TraumaticBrain Injury (TBI)
TraumaticBrain Injury (TBI)
Traumaticbrain injury (TBI) is deemed a nonhereditary impact to the brain froman outside force that causes a lasting or brief impairment of thebrains` cognitive, psychosocial and physical functions. In the UnitedStates, there are over 1.5 million traumatic brain injuries annually(Doanet al., 2016).This condition is considered the leading cause of death among peopleunder the age of 45. These injuries result in nearly 50,000 deathsand approximately 80,000 – 90,000 cases of incapacitations (Doanet al., 2016).The annual economic cost related to TBI is almost $80 billion in theUnited States. This cost occurs besides the emotional and physicalimpacts that the injuries inflict on the families. In most instances,victims of traumatic brain injury are deprived of their ability towork or conduct other activities that can earn them a living.
Intraumatic brain injuries, the most critical tool utilized to assessthe extent of brain damage and the prognosis is exam findings.According to the initial indicators of prognosis in severe cases ofTBI, approximately 88% of patients with unreactive pupils succumbedto death, while 4% of them experienced recovery or moderatedisability (Agarwal& Tisherman, 2014).Moreover, radiographic outcomes can be used to forecast the scale ofmorbidity and mortality and can be used to monitor surgicalmediation. The diagnostic procedure used for traumatic brain injuryis critical in the management of the condition. This is because ithelps the attending clinician to categorize the severity of theinjury as minor, moderate or severe. Consequently, this helps in thedetermination of the expected prognosis. Furthermore, the diagnosticprocedure utilized guides the application of diagnostic tests toreveal brain abrasions that need immediate management.
OnJanuary 23, 2017, a 31-year-old while the male was brought to theemergency department in an ambulance as a level 1 trauma. Reportsindicated that the patient was riding a motorcycle without a helmetwhen he lost control and went off-road. He was complaining headacheafter the impact but he presented unconscious. There was no vomiting,nausea or any unusual behavior. He was accompanied to the emergencyroom by a stranger who had witnessed the accident. His conditionnecessitated the performance of a physical and neurological exam anda computerized tomography (CT) scan. These diagnostic procedures arebased on the nature of a patient’s condition on arrival at thehospital. In this case, the physical and neurological examination wasdeemed necessary and given the fact that the patient was presented inan unconscious state, there was a necessity of using an advanceddiagnostic test, which in this case was the CT scan.
Physicaland Neurological Exam
Historysuggests that the signs in most patients with the head areself-evident. Nonetheless, considering brain trauma in the context ofcerebral pathology, there needs to be a physical and neurologicalexam to discern any signs that may hint towards the extent of theinjury. The patient presented with unconsciousness, confusion, adeteriorated mental status. These signs directly point to the needfor performing a physical exam. The physical exam entails an array ofactions, but their essence depends on the signs displayed by thepatient.
Thefirst major component of this exam is the GCS check that should bedone at regular intervals of 15-30 minutes until the patient regainsstability (Agarwal& Tisherman, 2014).This can help in monitoring the functioning of the neurologicalfunction of the patient. This should be followed by inspecting thepatient’s cranial nerves and the presence of discolored bloodbeneath the skin of the head and around the neck to establish if thebase of the skull is fractured.
Thephysical check of a patient with a head injury is used to evaluatethe observable signs of injury, while the neurological exam, throughthe GCS is utilized to evaluate the level of the patients’consciousness. These two examinations can provide importantprognostic facts that can give the physician the guideline for thenext action for further diagnostics and monitoring. A GCS score ofbetween 13 and 15 is deemed an indication of a good outcome, althoughit cannot be used as a basis for ruling out internal injury (Tidy,2014).A score of 9 and below is associated with a deteriorating state andpossibly unfortunate outcomes.
