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StatPearls . Treasure Isl& (FL): StatPearls Publishing; 20trăng tròn Jan-.


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Introduction

Traumatic Brain Injury (TBI) is a significant cause of morbidity and mortality in the United States, with an annual occurrence of more than 1.5 million. Patients with moderate & severe TBI comprise about 20% of TBI, and those with moderate TBI have sầu a mortality of about 15% while those with severe TBI have associated mortality approaching 40%. The majority (approximately 80%) of patients with TBI have sầu mild TBI which is associated with a less than 0.5% mortality, but about 25% experience extended post-concussive symptoms including a headabít, dizziness, difficulty concentrating, & depression. 

Etiology

Falls are the most common cause of TBI, & motor vehicle-related incidents are the second leading cause of TBI. Motor vehicle-related TBI includes autoSmartphone, motorcycle, và bicycle accidents and pedestrians struông chồng by those vehicles. Sports, recreation, & work-related injuries are the third leading cause of TBI, và assaults are the fourth leading cause of TBI. Blast injuries are the leading cause of TBI in active duty military personnel in war zones.

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Epidemiology

TBI is the most common cause of death in people younger than the age of 25. The majority of fatal TBI is due khổng lồ motor vehicle-related incidents, falls, and assaults. Mortality due lớn motor vehicle accidents is greatest in the young-adult age group attributed to alcohol use & excessive speed. Mortality due lớn falls is greathử nghiệm in patients over age 65, which is also the age group with the highest mortality in any TBI. Neurosurgical intervention such as craniotomy, elevation of skull fracture, intracranial pressure (ICP) monitor, or ventriculostomy is required in about 40% of patients with severe TBI & about 10% of patients with moderate TBI.

Pathophysiology

Most patients with moderate to severe TBI have sầu a combination of intracranial injuries. The majority of patients with moderate to severe TBI have related diffuse axonal injury khổng lồ some degree. The diffuse axonal injury typically is caused by a rapid rotational or deceleration force that causes stretching và tearing of neurons, leading lớn focal areas of hemorrhage và edema that are not always detected on the initial computed tomogram (CT) scan. Subarachnoid hemorrhage (SAH) is the most comtháng CT finding in TBI và is caused by tears in the pial vessels. Subdural & epidural hematomas are the most frequent type of mass lesion identified in TBI. Cerebral contusions occur in about a third of patients with moderate lớn severe TBI, caused by direct impact or acceleration-deceleration forces that cause the brain to strike the frontal or temporal regions of the skull. Intracerebral bleeding or hematoma, caused by coalescence of contusions or a tear in a parenchymal vessel, occurring in up lớn a third of patients with moderate to severe TBI.

History and Physical

The majority of patients with TBI have sầu a straightforward clinical presentation, but it is also important lớn solicit the mechanism of injury, current anticoagulation use, symptoms of the head or neông chồng pain, post-traumatic seizure, and any history of repeat head injury or past central nervous system surgeries.

After addressing any airway or circulatory deficits, a thorough head-to-toe physical examination must be performed with vigilance for occult injuries and careful attention to detect any of the following warning signs:

Fundoscopic examination for retinal hemorrhage (a potential sign of abuse in children) & papilledema (a sign of increased ICP)Optic nerve sầu sheath diameter of greater than 5 milimet on ultrasound has been shown lớn correlate well with increased intracranial pressure in patients with TBIPalpation of the scalp for hematoma, crepitus, laceration, & bony deformity (markers of skull fractures)Auscultation for carotid bruits, painful Horner syndrome or facial/nechồng hyperesthesia (markers of carotid or vertebral dissection)Evaluation for cervical spine tenderness, paresthesias, incontinence, extremity weakness, priapism (signs of spinal cord injury)

Evaluation

Non-contrast cranial CT is the imaging modality of choice for patients with TBI. CT findings associated with a poor outcome in TBI include midline shift, subarachnoid hemorrhage into the verticals, and compression of the basal cisterns. Magnetic Resonance Imaging scan may be indicated when the clinical picture remains unclear after a CT lớn identify more subtle lesions.

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Treatment / Management

Airway adjuncts are indicated in patients not able to maintain an open airway or maintain more than 90% oxygene saturation with supplementary oxyren. Oxygenation parameters should be monitored using continuous pulse oximetry with a target of more than 90% oxyren saturation. Ventilation should be monitored with continuous capnography with an end-tidal CO2 target of 35 mmHg to lớn 40 mmHg. Placement of a definitive airway is recommended in the patient with a Glasgow Coma Scale (GCS) score of less than 9.

Systemic hypotension negatively impacts the outcome in the setting of TBI, và current studies have demonstrated improved outcomes in patients with systolic blood pressure (BP) greater than or equal to lớn 1đôi mươi mmHg. Isotonic crystalloids should be used to lớn prsự kiện và correct hypotension; colloidal solutions have sầu not been shown lớn improve outcomes.

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Routine hyperventilation should be avoided during the first 24 hours, và should only be used as a temporizing measure in the setting of impending herniation. Hyperosmolar therapy such as mannitol or hypertonic saline can further reduce intracerebral volume. ICP monitoring is indicated in patients with TBI when they have a GCS score of less than 9, an abnormal CT, and the approach lớn refractory elevated intracranial pressure includes high-dose barbiturates và possibly a decompressive hemicraniectomy.