high.

Diagnostic criteria

  • Head injury may be associated with ophthalmic, ENT and dental injuries which are discussed separately.
  • It is classified into two:
    • Involving scalp only
    • Traumatic brain injury

Table 18. 2: Illustration of Traumatic Brain Injuries

Mild Traumatic Brain injury
  • Glasgow coma scale 13–14
  • Involves a “brief” period of loss of consciousness
  • Good progress with minimal or no long term sequel
Moderate Traumatic Brain injury
  • Glasgow coma scale 9–12
  • Confused patient with focal neurological deficits but able to follow simple commands
  • Some mild long-term sequel
  • Good prognosis
Severe Traumatic Brain injury
  • Glasgow coma scale <8 (This is the definition of coma)
  • Unable to follow commands initially
  • Significant long-term disability

Treatment

Community/Dispensary level Interventions

  • Clean and dress any wound
  • If unconscious, ensure airway is patent
  • Keep patient warm
  • Put in coma position
  • Prevent spinal injury by stabilizing the neck with neck collar
  • Refer to the centres/health facilities where there is expertise

Health Centre Interventions

  • Take full history from patient, relatives or whoever has brought patient where indicated, follow the ABCDE trauma protocol
  • Ensure adequate oxygenation by mask or ETT
  • Surgical debridement and suture wound as appropriate
  • Record and monitor vital signs including pupil size and symmetry
  • Give IV line Normal saline or Ringer’s lactate (do not give dextrose infusion!)
  • Catheterize
  • Refer if moderate or severe TBI, seizure or pupil asymmetry.

Hospital Level Interventions

  • History as above, follow the ABCDE trauma protocol
  • Examine patient thoroughly, note the level of consciousness, pupils’ asymmetry and any lateralizing signs
  • Treat seizures by:
    A: Diazepam inj. 10mg 8 hourly
    B: Phenobarbitone inj. 100mg 8 hourly
    C: Phenytoin inj 100mg 8 hourly
  • Brain CT scan if GCS score is 9 or below (absolute indication), GCS 10–14 relative indication for CT scan
  • Admit to ICU if GCS score is 8 and below, or refer if required
  • Craniotomy is indicated for specialist cases e.g. intracranial hematomas, depressed skull fractures based on pupil asymmetry, lateralizing signs and brain CT scan
  • Refer or Consult the specialist if indicated especially moderate and severe traumatic brain injury, pupil asymmetry is noted or evidence in brain CT scan

Table 18.3: Use GLASGOW Coma Scale

Severe Traumatic Brain Injury

It is the most disabling condition that is associated with great mortality if not treated optimally. It is invariably followed by permanent disabilities. Multidisciplinary approach is of paramount importance. Long-term hospitalization followed by rehabilitation is advised. Comorbidity is very often observed.

Treatment 

  • ICU admission observing the neurocritical care and ABCDE protocol
  • Craniotomy if indicated based on brain CT scan findings
  • Rehabilitation upon discharge from hospital

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