TBI &

Glasgow Coma Scale

Mandy Freeman

March 2010
Aims
 Highlight types of traumatic brain injuries
(TBI)
 Highlight the importance of Glasgow Coma
Scale
Aetiology
 Annual incidence (US) – 180-220 cases per
100,000 i.e. 600,000 new cases per year (Tennant
1995)
 Fatal 10%
 GCS - Mild – 75-80 %, moderate – 10%, severe –
10%
 Permanent disability
 100% in severe, 66% in moderate
 Male to female ratio – 2:1 (Sosin et al 1996)
 Age Range ?
 Most common causes??

 (Royal College of Surgeons of

England 2007)
Pathophysiology
 Skull – rigid, inelastic container
 = Vol (Brain) + Vol (CSF) + Vol (Blood)
= 80% + 10% + 10%
 Monro-Kellie Doctrine – states that total
intracranial volume is fixed because of the
inelastic nature of the skull
 Intracranial compliance – change in the pressure
due to the change in volume
 Cushings Triad -Sign of ICP
 ºLaceration ºBOS #
ºContusion ºAbrasion
SKULL
ºLaceration
ºConcussion ºContusions
ºEDH –
ºSubdural: ºCranial #
ºICH ºSAH
EDH
 Extradural hematomas
 Between inner table of skull and dura
 Biconvex
 Arterial injury – enlarge rapidly
 Venous in around 10%
 Classic example – temporal EDH by fracture
through course of middle meningeal artery
 Lucid interval before deteriorating
 If tackled early – good prognosis for isolated
lesion
SDH
 Subdural hematoma
 Between dura and brain
 Outer edge – convex, inner – concave
 Not limited by suture lines
 Usually venous – bridging veins (cortex to dura)
 In elderly brain more common due to cerebral
atrophy
Management
 Mild Head Injury
 3% will progress to more serious injuries
 Concussion – majority have concussion – physiological
injury to brain without structural alteration
 Monitored
 Would require neurological observations

 When discharged instructed to seek medical attention

if
severe headache, persistent nausea and vomiting, seizure,
confusion, unusual behaviour, watery discharge from ear or
nose
Contusions
 Most common and
evident in minor and
major head injuries
 Can present with GCS
15/15 worsening over
day 3 to 5
Strict fluid balance 2 litre
restriction
4hrly Observations
Diffuse Axonal Injury
 Neuronal injury in subcortical gray matter
or brain stem due to rotation or
deceleration injury
 Patients with severely depressed level of
consciousness
 CT – no significant injury
 ICP – within reference range
 Prognosis - poor
GCS
Severity of Head Injury
 Mild head injury – GCS 15 - 13

 Moderate head injury – GCS 12 – 9

 Severe head injury – GCS 8 and below

 Developed by Jennett and Teasdale (1974)
 Assess level of consciousness
 3 categories
 Eye opening – E
 Motor response – M
 Verbal response – V
Glasgow Coma Scale
Eye opening Best Verbal response
4 – spontaneously 5 – oriented and converses
3 – to verbal commands 4 – disoriented and converses
2 – to pain 3 – inappropriate words
1 – No response 2 – incomprehensible sounds
1 – No response

Best Motor response

6 – obeys commands
5 – Localizes to pain
4 – flexion withdrawal
Best – 15
3 – abnormal flexion
2 – extension Worst - 3
1 – no response
Poor Outcome
 Age older than 60 years
 GCS of <5
 Presence of fixed pupil
 Prolonged hypotension or hypoxia
 Presence of surgical treatable mass lesion
NAI Children
 Child with head injury – NAI must be
excluded
 HI is most common cause of morbidity and
mortality in NAI
 Multiple bilateral skull fractures, subdural
hematomas of different ages, cortical
contusions and shear injuries, cerebral
ischaemia, retinal haemorrhages
 Dunn L, Henry J, Beard D. Social deprivation and adult head injury: a
national study. (2003) J Neurol Neurosurg Psychiatry. 74:1060–1064
 National Institute for Clinical Excellence. (2007) Triage, assessment
Investigation and early management of head injury in infants, children
and adults Clinical Guidelines CG56. NICE;
 Swann IJ, Walker A. (2001) Who cares for the patient with head injury now?
Emerg Med.18:352–357.
 Sosin DM, Sniezek JE, Thurman DJ. (1991) Incidence of mild and moderate
brain injury in the United States. Brain Injury. 1996;10:47–54.
 Thornhill S, Teasdale G, Murray GD, McEwen J, Yoy CW, Penny KI.
Disability in young people and adults one year after head injury: prospective
cohort study. BMJ. 2000;320:1631–5
 Tennant A. Epidemiology of head injury. (1995) In: Chamberlain MA,
Neumann VC, Tennant A, editor. Traumatic Brain Injury Rehabilitation:
Services, treatments and outcomes. London: Chapman & Hall