Traumatic Brain Injury And Spinal Cord Injury

Front 1

what is the leading causes of traumatic death and disability?

Back 1

Traumatic brain injury (TBI) and traumatic spinal cord injury (TSCI)

Front 2

TBI conditions for which emergency neurosurgery is needed

Back 2

penetrating wounds

intracerebral hemorrhage with mass effect including subdural and epidural blood,

bony injury such as displaced fracture, and vertebral subluxation

Front 3

TBI conditions for which emergency neurosurgery is NOT needed

Back 3

focal
hypoxic-anoxic
diffuse axonal

and diffuse microvascular injuries

Front 4

The initial goals in TBI care are

Back 4

ABCs of airway, breathing, and circulation. Next is D for disability (neurologic).

Front 5

Every TBI patient should undergo a detailed

Back 5

neurologic examination to ascertain the level of neurologic disability.

Front 6

An initial ___________________should be assigned to each TBI patient.

Back 6

Glasgow Coma Score (GCS)

Front 7

Glasgow Coma Score (GCS) usefulness with TBI patients

Back 7

categorizes TBI patients and provides a quantifiable measure of impairment.

Front 8

Glasgow Coma Score (GCS)

Back 8

Front 9

In the early stage of TBI management, it is important to determine ___________

Back 9

the duration of amnesia or loss of consciousness a patient may have experienced

Longer periods of abnormal sensorium are associated with higher grades. Higher grades necessitate longer periods of convalescence.

Front 10

second impact syndrome

Back 10

It is essential that patients have adequate recovery even from mild TBI. A subsequent head injury before full recovery may be catastrophic as it could result in "second impact syndrome" (SIS), which leads to worse clinical outcome including death.

Front 11

Severe TBI is defined as an injury that results in a GCS score of

Back 11

eight or less

Front 12

Severe TBI medical management

Back 12

An important early intervention is airway protection, usually by endotracheal intubation.

If elevated intracranial pressure (ICP) is suspected or if GCS < 8, the ICP should be monitored.

patient's head should be elevated to 30 degrees and kept midline, with a rigid neck collar used (until the cervical spine can be evaluated for stability).

Mannitol should be given intravenously at a dose of 0.5 to 1.0 g/kg.

A head CT without contrast should be done as soon as possible both to identify lesions that will require surgery and to determine the extent of injury.

Front 13

postconcussive syndrome

Back 13

A complication of TBI

The most common symptoms are headache, difficulty concentrating, appetite changes, sleep abnormalities, and irritability.

In general, this condition lasts only a few weeks after injury. However, uncommonly, it can persist beyond a year or more.

Therapies are focused on managing symptoms. For headache, nonsteroidal anti-inflammatory agents, migraine drugs, and biofeedback can be effective.

For cognitive dysfunction, neuropsychologic testing may be helpful in determining appropriate intervention.

Front 14

Traumatic Spinal Cord Injury Management begins with

Back 14

therapy begins with the ABCs of airway, breathing, and circulation

Front 15

For patients with high cervical lesions what will be lost?

Back 15

spontaneous ventilation

Front 16

Lesions lower than C5 may also be associated with what?

Back 16

insufficient ventilatory capability.

Front 17

Maintaining adequate ____________ is of particular importance in the spinal cord-injured patient.

Back 17

intravascular volume

Hypotension may result from either neurogenic shock or hypovolemia

Front 18

Neurogenic shock in spinal cord-injured patient management

Back 18

For neurogenic shock, vasopressive pharmacologic agents such as phenylephrine may be needed. If tachycardia is present, then hypovolemia is the more likely cause, and fluid administration is the appropriate initial management.

As with TBI, normal saline is the preferred fluid.

Front 19

Up to 50% of TSCI patients have an associated _____

Back 19

TBI

Front 20

complaints of pain over the spine or of numbness, tingling, or weakness should raise the suspicion of__________

Back 20

spinal cord injury

Front 21

complaint of burning hands suggests

Back 21

cervical spinal cord injury

Front 22

The level of the spinal cord injury is defined as .....

Back 22

the lowest spinal cord segment with intact motor and sensory function.

Front 23

The prognosis for neurologic improvement is better if the lesion is ________

Back 23

incomplete than if it is complete.

Front 24

suspected spinal cord injury management

Back 24

patient should be immediately and appropriately immobilized, that is, with a rigid collar or back board or both.

Radiologic evaluation should begin with plain x-ray films of the bony spine.

Abnormalities on x-ray films should lead to further neuroimaging. Bony vertebrae should be examined with computed tomography (CT), and the spinal cord with magnetic resonance imaging (MRI).

Intervertebral and paravertebral soft tissue are best studied with MRI.

A chest radiograph should also be obtained in order to visualize the lower cervical and thoracic vertebrae. Presence of a pleural effusion in the setting of a possible thoracic spine injury suggests a hemothorax.

