Updated: 9/10/2019

Concussion / Traumatic Brain Injury

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Snapshot
  • A 53-year-old man is brought to the emergency department by his friend after losing consciousness following a bike accident in which he was not wearing a helmet. After falling, the patient hit his head and was difficult to arouse. Medical history is significant for atrial fibrillation currently on metoprolol and apixaban. In the emergency department, the patient appears agitated and had an episode of emesis. A noncontrast CT scan of the head demonstrates an epidural hemoatoma and small intraparenchymal bleeds.
Introduction
  • Definition
    • disruption in normal brain function secondary to traumatic injury to the brain
  • Epidemiology
    • incidence
      • a leading cause of disability in the United States
  • Etiology
    • motor vehicle accidents (leading cause)
    • falls
    • firearms
    • contact sports (e.g., boxing and football)
    • alcohol use
  • Pathogenesis
    • can be divided into primary and secondary brain injury
      • primary brain injury (occurs at the moment of trauma)
        • external mechanical forces are transmitted to the contents within the cranium leading to
          • cerebral contusions
          • hematomas
          • diffuse axonal injury
          • cerebral edema
      • secondary brain injury (occurs immediately after the trauma)
        • cascading molecular injury mechanism after the primary brain injury
          • neuronal excitotoxicity and apoptosis
          • inflammation
          • vascular injury (e.g., vasospasm and microvessel occlusion)
  • Associated conditions
    • cervical spine injury
Presentation
  • Symptoms/physical exam
    • mild traumatic brain injury
      • headache
      • remains conciouss or has loss of conciousness for a few seconds or minutes
      • behavioral or mood changes
      • trouble with memory or concentration
    • moderate and severe traumatic brain injury
      • similar symptoms as mild traumatic brain injury; however, patients may have
        • worsening headache
        • recurrent nausea and vomiting
        • seizures
        • pupillary changes
        • focal neurological deficits
        • clear liquid coming from the ears and nose (cerebrospinal fluid leak)
        • bruising behind the ears (Battle sign)
        • black eye
Imaging
  • Noncontrast head CT
    • indication 
      • initial imaging study in patients with recent moderate or severe mechanical brain injury
        • used to determine if there is an intracranial bleed and cranial fractures
  • CT of the cervical spine
    • indication
      • to rule out cervical spine injury with moderate or severe mechanical brain injury
Studies
  • Glasgow Coma Scale
    • scores the severity of the traumatic brain injury
    • score of 13-15
      • mild traumatic brain injury
    • score of 9-12
      • moderate traumatic brain injury
    • score of 8 or less
      • severe traumatic brain injury
Treatment
  • Conservative
    • stabilizing airway, breathing, and circulation
      • indication
        • initial step in management
    • intracranial pressure monitoring
      • indication
        • used in cases of severe traumatic brain injury
          • medical management follows depending on the intracranial pressure
          • other management options depends on the consequences of the traumatic brain injury (e.g., epidural hematoma)
    • rest and primary care follow-up 
      • indication
        • for concussions with proper return precautions 
Complications
  • Skull fractures
  • Intracranial hemorrhages
    • epidural hematoma
    • subdural hematoma
    • subarachnoid hemorrhages
    • intraventricular hemorrhages
    • intracerebral hemorrhages
  • Cerebral herniation
  • Encephalopathy
 

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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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