Twitter Icon Facebook


 DONATE TO VMS


   Anatomy

   Biochemistry

   Boards

   Book Store

   Cardiovascular

   Endocrinology

   Financial Articles

   Gastrointestinal

   Genitourinary

   Gynecology

   Healthy Living

   Hematology

   How to Section

   Infectious    Diseases

   Musculoskeletal

   Neurological

   Nutrition

   Obstetrics

   Pharmacology

   Physical
   Examination

   Physiology

   Psychiatry

   Pulmonary

   Renal

   Rheumatology

   Useful Links

   Home

   Resources for...

 Medical Students

   YouTube

      Google Analytics Alternative

Looking for help with nurse application essay? Visit MyCustomEssay.com and get it written from scratch.

Get custom college essays from https://123writings.com - a writing service for college students.

Ewritingservice.com is the custom writing service thousands of students trust all over the world.



    

    

Approach to the Acutely Brain Injured Patient (Nonoperative Management)

Clinical History || Physical Exam || Initial Testing || Management ||
Related Articles || References and Resources || Leave a Comment || Search





Managing a patient with acute traumatic brain injury (TBI) can be very stressful. However, by following a logical series of steps it may be possible to drastically alter the patient's overall prognosis.

Clinical History

The first step is to obtain some clinical history. It is important to get a description of how the injury occurred. Was it a high speed motor vehicle accident? Were seat belts used? Did they fall from 5 feet? 10 feet? 20 feet? What were the circumstances surrounding the accident? Were alcohol or drugs involved? Does the patient have a history of seizures? Was a seizure witnessed? What was the patient's Glasgow coma scale (GCS) when the paramedics arrived on scene? And was spinal immobilization utilized (many head injuries also have co-existent spine injuries)?

In addition, a quick trauma history should always be taken. This includes the following important questions, also known as the "AMPLE" history:

(1) A -> Allergies
(2) M -> Medications (especially anticoagulants/anti-platelets)
(3) P -> Past medical history
(4) L -> Last meal (especially if surgery is indicated emergently)
(5) E -> Events (see above)

In the acutely brain injured person a lot of this information may be missing since the patient may be non-communicative. If a family member or friend is present try to get as much information as possible.

Top

Physical Exam

We will neglect the rest of the body for the sake of this discussion and focus on the neurological exam. However, remember to always follow the "ABCs" (discussed elsewhere) when dealing with any traumatically injured patient.

The neurological exam in an acutely brain injured patient should focus primarily on the GCS score, pupillary, and spinal cord exams.

The GCS is an important indicator of the patient's overall level of consciousness. It can be used to follow a patient's clinical course throughout their hospitalization. It is also important in dictating how aggressively to manage the patient during their hospitalization.

GCS Severity
8 or less

Severe

9-13

Moderate

14-15

Mild

The pupillary exam is an extremely important part of the neuro check in a brain injured patient. An asymmetrically enlarged pupil (aka: a "blown pupil", see image below) could indicate that part of the brain is herniating due to increased intracranial pressure (see the Monro-Kellie doctrine article). This increased pressure could be due to bleeding in the brain (ie: subdural or epidural hematomas) or generalized edema (ie: swelling) secondary to the injury.

Blown Pupil

Head and brain trauma are also commonly associated with spine trauma. Therefore, it is very important to do a thorough neurological exam by checking the spine for tenderness, and assessing both motor and sensory functions. Decreased motor and/or sensory (ie: light touch, pin prick, hot, cold, proprioception) abilities in the extremities could indicate spinal cord injury.

To review, it is important to, at the very least, get the following physical exam data recorded*:

(1) The GCS score
(2) Pupillary exam
(3) Thorough spine exam

*Remember we are excluding all non-neurological issues. Trauma patients often have many other injuries that need to be adequately addressed.

Top

Initial Laboratory and Imaging Tests

The most important initial study in the head injured patient is a CT of the head without contrast. This will show any acute process like intracranial bleeding that may need emergency surgery. In addition, a CT (or plain films) of the cervical spine can also be obtained to assess bony spinal column injury.

Additional tests include a urine and blood toxin screen. This information may provide clues for why the injury occurred. It is also extremely important later to prevent agitation from possible withdrawal.

