Name: Traumatic Brain and Spinal Injury (TBSI)
Uploaded: 2024-02-03
Duration: 6 min 38 s
Description: We will now proceed with the management of Traumatic Brain Injury; TBI is managed within the ATLS Initial assessment, starting with the primary survey. The initial assessment and primary survey are the most important parts of the management of TBI. If this is not done well, CT scans and craniotomy will not be relevant..

[Audio] We will now proceed with the management of Traumatic Brain Injury; TBI is managed within the ATLS Initial assessment, starting with the primary survey. The initial assessment and primary survey are the most important parts of the management of TBI. If this is not done well, CT scans and craniotomy will not be relevant.. 

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[Audio] This study is from Uganda The intent, age gender, causes and distribution between unintentional and Intentional is similar throughout Eastern Africa.. 

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Traumatic brain injury (TBI) is a significant cause of morbidity and mortality in low/middle-income countries

Ugandan Study Similar to Tanzania and Ethiopia

Reference: Traumatic Brain Injuries in Uganda Nukhba Zia, Amber Mehmood, Rukia H Namaganda, Hussein Ssenyonjo, Olive Kobusingye. Adnan Hyder                                http://orcid.org/0000-0002-8417-1282 Intent  69.7% unintentional   30.3%  intentional  Both groups, Age and Gender   28±14 years  Average 70%  19- and 45-years age  80%  males   Unintentional TBI road traffic injuries (RTI) (88.9%) and falls (11.1%).  Pedestrians (42.1%) and motorcycle drivers (28.1*  43.6% were admitted, 34.0% were sent home Intentional TBI Assault (97.1%):  bodily force (33.7%), iron bar (24.2%) and hammer (12.0%) 42.6% were admitted and 37.1 % were sent home GCS  68.1% mild, 22.1% moderate, 14.2% severe category

[Audio] Monitoring alternations in consciousness, cognition, and neurological signs is mandatory. TBI mortality doubles when it is associated with hypoxia or hypotension. Timely airway and ventilation management is critical to prevent hypoxia-related complications.
Shock management, fluid resuscitation, and hemorrhage control are essential to improve outcomes.
. Ensuring a patent airway, adequate oxygenation, and hemodynamic stability are foundational to TBI patients' care. Continuous monitoring and assessment to detect evolving symptoms or complications is required.. 

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Early Diagnosis and Assessment:

 Early diagnosis and prompt intervention is crucial 

 Significant Blunt Injury Association:

 About  50% of deaths resulting from blunt trauma are associated with head injuries. 	

 Hypoxia and Mortality: 

 Shock and Mortality: 

 Mortality rates double  if the patient is in shock. 

 ABCs of Trauma: 

 ABCs (Airway, Breathing, Circulation) remain paramount in TBI management.

 Dynamic Nature of TBI: 

  The condition of the patient can change. .

 Mortality doubles in hypoxia occurs due to airway or breathing deficits.

[Audio] The initial management of the trauma patient starts with the Primary Survey.
Airway, breathing and circulation are critical. Life-threatening conditions must be promptly identified and addressed.. 

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Traumatic Brain Injury  Important in the  Initial Assessment of the Trauma Patient:  promptly identified life-threatening consequences

INITIAL ASSESSMENT AND TRIAGE
 Primary Survey Airway (with cervical spine control)  Breathing (respiratory rate & effort  Circulation (BP, pulse, hemorrhage  Disability (neurological status Exposure
 Secondary Survey: Head to Toe Exam

[Audio] The airway must be patent, and oxygen must be provided. Oxygen concentrators can be considered. The TBI and airway compromise both can cause altered mental status.. 

Scene 5

In patients with suspected TBI,

 A patent airway is essential to ensure 

 oxygenation and ventilation.

 signs of airway compromise  indicative of TBI

 altered mental status,

 vomiting

 facial trauma,

[Audio] If a head-injured patient has a compromised airway due to factors such as facial fractures, swelling, or bleeding that obstructs the airway, early intubation may be necessary.
Patients with head injuries may experience impaired ventilation, which can result from altered mental status, as neurological deficits affecting respiratory drive and chest trauma can impair ventilation. . Intubation may be required to support and maintain adequate oxygenation and ventilation.
In patients with a Glasgow Coma Scale (GCS) score of less than eight or an AVPU of P or U. (indicating severe impairment of consciousness), intubation is often necessary to protect the airway and ensure proper oxygenation and ventilation.. 

Scene 6

Airway Compromise

 Breathing Deficits:.

 Unconsciousness (GCS < 8

[Audio] Intubation helps protect the airway from aspiration of gastric contents or blood..
Mechanical ventilation allows control of oxygenation and ventilation, Intubation and controlled ventilation can help manage ICP by maintaining stable arterial carbon dioxide levels
ensuring that the patient receives the necessary oxygen and expels carbon dioxide is crucial for preventing secondary brain injury.
.Intubation can provide a controlled environment for frequent neurological assessment.. 

