C N S INJURY

DEPARTEMEN NEUROLOGI
FAKULTAS KEDOKTERAN
UNIVERSITAS ISLAM SUMATERA UTARA
A little miscommunication mistake...

Image from San Francisco Chronicle Oct. 7, 2003

could lead to a serious injury.

Fortunately, these guys were relatively lucky.
 The Human Brain

QuickTime™ and a
TIFF (LZW) decompressor
are needed to see this picture.

Images from Campbell Biology 7th Edition

The Cerebrum has different areas for different functions
Four lobes: Frontal, Parietal, Temporal, Occipital
Left & right hemispheres: connected by the Corpus callosum

Images from Campbell Biology 7th Edition

What is Traumatic Brain Injury (TBI)?

Two types of brain injury occur

• Closed brain injury
• Open brain injury
 Closed Head Injury

• Resulting from falls, motor vehicle crashes,

etc.
• Focal damage and diffuse damage to axons
• Effects tend to be broad (diffuse)
• No penetration to the skull
 Open Head Injury

• Results from bullet wounds, etc.

• Largely focal damage
• Penetration of the skull
• Effects can be just as serious
 TBI: A biological event within the brain

• Tissue damage
• Bleeding
• Swelling
 TBI: Changes in functioning

• Loss of consciousness/coma
• Other changes due to the TBI
• Post-traumatic amnesia (PTA)
 How to measure “severity”?

• Duration of loss of consciousness

• Initial score on Glasgow Coma Scale (GSC)
• Length of post-traumatic amnesia
• Rancho Los Amigos Scale (1 to 10)
Mild injury
0-20 minute loss of consciousness GCS = 13-15
PTA < 24 hours

Moderate injury
20 minutes to 6 hours LOC GCS = 9-12

Severe injury
> 6 hours LOC GCS = 3-8
 Cognitive functions

• Attention • Perseveration
• Concentration • Impulsiveness
• Memory • Language
• Speed of Processing
Processing • “Executive
• Confusion functions”
 Sensory/perceptual functions

• Vision • Taste
• Hearing • Touch
• Smell • Balance
• Vestibular
 Other physical changes
• Physical paralysis/spasticity
• Chronic pain
• Control of bowel and bladder
• Sleep disorders
• Loss of stamina
• Appetite changes
• Regulation of body temperature
• Menstrual difficulties
Types of Head Injuries
Concussion: Temporary alteration in neurological function or LOR

Cerebral Contusion: Bruised brain

Cerebral Haemotoma or bleed

epidural

sub-dural

sub-arachnoid

intra-cerebral
Signs and Symptoms

Headache

Dizziness

Nausea / Vomiting

Amnesia

Decreased responsiveness

Confusion

Combativeness

Loss of responsiveness
Assessment
First impression: Responsive or Unresponsive

Urgent Survey: LOR ABC’s

Open airway with C-spine

Check breathing: Ventilate; Oral airway; O2 when available

Check carotid artery pulse – CPR if indicated

Control any major bleeding

Assessment continued
Rapid Body Survey Sample, DCAP-BTLS

Stabilize head between knees

Call for equipment, assistance, transport

Maintain body temp.

Transport (head uphill)

Non-Urgent Survey

Ongoing Survey – seizures, vomiting, change in LOR

Assessment continued

Brain Swelling

Increased Intracranial Pressure (ICP)

Hypoxia

Further Secondary Brain Injury

More Swelling

Increased ICP
Localised Neurological Signs (ICP)

GENERAL SIGNS + PLUS +

Change in pupil size / light reactivity

Slowing pulse

Rising BP.

Change in respiration

Unilateral weakness

Incontinence

Seizure
Urgent Interventions - ATLS

Presume C-Spine injury

Immobilize neck

Open airway: administer oxygen

Treat bleeding and shock

Prevent aspiration of vomit / secretions

Transport immediately

Elevate head 6”

Transport head uphill

Glasgow Coma Scale

Scores 8 or less = needs urgent anaesthetic assessment.

Danger of airway compromise
13-15 = mild 9-12 = moderate 3-8 = severe