Traumatic Brain Injury
1. There are 400,000 new cases of acquired head injury each year in the United States. Prehospital resuscitation - acute management at the trauma center, ICU - during the rehabilitation phase
2. Studies have shown --- It is particularly important at this time as all the emphases are on cost reduction and managed care.
Cope and Hall (1982): 36 Severe Head Injury --- 16 early admission (< 35 days postinjury); 20 late admission (>35 days postinjury)--- both groups were comparable in their initial disability and outcome at 2 years postonset, late admissions required twice as long in rehab (144 days) as early admissions (64 days).
Morgan (1988): Early traumatic rehabilitation (² 7 days postinjury) was associated with better outcomes in the areas of cognition, perception, and motor skills at discharge (LOS: 24 days), compared to 45 days with late intervention.
Mackay (1992): 38 Severe Head Injury --- 21 No formalized TBI Rehab Program, 17 Formalized TBI Rehab Program: LOS: 106.5 vs. 239.5 days, mean cognitive levels higher, discharge to home: 94 vs. 57%.
Therefore, patients who come to rehab should be looked at with great caution to identify these problems and treat them appropriately.
I am going to discuss these medical complications by the organ system, and from top to bottom.
3. 56% of patients had neurologic problems which required further investigation and treatment.
4. PTE is classified according to the onset of seizure into immediate, early and late PTE. Dr. Jennettt and Teasdale have done much to add to our knowledge about the increased risk of developing PTE after certain injuries, such as 1) Acute intracranial hematoma requiring surgical evacuation within 2 weeks of injury. 3-25% 2) Early epilepsy. 3-25% 3) Depressed skull fracture.3-17% ----Dural tear, focal signs, PTA > 24 hours, early epilepsy. Children; early seizure 10%.
1/2-2/3 patients develop PTE within 12 months
Yablon 9/93 75-80% patients develop PTE within 2 years
no different from general population after 5 years
Published, randomized studies fail to substantiate evidence of efficacy for anticonvulsant prophylaxis in late PTE, but reduced incidence of early PTE. (3.6 vs.14.2% placebo)
Dilantin decreases attention, concentration, mental processing and motor speed. Tegretol: GI distress, headache, dizziness/diplopia. PTE: 50-80% Partial, 20-50% Generalized.
5.6. Posttraumatic hydrocephalus should be suspected when the patient is not progessing as expected or deteriorating. Kishoreís CT criteria. Some clinicians suggest monthly CT to detect progressive enlargement of the ventricle and continued cognitive and physical deficits.
CSF pressure > 276 mm H2O benefit from shunting, < 136 probably not.
CSF tap test : gait pattern and psychometric tests including memory, reaction time, perception are performed 1 day before and 2 hours after removal of 40 cc spinal fluid.
Lumbar perfusion testing.
7. Garland looked at 254 patients. Most authors recommend a minimal series of X-rays, which include the cervical spine, pelvis, hips and knees. The spine along with the brain make up the central nervous system. It is crucial for one to know about spinal care. If you would like further information on spinal issues, problems and medication visit spinalmedicine.com.
The physiatrists must have a high index of suspicion for the possibility of missed fractures and peripheral nerve injuries.
Sobus (9/93): 60 children with TBI; 16 had a total of 25 newly detected fracture sites and 19 had 24 newly detected soft tissue trauma. ---suggesting bone scan.
Osteomyelitis 2 %
10. DVT: Anticoagulation should be used with caution in agitated, confused patients who may be at higher risk for injury with bleeding.
11. Neurologic deficits frequently compromise breathing, coughing and pulmonary toilet. Rancho II and III high morbidity and mortality 31%.
Laryngeal and tracheal disorders 31%: It is unclear if these complication were as a result of intubation or the head injury or a combination of both.
12. Neurogenic bladder: usually an uninhibited detrusor hyper-reflexia. mx: condom for males, diaper for females. Time voids and Ditropan.
13. Hypercalcemia: N/V, constipation/weakness/emotional lability
---frequently returns to normal with mobilization.
15. SIADH: Treatment is usually through fluid restriction.
DI: treated with vasopressin or internasal DDAVP.
Anterior pituitary insufficiency should be suspected in patients who have anorexia, low temp, malaise, hypoglycemia, hyponatremia, bradycardia and hypotension.
B-HCG:indicated in all female patients of childbearing age regardless of reported sexual history or last menstrual period.
16. HTN: often the result of high ICP and catecholamine with increased CO and tachycardia. Tx: B-blocker in a hyperdynamic state.
Central fever: 2° to lesion in the anterior hypothalamus and generalized decerebration. Tx: cooling blanket/ tepid bath/bromocriptine/levodopa/NSAID/Dantrium.
Hypothermia: 2° to post hypothalamus, can result from myxedema and hypopituitarism as well as barbiturates.
17. 43% of patients had impaired LFT, >90% drug induced , mostly from Dilantin and phenobarbital, the remainder 2° to acute viral hepatitis.
1/3 of patients aspirated with delayed or absent swallowing reflex being the most common etiology.
H-2 blocker: cognitive and behavior disturbance. Reglan and antiemetics: sedation, EPS, dystonia, restless, tardive dyskinesia
Fecal incontinence: bowel program, diarrhea: osmotic overload from tube feeding or C. Difficile colitis.