Causes of severe Traumatic Brain Injury (TBI) to Coma
- 30% - 75% of cases
- Most severe TBI - coma
- Highest rate of mortality
- Most common in persons 10 - 44
- 40% of cases
- Most common cause of head trauma in children 0 - 16 and of the elderly over 65
- Other causes: Firearm accidents, sporting injuries, bicycle accidents and fighting
- Causes have been constant for many years
- Studies by: Adekoya. et al (2002), Arden. et al (2001), Bouamra. et al (2011), Bostanc. et al (2011), Cansever. et al (2009) & Colantonio. et al (2009)
Head Trauma
Brain Function
- Caused by physical impact or force related injury
- Damage may be temporary or permanent (irreversible)
- Damage to certain area causes loss of specific function
- Severe damage can impair consciousness
Consciousness
- Function of Reticular Activating System (RAS)
- AND function of at least one cerebral hemisphere
Unconsciousness/Coma
- Damage to the RAS
- OR diffuse damage to both hemispheres
Causes of Coma
- Eelco F.M. Wijdicks, MD and Coen A. Wijdicks, BS (2006).The portrayal of coma in contemporary motion pictures. Neurology 66: 1300–1303.
- Formisano R, Carlesimo GA, Sabbadini M, et al. (May 2004). "Clinical predictors and neuropleropsychological outcome in severe traumatic brain injury patients". Acta Neurochir 146: 457–62.
- Ferrari, M.D., Fitzsimons, R.B., Frants, R.R., Haan, J., Heywood, P., Jardine, P.E., Kors, E.E., Love, S., Terwindt, G.M., Van Den Maagdenberg, A.M. & Vermeulen, F.L. 2001, ‘Delayed cerebral edema and fatal coma after minor head trauma: role of the CACNA1A calcium channel subunit gene and relationship with familial hemiplegic migraine’, Annals of Neurology, Vol. 49, Iss. 6, pp. 753-60.
- Gould, B.E. 1997, ‘Neurologic Disorders’, Pathophysiology for the health-related professions, WB Saunders Company, Philadelphia, pp. 320-32. Harris, A., Jenkins, R.. Round, A., Williams, W.H. & Yates P.J. 2006, ‘An epidemiological study of head injuries in a UK population attending an emergency department’, Journal of Neurology, Neurosurgery and Psychiatry, Vol. 77, Iss. 5, pp. 699-701.
- Hannaman, Robert A. (2005). MedStudy Internal Medicine Review Core Curriculum: Neurology 11th Ed.
- Martini, F.H. & Nath, J.L. 2009, ‘Neural integration II’, in 8th edn, Fundamentals of anatomy and physiology, Pearson Benjamin Cummings, San Franciso, pp. 552-3.
- Mettinga, Z., Regtienc, J.G., Rigerb L.A. & Van Der Naalt, J. 2009, ‘Delayed coma in head injury: consider cerebral fat embolism’, Clinical Neurology and Neurosurgery, Vol. 111, Iss. 7, pp. 597-600.
- Rosenberg, R. 2009, ‘Consciousness, coma, and brain death—2009’, Journal of the American Medical Association, Vol. 301, Iss. 11, pp.1172-74.
- Sacks, J.J., Smith, S.M. & Sosin, D.M. 1989, ‘Head injury-associated deaths in the United States from 1979 to 1986’, Journal of the American Medical Association, Vol. 262, Iss. 16, pp. 2251-5.
How do we know?
- Head Trauma
- Haemorrhage
- Brain Tumour
- Swelling
- Lack of Oxygen
- Metabolic Disturbances
- Poisoning
Trauma leading to Loss Of Consciousness (LOC)
- Normal alertness
- Self-aware
- Interference to interconnected neural networks causes unconsciousness
- Closed Head Injury - Skull intact, Brain NOT exposed
- Penetrating Head Injury - Skull pierced, Dura Mater exposed
- Coup Injury - Impact related trauma at site of impact
- Contrecoup Injury - Impact related trauma at the opposite side to impact
What is Coma?
- Deep state of unconsciousness
- Unresponsive to physical and auditory stimuli
- Unable to wake
- Delta waves (0.5 - 4 Hz)
How do we know?
Coma is recognized when the individual fails to be aroused, their eyes remain closed but in some cases move peculiarly and fail to respond to external stimuli.
- Boutis, K., Laupacis, A., Maguire, J.L., Parkin, P.C. & Uleryk, E.M. 2009. ‘Should a head injured child receive a head CT scan? A systematic review of clinical prediction rules’, Pediatrics Vol. 124, Iss. 1, pp. 145 -54.
- Brenneman, F.D., Chughtai, T., Gelberg, J., Rizoli, S.B., Shek, P., Tien, H.C., Tikuisis, P. & Tremblay, L.N. 2006, ‘Association between alcohol and mortality in patients with severe traumatic head injury’, Vol.141, Iss. 12, pp. 1185-92.