Scene 7

Airway Protection:
 Adequate Oxygenation and Ventilation:
 Management of Increased Intracranial Pressure (ICP):
 Facilitation of Neurological Assessment:

[Audio] TBI impairs a patient's ability to maintain their airway, leading to airway compromise and respiratory distress
.The respiratory control center in the brain stem are impacted indirectly through raised intracranial pressure (ICP). 

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TBI can lead to respiratory distress or failure 

 Reduced level of consciousness disrupt the normal functioning of the respiratory control centers in the brainstem  




 Respiratory rate and effort are crucial to detect changes that may suggest worsening TBI. 

 timely intervention and support for the patient's breathing is often needed.

[Audio] Monitoring blood pressure and pulse can help identify signs of shock
Hypotension must be urgently rectified.
A pulse oximeter is very helpful. 

Scene 9

Circulation (BP, pulse, hemorrhage control):

 Circulatory instability can occur secondary to associated injuries.

[Audio] Maintaining appropriate fluid balance is crucial in managing head-injured patients to optimize cerebral perfusion and reduce the risk of complications related to in
Intracranial pressure. . Shock can result from hemorrhage, fractures, or concurrent injuries
Normal Blood pressure maintains adequate cerebral perfusion and avoids excessive intracranial pressure.
Ringers lactate or saline solutions are isotonic and do not cause shifts of fluid into or out of brain tissue Dextrose solutions can cause cerebral edema and worsen intracranial pressure\
Hypoglycemia must be treated, but It is essential to avoid hyperglycemia as it may exacerbate brain injury.. 

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Fluid resuscitation in the head injured patient\

Fluid Resuscitation and Shock: If a head-injured patient presents with signs of shock, it is crucial to investigate, and address causes other than the head injury. Maintaining Normotension:  keep head-injured patients normotensive, meaning blood pressure  within the normal range for age and medical conditions.  Choice of Intravenous Solutions: Ringer's lactate or Normal Saline (0.9% saline) are appropriate for fluid resuscitation in head injury patients.  Avoid Hypotonic Solutions: Hypotonic solutions, such as 5% dextrose (D5W), should not be given to the head injury patient.  Role of Dextrose (Glucose): If a head-injured patient experiences hypoglycemia, 50% dextrose (D50W) is appropriate to correct the hypoglycemic state rapidly

[Audio] The AVPU disability assessment helps triage TBI patients for further evaluation and intervention, such as neuroimaging. Front-line health workers should use AVPU in the primary survey, while GCS in the secondary survey. pupil size and reactivity are important assessments which accompany GCS or AVPU. 

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AVPU  Required in Primary Survey 

 Glasgow Coma Scale (GCS)  Required in Secondary Survey

 Assessing the patient's level of consciousness,

 pupil size and reactivity  

 motor responses

 verbal responses

[Audio] AVPU is a quick and useful tool for initial assessment, especially in situations where time is of the essence, such as during emergency care or triage in trauma scenarios. It should be taught to frontline health workers.. 

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2.7  AVPU  
Simplified Assessment of Level of Consciousness

- Alert:         a minor injury        relatively normal level of consciousness. responsive, able to interact appropriately
 V - Vocal:         a moderate injury        some degree of altered consciousness. responsive may not be fully alert or oriented. makes vocal responses
 P - Pain:         severe Injury        Significant alteration in Consciousness unresponsive to verbal or vocal stimuli  Reacts to painful stimuli (pinch or sternal rub)
 U - Unresponsive:         a very severe injury         a state of unconsciousness Unresponsive to verbal, vocal, and painful stimuli.

[Audio] Exposure must be done while maintaining patient privacy and dignity Maintain body temperature: prevent hypothermia or hyperthermia
Use blankets or clothing as necessary
Remove hazards in the patient's environment
.
NOTE:. bruising, bleeding, rashes, or other abnormalities, which may be signs of serious underlying injury.. 

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E - Exposure or Environmental Control: 
 assessing and addressing factors related to the patient's exposure to the environment. It includes actions such as:

Ensure adequate exposure for a thorough examination.

 .

 Prevent further injury




 Note any visible signs of injury or medical conditions on the skin

[Audio] Nest is a head-to-toe exam and AMPLE history. But if the patient deteriorates at any time, you must return to the primary survey, reevaluate ABCDE, and respond to any deterioration promptly.. 

Scene 14

But return to evaluate ABCDE if the patient becomes unstable.


