1. Management of
Traumatic Brain Injury
Nakornchai Phuenpathom M.D.
Department of Surgery
Faculty of Medicine
Prince of Songkla University
Definition
• A patient was classified as one with a head
injury if he had one or more of the following
features:
• Definite history of a blow to the head
• Laceration of the scalp or forehead
• Altered consciousness after a relevant
injury, no matter how brief
Scottish Head Injury Management Study. Head injuries in Scottish Hospitals. Lancet 1977; 2: 696-698.
What is TBI?
A blow or jolt to the head that disrupts
- the function of the brain
- a person’s life
- the lives of their families/caregivers.

2. Traumatic Brain Injury
(TBI)
• An alteration in brain function manifest as:
– Confusion
– Altered level of consciousness
– Seizure
– Coma
– Focal sensory or motor neurological deficit
• Resulting from blunt or penetrating force to
the head
Bruns J, Hauser WA. The epidemiology of traumatic brain injury: A review.
Epilepsia 2003; 44(Suppl. 10): 2-10.
Primary Survey
• A: airway maintenance with cervical spine
protection
• B: breathing and ventilation
• C: circulation with haemorrhage control
• D: disability or neurologic status
• E: exposure / environmental control

3. D: Disability
• Glasgow Coma Scale (GCS) score: Conscious
level
• Pupillary size and reaction
• Lateralizing signs: motor weakness
• Spinal cord injury level
Glasgow Coma Scale
■ Input
• Command or pain
■ Output
• Best motor response
• Best verbal response
• Eye opening
■ Score range
• 3-15

4. Decreased Conscious Level
• Decreased cerebral oxygenation and / or
perfusion
• Direct cerebral injury
• Hypoglycemia
• Intoxications from alcohol, narcotics, and other
drugs.

5. Definition of Severe
Traumatic Brain Injury
■ The patient had a Glasgow coma scale (GCS)
score of 8 or less following nonsurgical
resuscitation or a GCS score deteriorating to 8
or less within 48 hours after head trauma.
■ Nonsurgical resuscitation means endotracheal
intubation, mannitol administration, and volume
support.
Secondary Insults & Injury
• Secondary insults
• detrimental events
• Increased damage to the primary injury
• Hypoxia and hypotension
• Secondary injuries
• processes that develop in the hours to days after the
unavoidable primary injury
• Result of the biochemical cascades initiated by trauma

7. Mild Traumatic Brain
Injury
Definition ?
• An acute brain injury resulting from mechanical
energy to the head from external physical forces.
Criteria for identification include:*
– One or more of the following
• Confusion or disorientation
• Loss of consciousness for 30 minutes or less
• Post-traumatic amnesia for less than 24 hours
• And/ or other transient neurological abnormalities
– GCS score of 13-15 after 30 minutes post-injury.
– Not be due to drugs, alcohol, medications, caused by
other injuries or treatment for other injuries, caused by
other problems, or caused by penetrating injury.
*MTBI Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation
Medicine1993.
Intracranial Complications
GCS
score
Prevalence of
CT abnormal
Prevalence of
surgical
intervention
Mortality rate
13 30 % 7.5 % 1.1 %
14 20 % 3.6 % 0.01 %
15 5 – 8 % 0.08 % 0.01 %
Borg J, et al. Diagnostic procedures in MTBI: Result of the WHO Collaborating Centre Task Force on MTBI.
J Rehabil Med 2004; Suppl.43:61-75ใ

8. Diffuse Brain Injury
Cerebral concussion
Physiological change/
dysfunction
Severe traumatic axonal
Injury.
Anatomical damage.
Injury severity
New
Orleans
Criteria
(NOC)
• Headache
• Vomiting
• An
age
over
60
years
• Drug
or
alcohol
intoxication
• Deficits
in
short-­‐term
memory
• Physical
evidence
of
trauma
above
the
clavicles
• Seizure
Haydel
MJ,
Preston
CA,
Mills
TJ,
et
al.
Indications
for
computed
tomography
in
patients
with
Minor
head
injury.
N
Engl
J
Med
2000;
343:
100-­‐5.

9. The
Canadian
CT
Head
Rule
(CCHR)
• High
risk
(for
neurological
intervention)
– GCS
score
<
15
at
2
hour
after
inury
– Suspected
open
or
depressed
skull
fracture
– Any
sign
of
basal
skull
fracture
(hemotympanum,
racoon
eyes,
CSF
otorrhea/
rhinorrhea,
Battle’s
sign)
– Vomiting
≥
2
episodes
– Age
≥
65
years
• Medium
risk
(for
brain
injury
on
CT)
– Amnesia
before
impact
>
30
min
– Dangerous
mechanism
Stiell
IG,
Wells
GA,
Vandemheen
K,
et
al.
The
Canadian
CT
head
rule
for
patients
with
minor
head
injury.
Lancet
2001;
357:
1391-­‐96.