Front 25

If the C-spine radiograph is normal but the patient complains of neck pain

Back 25

ligamentous injury may be present.

Ligamentous injury is evaluated by flexion-extension C-spine x-ray studies. However, in the acute period, pain may prevent an adequate study.

Such patients should be kept in a rigid cervical collar for at least 24 to 48 hours until the pain and neck muscle spasm resolve.

At that time, the study may be performed.

If abnormal, the patient will need surgical evaluation.

Front 26

Confirmed spinal cord injury management

Back 26

methylprednisolone should be given at an initial dose of 30 mg/kg intravenous bolus followed by a continuous infusion of 5.4 mg/kg/hr.

The infusion should be for 23 hours if it is started within 3 hours of injury.

If beyond 3 hours but still within 8 hours, then methylprednisolone should be given for 48 hours.

this therapy is reserved only for closed compartment injury (NOT PENETRATING).

This is the only indication for steroid use in TSCI.

At this time, the decision for surgical intervention should be made, based on the stability of the vertebral column.

Front 27

SPINAL CORD SYNDROMES: Anterior cord syndrome

Back 27

associated with deficits referable to bilateral anterior and lateral spinal cord columns.

There is loss of touch, pain, and temperature sensations and motor function below the level of the lesion.

The posterior column functions of proprioception and vibratory sensation remain intact.

Front 28

SPINAL CORD SYNDROMES: Brown-Séquard syndrome

Back 28

the deficits are caused by injury to a lateral half of the cord.
There is functional loss of ipsilateral motor function, touch, proprioception, and vibration sensations, and contralateral pain and temperature sensations.

Front 29

SPINAL CORD SYNDROMES: Central cord syndrome

Back 29

syndrome manifests as motor paralysis of both upper extremities while the lower extremities are spared.

Weakness is greater proximally than distally.

Pain and temperature sensations are generally reduced, but proprioception and vibration are spared.

Front 30

SPINAL SHOCK

Back 30

After acute injury, spinal shock may occur, causing a temporary loss of spinal reflexes below the level of injury.

Neurologic examination will reveal loss of deep tendon reflexes, bulbocavernosus reflex, and the anal wink. In high cervical injuries, the lower reflexes (bulbocavernosus and anal wink) may be preserved.

there will likely be loss of autonomic reflexes, leading to neurogenic shock, bowel ileus, and urinary retention.

Front 31

"Schiff-Sherrington" phenomenon

Back 31

in which reflexes are affected above the level of injury.

sometimes seen in spinal shock

Front 32

Patients with spinal cord injury are at risk for

Back 32

neurogenic shock and dysautonomia

Front 33

neurogenic shock and dysautonomia can lead to

Back 33

peripheral vasodilation and hypotension

Front 34

If spinal cord lesion is at T3 or above then ________ is compromised

Back 34

then sympathetic tone to the heart is compromised.

In this setting, hypotension is accompanied by bradycardia: the classic neurogenic shock triad of bradycardia, hypotension, and peripheral vasodilation.

Front 35

classic neurogenic shock triad

Back 35

bradycardia, hypotension, and peripheral vasodilation.

Front 36

Therapy for dysautonomia

Back 36

begins by ensuring adequate circulating volume.

The goal is to administer fluids to restore a euvolemic state.

Blood should be transfused if the patient is anemic-that is, if the hematocrit is less than 30.

If blood is not required, then either colloid (e.g., albumin solutions) or crystalloid (e.g., normal saline) may be used to maintain a central venous pressure (CVP) of 4 to 6 mm Hg.

Hypervolemia should be avoided, as this will exacerbate peripheral edema.

Once an adequate circulating volume has been achieved, a vasopressive agent such as phenylephrine, norepinephrine, or dopamine can be used.

The goal MAP is 85 mm Hg or greater.

Symptomatic bradycardia can be treated with atropine.

Front 37

Spinal cord patients are at risk for

Back 37

ventilatory compromise

Front 38

Patients whose injuries are at C5 or higher typically require

Back 38

mechanical ventilation with an appropriate tidal volume (6 to 10 ml/kg) and Fio2 and mandatory machine-driven rate.

The Fio2 should be set at a value that gives a Po2 of 80 to 100 mm Hg.

The rate should be set to give a Pco2 of 40 mm Hg.

Positive end-expiratory pressure (PEEP) should also be used to minimize atelectasis.

If the patient does not show signs of ventilatory recovery within 2 weeks of intubation, a tracheostomy should be considered.

Front 39

Lesions below C5 may also be associated with

Back 39

with inadequate spontaneous ventilation

Front 40

Patients with cervical lesions at C6 and below, including the thoracic cord, are generally

Back 40

not mechanical ventilator-dependent.

However, their ventilatory effort may be inadequate, as the thoracic cord innervates intercostal muscles, which are accessory muscles of respiration.

Such patients have decreased cough and inability to increase ventilation when needed.