TheGCS major components are the eye response, verbal response, and motorresponse. Scoring for each of them should be independent. Shortfallsin a patient`s motor response are deemed to have the strongestcorrelation with poor outcomes (Doanet al., 2015).The eye component should indicate a pupil size of between 2 and 5 mmwith a normal symmetry of approximately 1mm. The performance of theseexams is not associated with any risks or harm to the patient
ComputerizedTomography (CT) Scan
Thistechnology is intended to reveal the internal injury to guide themedical and surgical management of a traumatic brain injury. Thedecision to utilize this technology is made by the attendingclinician based on the signs presented by the patient. A CT scan wasfirst used in a London hospital in 1972 (Tidy,2014).Since then, and given the technological advancements of the past twodecades, CT scanning has become the backbone of brain injurydiagnostics. It is extremely valuable in investigating acutesituations of brain injury because they are readily available andless expensive compared to MRI systems.
Thepatient in this case presented with an unconscious state of mind, alow heartbeat rate, and a low brain activity. The reduction of thebrain activity after the impact may have caused internal hemorrhagein the brain or a fracture in the skull, which could be indicationsof a severe traumatic injury. CT scanning is a reliable diagnosticapproach that can be relied on in excluding the known causes of braintrauma (Amyotet al., 2015).
CT-scanscan reveal evidence of hemorrhage in the brain if it is performedwithin the first 48 to 72 hours after an accident (Amyotet al., 2015).It is normally indicated in a headache accompanied by focalneurological signs, nausea, and vomiting. In this patent`s case,there was no evidence of nausea and vomiting because he wasunconscious. However, his focal neurological signs had been affectedgiven that he depicted fixed pupils with the negative response of thecornea. This meant that his brain might have been affected andtherefore, a CT scan was the ideal procedure for that diagnosis.
Despitethe fact that CT scans are exceptionally valuable diagnosticprocedures, they are considered to have a high level of radiation.This radiation can be harmful when a CT scan is performed on a youngpatient whose brain is still developing, a pregnant woman orindividuals with weakened immune systems (Agarwal& Tisherman, 2014).Therefore, the performance of this procedure is risky in theaforementioned groups of people because it can inflict harm to thecells of the affected part.
Theperformance of the above tests on the patient produced results thatwere consistent with the expectations. A physical exam of his initialneurologic function indicated a GCS of 3T, 4mm-fixed pupils, negativeresponse of the cornea, and a shifted cerebral spinal fluid (CSF). Inaddition, a CT scan on the patient indicated subarachnoid hemorrhagewith left and anterior subdural blood flow. The CT scan revealed apronounced accumulation of blood in right and middle segments of thebrain. There was a fracture on the anterior part of the brain and theright temporal bone. He had a slow heartbeat rate and his lowest ratewas recorded at 28 bpm, and hypersensitive with and preliminary bloodpressure of 172/118 mmHg. This level was elevated after his arrivalat the hospital.
Followingthe initial interventions of nicardipine infusion and, fluid and drugadministration, the patient was examined again, and his neurologicfunction was found to be have increased to 5T, with reactive pupils,and an affirmative cornea response of the eye. A further CT scan ofthe brain revealed an improvement of its midline shift. The nurseskept a close eye of the patient while conducting the normalmanagement procedures.
Thiscase report shows that when calculating the mortality and unfavorableoutcomes of a traumatic injury to the brain physical examinationfindings, laboratory results and imaging findings can be used asdiagnostic criteria. Following a traumatic brain injury, theunfavorable outcome is death, instability of the brain, or severedisability. The patient presented with a GCS of three and fixedpupils, and CT indications of bleeding in the brain, and a shift inthe midline among others. Physical and neurological exams and CTscanning were conducted to provide results that formed the basis offurther intervention.
Agarwal,V., & Tisherman, S. A. (2014). Traumatic brain injury. In Imagingthe ICU Patient (pp.365-375). Springer London.
Amyot,F., Arciniegas, D. B., Brazaitis, M. P., Curley, K. C.,Diaz-Arrastia, R., Gandjbakhche, A., … & Razumovsky, A. (2015).A review of the effectiveness of neuroimaging modalities for thedetection of traumatic brain injury. Journalof neurotrauma, 32(22),1693-1721.
Doan,N., Patel, M., Doan, H., Janich, K., & Nguyen, H. S. (2016).Traumatic brain injury. IntJ Phys Med Rehabil, 4,e120.
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