- Cansever, T., Dolaş, I., Hepg, K.T., Imer, M., Karasu, A., Sabanci, P.A. & Taviloğlu, K. 2009, ‘Epidemiological study in head injury patients’, Ulus Travma Acil Cerrahi Derg, Vol. 15, Iss. 2, pp. 159-63.
- Chamoun, R.B., Gopinath, S.P. & Robertson, C.S. 2007, ‘Outcome in patients with blunt head trauma and a Glasgow Coma Scale score of 3 at presentation’ Journal of Neurosurgery, Vol. 111, Iss. 4, pp. 683-7.
- Colantonio, A., Coyte, P., Croxford, R., Farooq, S. & Laporte, A. 2009, ‘Trends in hospitalisation associated with traumatic brain injury in a publicly insured population, 1992-2002’, Journal of Trauma-Injury Infection & Critical Care, Vol. 66, Iss. 1, pp. 179-83.
- Cuthbert, J.P., Coronado, V., Corrigan, J.D., Dijkers, M.P., Harrison-Felix, C., Heinemann, A.W. & Whiteneck, G.G. 2011, ‘Factors that predict acute hospitalization discharge disposition for adults with moderate to severe traumatic brain injury’, Archives of Physical Medicine and Rehabilitation, Vol. 92, Iss. 5, pp. 721-30.
- Dagher, J., De Guise, E., Feyz, M., Jishi, A.A., Lamoureux, J., Leblanc, J., Maleki, M. & Marcoux, J. 2009, ‘Early outcome in patients with traumatic brain injury, pre-injury alcohol abuse and intoxication at time of injury’, Brain Injuries, Vol. 23, Iss. 11, pp. 853-65.
- Dempsey, R.J., Gale, S.D., Hess, T.M, Johnson, S.C., Rowley, H.A., Trivedi M.A. & Ward, MA. 2007, ‘Longitudinal changes in global brain volume between 79 and 409 days after traumatic brain injury: relationship with duration of coma’, Journal of Neurotrauma, Vol. 24, Iss. 5, pp. 766-71.
- Daltrozzo, J., Wioland, N., Mutschler, V., Kotchoubey, B. (2007). Predicting Coma and other Low Responsive Patients Outcome using Event-Related Brain Potentials: A Meta-analysis. Clinical Neurophysiology, 118: 606-614
- Daltrozzo, J., Wioland, N., Mutschler, V., Lutun, P., Jaeger, A., Calon, B., Meyer, A., Pottecher, T., Lang, S., Kotchoubey. B. 2009. Cortical Information Processing in Coma, Cognitive & Behavioral Neurology, 22: 53-62.
- Daltrozzo, J., Wioland, N., Mutschler, V., Lutun, P., Jaeger, A., Calon, B., Meyer, A., Pottecher, T., Lang, S., Kotchoubey, 2010, Electrodermal Response in Coma and Other Low Responsive Patients, Neuroscience Letters, 475: 44-47.
- Enander, C., Forsberg, S., Her, J. & Ludwigs, U. 2009, ‘Coma and impaired consciousness in the emergency room: characteristics of poisoning versus other causes’, Emergency Medical Journal, Vol. 26, Iss. 2, pp. 100-2.
Trauma leading to LOC
- Brain Haemorrhage
- Severe head trauma
Coma
Head Injury
- Confusion, Drowsiness
- Change in personality
- Infection in the central nervous system
- Headache, fever, rash and muscular pains
- Signs of lethargy and obtundation
Physical Damaged Caused
- Fracture, lesion, contusion, haemorrhage, swelling
- Stretching, shearing, tearing of axons resulting in neuronal death
- Diffuse Axonal Injury
- Increased Intercranial Pressure (ICP) - Compression of surrounding brain and brain stem tissue, neuronal death
- Onset of coma may be rapid or slow, depending on the level of trauma
References
Other Studies...
- Adekoya, N., Thurman, D., Webb, K. & White, D. 2002, ‘Surveillance for traumaticbrain injury deaths 1989—1998’, Morbidity and Mortality Weekly Report, Vol. 51, Iss. 10, pp. 1-16.
- Alday, R., Alen, J.F., Arrese, I., Gez, P.A., Kaen, A., Lagares, A., Lobato, R.D., Miranda,,P., Pascual, B. & Perez-Nuz, A. 2005, ‘Value of serial CT scanning and intracranial pressure monitoring for detecting new intracranial mass effect in severe head injury patients showing lesions type I-II in the initial CT scan’, Neurocirugia (Astur), Vol. 6, Iss. 3, pp. 217-34.
- Ardern, C., Brison, R.J. & Pickett, W. 2001, ‘A population-based study of potential brain injuries requiring emergency care’, Canadian Medical Association Journal, Vol. 165, Iss. 3, pp. 288-92.
- Bandiera, G., Brison, R., Cass, D., Clement, C.M., Dreyer, J., Eisenhauer, M.A., Greenberg, G., Holroyd, B., Lee, J.S., Lesiuk, H., McKnight, R.D., MacPhail, I., Reardon, M., Rowe, B.H., Schull, M.J., Stiell, I.G., Wells, G.A. & Worthington, J.R. 2005,‘Comparison of the Canadian CT head rule and the New Orleans criteria in patients with minor head injury’ JAMA, Vol. 294, Iss. 12, pp. 1511-8.
