Surgical Management of Traumatic Brain Injury

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SURGICAL MANAGEMENT OF TRAUMATIC BRAIN INJURY Edward (Ned) Hames, III, M.D., Ph.D., F.A.C.S. University of Minnesota Physicians Fairview Southdale Neurosurgery Clinic Spine, Brain and Stroke Institute CDC DEFINITION of Traumatic Brain Injury (TBI) • An occurrence of injury to the head (arising from blunt or penetrating trauma) or from acceleration/deceleration forces that causes craniocerebral trauma. Spine, Brain and Stroke Institute SYMPTOMS ATTRIBUTABLE TO TBI 1. Amnesia 2. Decreased levels of consciousness 3. Skull fracture 4. Diagnosed intracranial abnormalities 5. Death 6. Other neurological of neuropsychological abnormalities TRAUMATIC BRAIN INJURY • Case definitions and inclusion criteria vary tremendously from one study to another BRAIN INJURY OCCURRENCES • Rates range from 92 ≥ 618/100,000 population • Fatal and nonfatal hospitalized brain injuries in the Midwest urban areas 150/100,000 population • The extent of E.D. and non E.D. diagnosis and treatment of TBI is unknown HIGH RISK GROUP CHARACTERISTICS • Age 15-24 years> 72 years • Gender M:F = 3:1 • Alcohol • Low income families • Relative risk of recurrence TBI with previous injury in 3 times higher than general population risk CONTUSION VS CONCUSSION CONCUSSION SEVERITY LOSS of GRADE SYMPTOMS CONSCIOUSNESS 1. Mild - transient confusion No - symptoms of mental status abnormalities < then 15 min 2. Moderate - transient confusion No - mental status abnormalities > 15 min 3. Severe ANY loss of consciousness GLASCOW COMA SCALE • A clinical prognostic indicator which is an important contribution to standardizing early and continued assessments of the severity of brain injury TYPES OF BRAIN LESIONS A) Intracranial WITH skull fracture B) Intracranial WITHOUT skull fracture - Hemorrhage - Contusion - Laceration ANATOMY Scalp= skin and subcutaneous tissue galea poneurotia Skull= Outter Table Diploe Inner Table Epidural Space Dura Mater Intracranial Subdural Space Pia Mater Subarachnoidal Space Cerebrum Skull Fracture Open Closed (Compound) Linear skull fracture Compound skull fracture Depressed skull fracture Basilar skull fracture EPIDURAL HEMATOMA • 3-4% of major head injuries • The source is usually arterial SUBDURAL HEMATOMAS • Usually the result of an acute venous hemorrhage caused by rupture of cortical bridging veins INTRACEREBRAL HEMATOMA- CONTUSION .

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Diagnoses to Include in the Problem List Whenever Applicable
Diagnoses to include in the problem list whenever applicable Tips: 1. Always say acute or open when applicable 2. Always relate to the original trauma 3. Always include acid-base abnormalities, AKI due to ATN, sodium/osmolality abnormalities 4. Address in the plan of your note 5. Do NOT say possible, potential, likely… Coders can only use a real diagnosis. Make a real diagnosis. Neurological/Psych: Head: 1. Skull fracture of vault – open vs closed 2. Basilar skull fracture 3. Facial fractures 4. Nerve injury____________ 5. LOC – include duration (max duration needed is >24 hrs) and whether they returned to neurological baseline 6. Concussion with or without return to baseline consciousness 7. DAI/severe concussion with or without return to baseline consciousness 8. Type of traumatic brain injury (hemorrhages and contusions) – include size a. Tiny = <0.6 cm b. Small/moderate = 0.6-1 cm c. Large/extensive = >1 cm 9. Cerebral contusion/hemorrhage 10. Cerebral edema 11. Brainstem compression 12. Anoxic brain injury 13. Seizures 14. Brain death Spine: 1. Cervical spine fracture with (complete or incomplete) or without cord injury 2. Thoracic spine fracture with (complete or incomplete) or without cord injury 3. Lumbar spine fracture with (complete or incomplete) or without cord injury 4. Cord syndromes: central, anterior, or Brown-Sequard 5. Paraplegia or quadriplegia (any deficit in the upper extremity is consistent with quadriplegia) Cardiovascular: 1. Acute systolic heart failure 40 2. Acute diastolic heart failure 3. Chronic systolic heart failure 4. Chronic diastolic heart failure 5. Combined heart failure 6. Cardiac injury or vascular injuries 7.
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