Traumatic Brain and Spinal Injury (TBSI)

Scene 0

We will now proceed with the management of Traumatic Brain Injury; TBI is managed within the ATLS Initial assessment, starting with the primary survey. The initial assessment and primary survey are the most important parts of the management of TBI.  If this is not done well, CT scans and craniotomy will not be relevant.

avatar

This study is from  Uganda The intent, age gender, causes  and distribution between unintentional and Intentional is similar throughout Eastern Africa.

 Reference: Traumatic Brain Injuries in Uganda Nukhba Zia, Amber Mehmood, Rukia H Namaganda, Hussein Ssenyonjo, Olive Kobusingye. Adnan Hyder                                http://orcid.org/0000-0002-8417-1282 Intent  69.7% unintentional   30.3%  intentional  Both groups, Age and Gender   28±14 years  Average 70%  19- and 45-years age  80%  males   Unintentional TBI road traffic injuries (RTI) (88.9%) and falls (11.1%).  Pedestrians (42.1%) and motorcycle drivers (28.1*  43.6% were admitted, 34.0% were sent home Intentional TBI Assault (97.1%):  bodily force (33.7%), iron bar (24.2%) and hammer (12.0%) 42.6% were admitted and 37.1 % were sent home GCS  68.1% mild, 22.1% moderate, 14.2% severe category



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Monitoring alternations in consciousness, cognition, and neurological signs is mandatory.

TBI mortality doubles when it is associated with hypoxia or hypotension. Timely airway and ventilation management is critical to prevent hypoxia-related complications.
Shock management, fluid resuscitation, and hemorrhage control are essential to improve outcomes.
. Ensuring a patent airway, adequate oxygenation, and hemodynamic stability are foundational to TBI patients' care.
 Continuous monitoring and assessment to detect evolving symptoms or complications is required.

slide3-hotlink5

The initial management of the trauma patient starts with the Primary Survey.
Airway, breathing and circulation are critical. Life-threatening conditions must be promptly identified and addressed.

The airway must be patent, and oxygen must be provided.  Oxygen concentrators can be considered. The TBI and airway compromise both can cause altered mental status.

If a head-injured patient has a compromised airway due to factors such as facial fractures, swelling, or bleeding that obstructs the airway, early intubation may be necessary.
Patients with head injuries may experience impaired ventilation, which can result from altered mental status, as neurological deficits affecting respiratory drive and chest trauma can impair ventilation. 
. Intubation may be required to support and maintain adequate oxygenation and ventilation.
In patients with a Glasgow Coma Scale (GCS) score of less than eight or an AVPU of P or U  (indicating severe impairment of consciousness), intubation is often necessary to protect the airway and ensure proper oxygenation and ventilation.

Intubation helps protect the airway from aspiration of gastric contents or blood..
Mechanical ventilation allows control of oxygenation and ventilation, 
Intubation and controlled ventilation can help manage ICP by maintaining stable arterial carbon dioxide levels
ensuring that the patient receives the necessary oxygen and expels carbon dioxide is crucial for preventing secondary brain injury.
.Intubation can provide a  controlled environment for frequent neurological assessment.

TBI impairs a patient's ability to maintain their airway, leading to airway compromise and respiratory distress
.The respiratory control center in the brain stem are impacted indirectly through raised intracranial pressure (ICP)

Monitoring blood pressure and pulse can help identify signs of shock
Hypotension must be urgently rectified.
A pulse oximeter is very helpful

Maintaining appropriate fluid balance is crucial in managing head-injured patients to optimize cerebral perfusion and reduce the risk of complications related to in
Intracranial pressure.
 . Shock can result from  hemorrhage, fractures, or concurrent injuries
Normal Blood pressure maintains adequate cerebral perfusion and avoids excessive intracranial pressure.
Ringers lactate or saline solutions are isotonic and do not cause shifts of fluid into or out of brain tissue 
Dextrose solutions can cause cerebral edema and worsen intracranial pressure\
Hypoglycemia must be treated, but  It is essential to avoid hyperglycemia as it may exacerbate brain injury.

The  AVPU disability assessment helps triage TBI patients for further evaluation and intervention, such as neuroimaging. Front-line health workers should  use AVPU in the primary survey, while GCS in the secondary survey. 
pupil size and reactivity are important assessments which accompany  GCS or AVPU

AVPU  is a quick and useful tool for initial assessment, especially in situations where time is of the essence, such as during emergency care or triage in trauma scenarios. It should be taught to frontline health workers.

Exposure must be done while maintaining patient privacy and dignity 
Maintain body temperature: prevent hypothermia or hyperthermia
Use blankets or clothing as necessary
Remove hazards in the patient's environment
.
NOTE:. bruising, bleeding, rashes, or other abnormalities, which may be signs of serious underlying injury.

Nest is a head-to-toe exam and AMPLE history. But if the patient deteriorates at any time, you must return to the primary survey, reevaluate ABCDE, and respond to any deterioration promptly.