- Barmparas, G., Chan, L., Demetriades, D., Dubose, J., Inaba, K., Lam, L., Plurad, D. & Talving, P. 2010, ‘Isolated severe traumatic brain injuries: association of blood alcohol levels with the severity of injuries and outcomes’, Journal of Trauma, Vol. 68, Iss. 2, pp. 357-62.
- Bostanc, U., Gyar, A., Işık, HS., Ozdemir, C. & Yıldız, O. 2011, ‘Retrospectiv analysis of 954 adult patients with head injury: an epidemiological study’, Ulus Travma Acil Cerrahi Derg, Vol. 17, Iss. 1, pp. 46-50.
- Bouamra, O., Coats, T.J., Fuller, G., Hutchinson, P.J., Jenks, T., Lecky, F., Mendelow, A.D., Oakley, P., Patel, H.C, Pigott, T. & Woodford, M. 2011, ‘Temporal trends in head injury outcomes from 2003 to 2009 in England andWales’, British Journal of Neurosurgery, April 22.
- Bouamra, O., Coats, T.J., Fuller, G., Hutchinson, P.J., Jenks, T., Lecky, F., Mendelow, A.D., Oakley, P., Patel, H.C, Pigott, T. & Woodford, M. 2011,‘The effect of specialist neurosciences care on outcome in adult severe head injury: a cohort study’, Journal of Neurosurgery and Anaesthesiology, May 4.
- Bouamra, O., King, A.T., Lecky, F.E., Patel, H.C., Woodford, M. & Yates, D.W. 2005, ‘Trends in head injury outcome from 1989 to 2003 and the effect of neurosurgical care: an observational study’, Lancet, Vol. 366 Iss. 9496, pp. 1538-44.
- Gender (Bostanc . et al, 2011; Cansever. et al, 2009 & Harris. et al, 2006)
- Males higher incidence of brain injury compared to females, 3:1 respectively
- Beneficial at revealing abnormalities in the brain that may have otherwise been overlooked
- Patients with severe TBI that were treated by specialists in neuroscience units had an improved outcome with lower mortality than those treated in non - neuroscience units
- Relationship between inexperience of medical staff and mortality
Axonal Injury
Diagnostic Tools 1
Prevention
- Glasgow Coma Scale (GCS) (1974) by Teasdale and Jennett is score widely accepted as an objective measure of level of consciousness
- Aid in the clinical assessment of post - traumatic unconsciousness
- The GCS has three components: eye (E), verbal (V) and motor (M) response to external stimuli
Future Directions and Conclusion
- Key to lowering incidence of trauma associated coma is to reduce the incidence or severity of TBI
- Improved scanning equipment and technique
- Improved surgical technique
- Stem cell research into regeneration of neurons
- Improve Road safety
- Better care of children and the elderly
- Follow studies by Bouamra. et al (2005) and Bouamra. et al, 2011).
- Better care of cases of mild to moderate head trauma could reduce the number of patients that become comatose
- More correlational studies into incident of head trauma due to traffic accidents and blood alcohol content
- Establish relationship between accidents and substance impairment.
- Routine CT canning has had good results in avoiding preventable delayed severe head trauma and coma and should be further investigated, as well as financial costs for such practices
Glasgow Coma Scale
Treatments
To prevent coma, secondary injuries accompanying head trauma must be treated, such as swelling, infection and intracranial pressure (ICP).
- Often complex and prolonged
- Unconscious patients initially in ICU
- Mechanical ventilation
- Prevention of pneumonia and bedsores
- Balanced nutrition via IV
- Physical therapy
- Relieve intracranial pressure in brain through surgery
- Ventriculostomy and monitoring intracranial pressure
- Medications: diuretics, anti - seizure medication, coma - inducing drugs
- Treatment plans vary depending on patient's injury and health
Brain Contusion
Diagnostic Tools 2
- Epidural, Subdural, Subarachnoid
- A CT (computerized axial tomography) and MRI (magnetic resonance imaging) can both be used to visualize most abnormalities in the brain.
- A lumbar puncture, known as a spinal tap, may be done to remove some of the cerebrospinal fluid for evaluation.
- Single - Photon Emission Computed Tomography (SPECT) can be useful in examining the brain of a person in a coma, to see if there are abnormalities in cerebral blood flow.
- If a seizure is suspected, an electroencephalography (EEG) can be done to confirm it or rule it out. EEG may be of some prognostic utility when performed between 6 and 72 hour after anoxic injury.
Journal Article
- A study of 40 patients with intact brain stem function found that none of 11 who demonstrated malignant EEG findings recovered. If the coma is related to increased pressure in the brain, there are various things that can be done to reduced it, including hyperventilation, diuretics and surgery.
- Eelco F. M et al, 'Clinical Diagnosis of Prolonged States of Impaired Consciousness in Adults', MD August 2005; 80 (8): 1037 - 1046