Traumatic Brain Injury

By Dr.A.Sridhar

Criteria for classifying the severity of traumatic brain injury

Assessment
Assessment should identify:
the mechanism of injury the presence of vomiting since injury the presence of headaches and seizures the presence and duration of anterograde and posttraumatic amnesia the Glasgow Coma Score (GCS) whether there is evidence of an open, depressed, or basal skull fracture evidence of trauma above the clavicles evidence of drug or alcohol intoxication.

Gcs- best eye response (4)

No eye opening Eye opening to pain Eye opening to verbal command Eyes open Spontaneously

Best verbal response (5)

1. No vocal response 2. Occasionally whimpers and/or moans 3. Cries inappropriately 4. Less than usual ability and/or spontaneous irritable cry 5. Alert, babbles, coos, words or sentences to usual ability

Best grimace response (5)

A grimace alternative to verbal responses should be used in those infants or children who are preverbal or intubated. 1. No response to pain 2. Mild grimace to pain 3. Vigorous grimace to pain 4. Less than usual spontaneous ability or only responds to touch stimuli 5. Spontaneous normal facial/oro-motor activity

Best motor response (6)

1. No motor response to pain 2. Abnormal extension to pain (decerebrate) 3. Abnormal flexion to pain (decorticate) 4. Withdrawal to painful stimuli 5. Localises to painful stimuli or withdraws to touch 6. Obeys commands or performs normal spontaneous movements

On Admission
Glasgow Coma Scale He was transferred to the intensive care unit where he was intubated, sedated, ventilated. Patient reviewed by the neurosurgical team and his prognosis is documented. A right frontal external ventricular drain was inserted to help control the rising intracranial pressure (ICP), which was in the region of 30 mm Hg. A nasogastric tube was inserted for nutritional needs

Intensive Care Unit (days 18)

Respiratory status:
Progressed from full ventilation to synchronized intermittent mandatory ventilation, continuous positive airways pressure with T-piece. On day 6 a tracheostomy and wiring of the mandible were undertaken His chest was productive of very foul-smelling sputum throughout this period, requiring oxygen therapy (2835%) to maintain satisfactory saturation levels.

 Neurological status :
Unable to assess for approximately four days as a result of sedation and paralysis. ICP levels remained > 20 mm for most of the time. As sedation levels were decreased, signs of marked agitation and fluctuating flexion and extension tone in all limbs and extensor tone in the trunk became apparent. A small soft tissue injury of the right malleolus was noted, which was thought to have occurred at the time of injury. Full range of motion could be maintained Transference to other ward

Neurosurgical Ward (days 920)

High respiratory rate (> 40) and tachycardic (> 150) especially on stimulus. Oxygen saturation level of approximately 97%, on 28% oxygen. Pyrexia 40. Secretions thick and bloodstained with an offensive odour.

 Neurological status: No eye opening, fitting, and extending in response to any stimulus. Decision taken by medical team that Mr ND was not appropriate for active management

Days 10 and 11 Respiratory status

Coughing spontaneously. Chest continued to be productive but on ausculation air entry present throughout. Blood pressure and pulse stable during treatment. Neurological status: Tone in the lower limbs and trunk now constantly increased and in extension. The upper limbs continued to fluctuate between flexion and extension, although the right showed more sustained flexion

Days 1220:
There was a dichotomy of views between therapists and medical staff.
Doctors continued to feel very pessimistic with regard to prognosis. Therapists considered a more proactive approach was necessary as the patients physical status was being compromised.

Summary of Neurological Status (in supine)

Head: tendency to pull into right-side flexion with rotation. Right eye remained shut but with minimal left eye opening to command. Trunk: over-extension throughout with additional right-side flexion. Pelvis: tilted anteriorly with obliquity to the left. Right anterior superior iliac spine higher than left.

Left arm: beginning to move spontaneously at all joints. Movement gross and dominated by flexor activity.

Cont
Right arm: held in internal rotation and adduction at the shoulder. Shoulder girdle elevated and protracted, complicated by a sprung acromion. Elbow, wrist and fingers all dominated by marked flexor tone. No voluntary movement evident. Left leg: moderate increase in extensor tone throughout. Some evidence of gross flexor movements. Tendo Achilles noted to be 15 to plantargrade, with considerable muscle stiffness on handling. Right leg: moderate to severe increase in extensor tone with mild adduction at the hip. A loss of 20 to plantargrade at tendo Achilles noted.There was poor carry-over between treatment sessions. No voluntary movement was evident.The sore was still present over right malleolus but much reduced in size.

Now stable enough to be stood for short periods of two to three minutes. Five therapists are required to stand him with good alignment. Tendo Achilles became contracted over the weekend because of periods of sustained posturing

 attempting to communicate and appeared to be reliable in squeezing a hand for yes and no to simple questions.

General Surgical Ward (3 weeks postinjury)

Surgical process should be mentioned Sutures should be mentioned Removal date Respiratory weaning Physiotherapy referral

Neurological Summary
Trunk: selective lumbar trunk extension achieved for short periods. Tone remains generally low in trunk and pelvis. Pelvis remains stiff into end of range of anterior and posterior tilt. Right-side flexion in trunk is compounded by shortening of muscles, especially latissimus dorsi. Head: control much improved, but pt continues to show a preference to right side flexion and rotation; his right eye remains closed. Left arm: full range active movement but with no co-ordination.

Cont
Right arm: mild weakness. Movement present at all joints, although the propensity towards flexor activity persists, especially at the elbow. Poor alignment at shoulder girdle, especially at the acromio-clavicular joint. Muscle tightness in the upper fibres of trapezius, pectoralis major and minor, latissimus dorsi and teres major.

Left leg: full range active movement but Mr ND lacks hip stability and there is minimal co-ordination.Tendo Achilles remains slightly short but his heel touches the floor during standing. Right leg: mild weakness.Voluntary movement throughout range. Mixed tone, but mostly low proximally. Persistent shortening of approximately 10 at the tendo Achilles

 Speech type should be mentioned

Memory problems becoming apparent

Dr.A.Sridhar, MPT(Neurology)

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