Blood tests should include prothrombin time (PT), and activated partial thromboplastin time (aPTT). These will help determine if the patient is coagulopathic. In addition, a type and screen should always be ordered on any trauma patient in case resuscitation with blood products, or operative management becomes necessary. A complete metabolic panel (CMP) and complete blood count (CBC) are also routinely ordered.

Additional imaging may include MRI of the brain to assess for diffuse axonal injury (DAI). This devastating form of injury is not seen on CT scans. MRI of the spine may also be necessary to assess for ligamentous injury of the spine if the initial CT (or plain films) is read as normal, but the patient is still deemed a high risk for spine injury.

Top

Non-Operative Management

Non-operative management is dictated by several factors. The GCS score, presence of raised intracranial pressure, and the type of injuries dictate how the patient is managed in the ICU.

Patients with a GCS of 14-15 (ie: "mild" injuries) are usually admitted to the hospital for observation. Neurological exams should happen every two to four hours. IV fluids (isotonic saline) should be started. Pain and nausea control with medications like acetaminophen (aka: Tylenol®) and ondansetron (aka: Zofran®) should also be administered. The patient can often be allowed to eat, especially if they are alert and oriented. However, there should be a low threshold for repeating a head CT if the patient appears to be getting worse.

Patients with a GCS of 9-13 (ie: "moderate" injuries) are admitted to the ICU. Neurological exams should occur at least every two hours. In addition to the above the patient should be made "NPO" (ie: nothing by mouth) in case they need to be taken to the operating room. Many physicians order a routine repeat head CT six hours after admission; however, a repeat CT should be done immediately if the patient's clinical status worsens. Depending on how mobile the patient is deep venous thrombosis prophylaxis may be warranted.

Patients with a GCS of 8 or less (ie: "severe" injuries) are admitted to the ICU with hourly neurological exams. The patient should be made "NPO". In addition to all of the above, these patients often have intracranial pressure monitors placed by a neurosurgeon. A monitor is recommended if the GCS is < 8 and they have an abnormal head CT or if the head CT is normal, but they have two or more of the following: age > 40 years, systolic blood pressure < 90 mmHg, or posturing movements. Controlling pain and agitation is important because it helps decrease intracranial pressure; therefore, judicious use of narcotics for pain and sedatives for agitation are indicated. In addition, since these patients are often immobile for a long period of time they should have some form of deep venous thrombosis (DVT) prevention once their head CT findings are stable.

Top

Related Articles

- Dislocated cervical facet joint

- Diffuse axonal injury

- Thoracolumbar burst fractures

Top

References and Resources

(1) Blackbourne LH. Surgical Recall, Fifth North American Edition (Recall Series). Fifth Edition. Philadelphia: Lippincott Williams and Wilkins, 2009.

(2) Frontera JA. Decision Making in Neurocritical Care. First Edition. New York: Thieme, 2009.

(3) Simon RP, Aminoff MJ, Greenberg DA. Clinical Neurology, Seventh Edition (LANGE Clinical Medicine). Seventh Edition. New York: McGraw Hill, 2009.

(4) Greenberg MS. Handbook of Neurosurgery. Sixth Edition. New York: Thieme, 2006. Chapter 25.

Top

HTML Comment Box is loading comments...

Top

Search VirtualMedStudent.com

Loading
The Glasgow Coma Scale (GCS) is a measure of the patient's level of consciousness. It is scaled from 3 to 15 with 15 being the best possible score (ie: completely conscious). The GCS has 3 important components: motor, visual, and verbal components. To get a GCS score add the motor, verbal, and eye components together. For example a patient could have a GCS of 12 with the following component values M5, V4, E3.

Motor:
(1) No movement -> 1 point
(2) Decerebrate posturing (abnormal extension of extremities) -> 2 points
(3) Decorticate posturing (abnormal flexion of extremities) -> 3 points
(4) Withdraw from painful stimuli -> 4 points
(5) Localize painful stimuli -> 5 points
(6) Follows commands (ie: "wiggle your toes", "grab my fingers") -> 6 points

Verbal:
(1) None -> 1 point
(2) Garbled and incomprehensible -> 2 points
(3) Inappropriate -> 3 points
(4) Confused and disoriented -> 4 points
(5) Normal speech -> 5 points

Eyes:
(1) No eye movement -> 1 point
(2) Opens eyes to pain -> 2 points
(3) Opens eyes to command -> 3 points
(4) Opens eyes spontaneously -> 4 points