Traumatic brain injury (TBI) is the most common and severe form of damage to the central nervous system. It occurs in 30-40% of victims with mechanical injuries and ranks first among the causes of death and disability resulting from injuries.
Classification and diagnosis of TBI
Classification
According to the presence of wounds communicating with the external environment, there are:
- closed TBI. Against the background of damages to the bones of the skull and brain, wounds of soft tissues of the head are either absent or not associated with damage to the skull aponeurosis;
- open TBI. Injuries of the skull and brain are considered open, where either the aponeurosis of the skull is damaged, or there are fractures of the base of the skull, accompanied by bleeding and liquorrhea (outflow of cerebrospinal fluid from the external auditory canal or nose). If the integrity of the dura mater is not broken, open TBI is considered non-penetrating, and if it is broken - penetrating. For open damages, there is always a risk for infection of the intracranial contents, which determines the tactics of treatment.
According to the presence of concomitant injuries, the following TBIs are distinguished:
- isolated;
- connected - accompanied by mechanical damages of other organs and systems;
- combined - in combination with the action of other damaging factors (thermal, radiation, chemical).
The development of shock significantly aggravates the course of TBI, changing the clinical picture, complicating diagnostics and masking developing complications. When assessing the severity of TBI, the degree of possible alcohol or narcotic intoxication should be also taken into account.
According to the level of severity, the following TBIs are distinguished:
- mild - concussion of the brain and cerebral contusion of mild severity;
- moderate - cerebral contusion of moderate severity;
- severe - severe cerebral contusion, diffuse axonal damage to the brain, compression of the brain (Fig. 17.1).
&hide_Cookie=yes)
Fig. 17.1. Classification of traumatic brain injuries according to the severity of lesion
General clinical manifestations of TBI
Loss of consciousness
| Disorders of consciousness are the main feature of the clinical course of all forms of TBI. |
There are the following gradations of the state of consciousness: clear, stunning, sopor, coma.
- Сlear consciousness is characterized by complete preservation of consciousness with adequate reactions to the environment.
- Stupor is a violation of consciousness with the preservation of limited verbal contact against the background of an increase in the threshold of external stimuli and a decrease in the activity of the victim. Stupor is divided into moderate (partial disorientation, moderate drowsiness, execution of commands) and deep (complete disorientation, deep drowsiness, execution only the simplest commands).
- Sopor is a disturbance of consciousness with the preservation of coordinated protective reactions. The leading signs are pathological drowsiness, opening of the eyes in response to pain and other stimuli.
- Coma is the shutdown of consciousness with a complete loss of perception of external stimuli and one's own personality.
There are three degrees of severity of coma (Table 17.1).
| TBI, which occurs with loss of consciousness, is characterized by retrograde amnesia (victims do not remember the moment of injury). |
Vomiting
Vomiting often occurs immediately after a brain injury. An increase in intracranial pressure with progressing of cerebral edema or its compression by a hematoma is accompanied by vomiting.
Table 17.1. Severity levels of coma
| Severity | Characteristics |
| Moderate (coma I) | The sufferer cannot be awakened from the state of deep sleep; there is no reaction to external stimuli (except for pain, in response to which uncoordinated protective motor reactions appear). The eyes do not open, control over the sphincters is impaired, pupillary and corneal reflexes are usually reinforced. Breathing and cardiovascular activity without threatening abnormalities |
| Deep (coma II) | Lack of protective movements in response to painful stimuli, decreased muscle tone, depression or lack of reflexes. Spontaneous breathing and cardiovascular activity are preserved, but they are substantially impaired |
| Terminal (coma III) | Bilateral mydriasis, areflexia, muscle atony, critical impairment of vital functions (dyspnea or apnea, sharp tachycardia, hypotension with systolic BP below 60 mm Hg) |
| Vomiting against the background of loss of consciousness during TBI poses a significant threat to life due to possible aspiration of vomit and the development of asphyxia. |
Psychomotor agitation
Psychomotor agitation is manifested by inadequate motor and speech reactions: victims tend to continue the actions that they performed before the moment of injury, it is difficult to keep them in bed. Often, chattiness and meaningless speech are noted.
Seizures
Seizures can be generalized but, in many cases, remain local. There are both clonic and tonic seizures. Hemorrhage in the ventricles of the brain is characterized by tonic contractions of all limbs and a state of decerebration rigidity.
Disorders of cardiovascular activity
Immediately after the injury, there is often a slowing of the pulse. Fluctuations of BP are possible, but hypotension is characteristic only for extremely severe lesions.