TBII

The leading cause of traumatic brain injury

• Sports Related

• MVA

• Falls

• Violence

Risk of TBI increases sharply after this age:

• 45

• 55

• 60

• 65

Helmets do all of the following, EXCEPT

• Prevent Concussions

• Prevent Skull Fractures

• Increase visibility

• Absorb Some of the Energy Produced by Impact

Your 23 year-old traumatic brain injury patient (TBI) has been exhibiting increasing confusion over the past several days. His vitals include heart rate of 122 and blood pressure of 100/60. Labs are drawn, and the sodium level is 122. What is the next best step?

• DDAVP

• IV Fluids

• Salt Tablets

• Restrict Water

Answer explanation

This patient with hypovolemic hyponatremia (tachycardia, low blood pressure, low sodium) is experiencing cerebral salt wasting (CSW), which is known to occur after TBI. In CSW the patient excessively wastes salt out of their body; water follows the salt out of the body, resulting in hypovolemic hyponatremia. ADH is appropriately elevated in these patients as the patient’s body attempts to hold onto the water that is being lost. The first line of treatment for CSW is IV fluids to replace both the sodium and water that is being lost.

Your 23 year-old traumatic brain injury (TBI) patient has been exhibiting increasing thirst and dry mucous membranes for the past few days. His vitals include heart rate of 122 and blood pressure of 100/60. Labs are drawn, and the sodium level is 155. What is the next best step?

• DDAVP

• IVF

• Restrict Water

• Oral Salt Tabs

Answer explanation

This patient with increased thirst, hypovolemia, and sodium of 155 is suffering from central diabetes insipidus (CDI), which can occur following a TBI. In CDI the patient fails to produce antidiuretic hormone (ADH), thus their body urinates out water freely, and the patient cannot keep up with fluid intake (they are thirsty with dry mucous membranes). They exhibit hypernatremia on labs due to water loss concentrating the blood with sodium. First line treatment for CDI is to simply administer ADH (in the form of DDAVP).

You are called to the bedside on PM&R consult service rounds to examine a brain injury patient. The patient exhibits open eyes. He is nonverbal. He follows commands inconsistently. He does maintain sleep-wake cycles on EEG. When you pinch his arm, he reaches across his body with his other arm to cover up the spot where you pinched him. How would you define this patient’s arousal status?

• Emerging

• Minimally Conscious state

• Coma

• Vegetative State

Answer explanation

•Coma is defined as closed eyes, no sleep/wake cycles on EEG, and no purposeful behavior or comprehension. In vegetative state, the patient does have sleep/wake cycles on EEG, and eyes are open, but there is no purposeful activity, only reflexive actions. Minimally conscious state is defined as open eyes, presence of sleep-wake cycles on EEG, and inconsistent awareness of the environment with purposeful behaviors. When this becomes consistent, the patient is said to have “emerged” and is considered to exhibit “normal” arousal at that point, or to at least not possess a disorder of consciousness (DOC).

You are called to the bedside on PM&R consult service rounds to examine a brain injury patient. The patient exhibits open eyes. He follows no commands. He does appear to maintain sleep-wake cycles on EEG. When you pinch his arm, he flexes his elbow. How would you define this patient’s arousal status?

• Vegetative State

• Minimally conscious state

• Coma

• Emerged

Answer explanation

In short, coma is defined as closed eyes, no sleep/wake cycles on EEG, and no purposeful behavior or comprehension. In vegetative state, the patient does have sleep/wake cycles on EEG, and eyes are open, but there is no purposeful activity, only reflexive actions. Minimally conscious state is defined as open eyes, presence of sleep-wake cycles on EEG, and inconsistent awareness of the environment with purposeful behaviors. When this becomes consistent, the patient is said to have “emerged” and is considered to exhibit “normal” arousal at that point, or to at least not possess a disorder of consciousness (DOC).

A 71 year-old male sustains a ground-level fall and is rushed to the emergency department. Stat head CT reveals a long, crescent-shaped opacity along the left hemisphere. What is the pathophysiologic mechanism behind this abnormality?

• Rupture of a saccular (berry) aneurysm at the posterior communicating artery

• Rupture of a saccular (berry) aneurysm at the anterior communicating artery

• Rupture of the bridging veins between the dura and the arachnoid mater

• Rupture of the middle meningeal artery

Answer explanation

The radiologic description of this patient’s head CT is that of a subdural hematoma which occurs due to head trauma resulting in rupture of the bridging veins between the dura and arachnoid mater. These veins are more likely to be stretched and more prone to rupture in cases of brain atrophy (e.g. alcoholism or the aging process). Epidural hematoma is a lens-shaped opacity due to rupture of the middle meningeal artery. Rupture of a berry aneurysm causes subarachnoid hemorrhage.

ou are called to the bedside on PM&R consult service rounds to examine a brain injury patient. The patient exhibits closed eyes. He follows no commands. He does not appear to maintain sleep-wake cycles on EEG. How would you define this patient’s arousal status?

• Perpetual somnolence

• Minimally conscious state

• Coma

• Vegetative state

Answer explanation

In short, coma is defined as closed eyes, no sleep/wake cycles on EEG, and no purposeful behavior or comprehension. In vegetative state, the patient does have sleep/wake cycles on EEG, and eyes are open, but there is no purposeful activity, only reflexive actions. Minimally conscious state is defined as open eyes, presence of sleep-wake cycles on EEG, and inconsistent awareness of the environment with purposeful behaviors. When this becomes consistent, the patient is said to have “emerged” and is considered to exhibit “normal” arousal at that point, or to at least not possess a disorder of consciousness (DOC).

Non-accidental traumatic brain injury in young children is characterized by the clinical triad of subdural hematoma, retinal hemorrhages, and encephalopathy. As the child’s history is taken, which
finding is classically noted?

• the history given is consistent with the severity of the injuries

• the injuries are reported as unwitnessed

• multiple care providers were present at time of injury

• medical attention was sought promptly after the injury

Answer explanation

The classic history for nonaccidental traumatic brain injury (shaken baby syndrome) is that of a history incompatible with the severity of injuries, an unwitnessed event, so detail is missing, and the injury is inflicted by a solitary care provider. There is often a delay in seeking medical attention. Recent studies indicate that the child usually experiences a physical impact, in addition to the shaking.