This leads to atelectasis and comprised ability to clear secretions, which may lead to pneumonia.

These patients may benefit from chest physical therapy.

Front 41

TRAUMATIC SPINAL CORD INJURY MANAGEMENT ISSUES

Back 41

cardiovascular, ventilatory, genitourinary, bowel, infectious disease, nutrition, skin and prophylaxis against skin ulcers, and DVT formation.

Front 42

TRAUMATIC SPINAL CORD INJURY MANAGEMENT ISSUES: DVT

Back 42

Therefore all patients with TSCI should receive both anticoagulation and leg mechanical compression devices.

As soon as possible, sequential compression devices (SCDs) or compression stockings should be placed on patients.

Then, as soon as hemostasis is ensured, low-molecular-weight heparin (LMWH) should be initiated. Unfractionated heparin may also be used in conjunction with SCD, but LMWH is preferred.

An inferior vena cava filter may be placed in those patients in whom anticoagulation therapy is contraindicated but should not be the primary means of preventing DVT.

Front 43

TRAUMATIC SPINAL CORD INJURY MANAGEMENT ISSUES: ILEUS

Back 43

A nasogastric tube should be placed to decompress the stomach.

Parenteral nutrition should be started as soon as possible.

Enteral feeding should be delayed until gastrointestinal motility returns.

This normally takes about 2 to 3 weeks. The pharmacologic agents metoclopramide, erythromycin, and cisapride may promote gastrointestinal motility.

Front 44

TRAUMATIC SPINAL CORD INJURY MANAGEMENT ISSUES: Gastrointestinal

Back 44

Gastric ulcer prophylaxis needs to be administered: H2-receptor antagonists, proton pump inhibitors, antacids, or sucralfate.

Pancreatitis and trauma-related perforated bowel are potential problems.

Loss of abdominal muscle tone and visceral sensation may mask clinical signs such as pain, guarding, or rigidity.

Front 45

TRAUMATIC SPINAL CORD INJURY MANAGEMENT ISSUES: GENITOURINARY

Back 45

Bladder tone may be lost because of spinal shock. A Foley catheter should be placed and maintained for a minimum of 5 to 7 days to help drain the bladder and to evaluate circulatory volume and renal function.

After spinal shock has resolved, autonomic dysreflexia may occur from bladder distention.

Front 46

autonomic dysreflexia

Back 46

After spinal shock has resolved, autonomic dysreflexia may occur from bladder distention.

Clinical signs such as sweating, skin flushing, and hypertension may be present.

Clinical examination using palpation and percussion will reveal a distended bladder, which can be treated with bladder training or intermittent catheterization.

Phenoxybenzamine may be helpful in this condition.

Front 47

TRAUMATIC SPINAL CORD INJURY MANAGEMENT ISSUES: NUTRITION

Back 47

Until enteral feeding can begin, parenteral nutrition should be used.

A caloric level of 80% of the Harris-Benedict prediction, which approximates a patient's total daily energy expenditures, should be used for quadriplegic patients.

This is an approximation of a patient's total daily energy expenditure and is based on the patient's basal metabolic rate and activity level.

The full Harris-Benedict predicted amount should be used for patients with thoracic spine injuries and below.

Front 48

TRAUMATIC SPINAL CORD INJURY MANAGEMENT ISSUES: DECUBITUS ULCERS

Back 48

There is a propensity for decubitus ulcers from pressure to develop in patients with TSCI.

Mechanical kinetic beds, regular log rolling (every 2 hours), and padded orthotics are all useful in minimizing this complication.

Front 49

TRAUMATIC SPINAL CORD INJURY MANAGEMENT ISSUES: REHABILITATION

Back 49

Orthotics, physical therapy, and occupational therapy (for cervical cord injury) are also important.

Therapy should begin as soon as the spine is stabilized.

This will serve to minimize contractures and to begin the rehabilitation process.

It should be remembered that once therapy begins, energy expenditures will increase, and consequently additional nutrition will be needed.

Also, as intermittent compression devices will need to be removed during therapy, the heparin dose may need to be increased.

Front 50

The most useful prognostic indicator after TBI is

Back 50

the neurologic examination at presentation.

Clearly, the better the neurologic examination findings, the higher the likelihood of improved recovery.

Front 51

Usefulness of GCS as prognostic indicator after TBI

Back 51

The initial GCS is a very reliable prognostic indicator. The lower the initial GCS, the less likely a patient will have meaningful neurologic or functional recovery.

Front 52

the most useful prognosticator for TSCI

Back 52

the completeness of the injury

The American Spine Injury Association Impairment Scale grades spinal cord injury on the basis of completeness (Table 125-3).

A grade A or complete motor and sensory deficit below the lesion is associated with the most ominous prognosis.

If this status persists for longer than 24 hours, there is little reasonable likelihood of meaningful recovery.

On the other hand, partial injuries, even severe, have substantial probability of recovery.