The Overlooked Injury: Closed Head Brain Trauma Presenter: Roger N. Braden, Esq. R.N.

1. Roger N. Braden, Esq., R.N.
Chairman of Annual Northern Kentucky
Traumatic Brain Injury Conference
Braden and Associates, LLC
7000 Houston Road, Suite 36,
Florence, KY 41042-4873
rbraden@bradenlawfirm.com
http://www.bradenlawfirm.com/

2. What is the Brain?

3. Centers for Disease Control and
Prevention
 Dept. of Health and Human Services
 Children’s Health Act of 2000

4. Centers for Disease Control
Brain Injuries in the U.S.
An estimated 1.5 million people sustain a TBI annually.
(2001)
5.3 Million currently living in the U.S. with TBI

5. Brain Injuries in the U.S.
 2 million seen annually in ER for TBI – 25% admitted
(2005)
 A TBI occurs every 7 seconds
 A TBI related death occurs every 5 minutes
 200,000 people are killed or injured annually
 80,000 Americans experience onset of long-term
disability from TBI
 50,000+ die annually from TBI
 75% are mild TBI

6. Brain Injuries in Ohio
 Ohio does not currently have a TBI tracking system in
place
 Estimated 118,760 live with residual effects of TBI
 7,300+ hospitalized annually
 142% increase in sports/recreation related TBIs over a 7
year period in 18 and younger
 March 2011 – House Bill 143

7. Brain Injuries in Kentucky
 Approximately 212,000 to 250,000 Kentuckians live
with TBI
 Kentucky’s TBI rate is twice the national average
 1 in 5 households affected by TBI
 #1 killer based on population

8. Brain Injuries in Indiana
 Over 150,000 living with TBI
 6,100 injuries occur annually

9. Chronic Traumatic Encephalopathy
 Progressive degenerative disease found in individuals
who have been subjected to multiple concussions and
other forms of head injury
 Dementia pugilistica (boxing)
 Degeneration of tissue and accumulation of tau
protein
 Memory loss, aggression, confusion and
depression - within months to decades later
 Chris Henry – July 2010

10. ABI vs. TBI
 Acquired Brain Injury
 Sustained during one’s lifetime
 Includes stroke, trauma or tumor
 Excludes neuro-degenerative disorders and brain
injuries sustained at birth
 Traumatic Brain Injury
 Caused by external force
 Can involve damage to scalp and skull
 Falls, accidents, violence

11. Shaken Baby Syndrome
(Pediatric Abusive Head Trauma)
 Form of child abuse
 Generally diagnosed from a triad of symptoms:
 Retina hemorrhage
 Subdural hematoma
 Brain swelling
 In majority of cases - no signs of external trauma
 Estimated death rates in infants - 15% to 38%
 Usual mechanism of injury - rotational acceleration of
the head

12. Shaken Baby Syndrome
 From 2001 - 2005: 8-10 children in Ohio died each year
 150 children are seriously injured
 Ohio - Claire’s Law - ORC 3701.63, 11/30/2007
OHIO DEPARTMENT OF HEALTH
SHAKEN BABY SYNDROME PROGRAM
246 N. HIGH STREET
COLUMBUS, OHIO
614-728-0773
FAX: 614-564-2442
Sbs@odh.ohio.gov

13. Shaken Baby Syndrome
 Kentucky
 HB 285 (May 27, 2010)
 Nationally
Sarah Jane Brain Foundation
339 Fifth Avenue, Suite 405
New York, NY 10016
(212) 576-1180
patrick@TheBrainProject.org

14. Military/Veterans
 U.S. MILITARY CASUALTY STATISTICS: OPERATION
NEW DAWN, OPERATION IRAQI FREEDOM, AND
OPERATION ENDURING FREEDOM, Congressional
Research Service, September 28, 2010
 TBI signature injury for Iraq and Afghanistan wars
 TBI cases in military from 2000 to part of 2010 - 178,876
 300,000 have suffered concussions

15. Age Groups
Age groups most likely to sustain a TBI:
- Children 0-4 years
- Adolescents 15-19 years
- Adults 65 years and older
Males twice as likely as females to have TBI
Males 15 to 24 have highest rate of TBI

16. Injury Categories
 Motor vehicle accidents - 44%
 Falls – 26%
 #1 cause of TBI in ages 1-4 and 65 and over
 Assaults and firearms - 17%
 Sports and recreation - 13%

17. Prison Statistics
 More than 2,000,000 people in U.S. prisons and jails
 25-87% of prisoners have history of TBI
 TBI experience mental health problems
 Female inmates convicted of a violent crime are more
likely to have suffered TBI prior to committing crime

18. Disability/Medical Costs
 $73.7 billion in 2010 for stroke-related medical costs
and disability
 $60.0 billion in 2000 for medical and disability-related
costs for TBI

19. Types of Brain Injuries
 Severe traumatic brain injury
 GCS score 3-8
 Rancho los Amigos scale
Think life care planner!

20. Types of Brain Injuries
 Moderate Brain Injury
 Length of stay at least 48 hours
 GCS score 9-12 or higher
 Operative cranial lesion
 Abnormal findings
Think life care planner!

21. Types of Brain Injuries
 Mild Brain injury
 An injury to the head as a result of blunt trauma or
acceleration or deceleration forces that result in one or
more of the following conditions that are observed or
self-reported:
 Transient confusion, disorientation, or impaired
consciousness;
 Dysfunction of memory around the time of injury;
 Loss of consciousness lasting less than 30 seconds

22. Mild Traumatic Brain Injury
 TBI - “The Silent epidemic”
 Accounts for at least 75% of all TBIs in the U.S.
 Can cause long-term or permanent impairments and
disabilities
 Difficulty returning to work to routine, daily activities
and may be unable to return to work for many weeks
or months
 Costs the nation nearly $17 billion annually

23. Post Concussive Syndrome
 Misleading
 Affected individuals need not have suffered a loss of
consciousness
 No criteria in the etiology of post concussive syndrome

24. Polytrauma/Disease
 Multiple trauma
 Psychological
processes/illness
 Behavior risk factors
 Pre-existing conditions

25. From Bone to Brain
 Skull – upper / lower
 Cerebrospinal fluid – maintains uniform pressure
within brain and spinal cord
 Meninges
 Arachnoid
 Dura mater
 Pia mater

26. From Bone to Brain
 Subdural Hematoma
 Under dia mater of between dura mater and arachnoid
 Epidural Hematoma
 Outside dura mater
 Subarachnoid Hemorrhage
 Under arachnoid
 Cerebro-vascular
 Involves cerebrum and blood vessels supplying it

27. Knowing the Brain’s Anatomy
 Frontal lobe
 Planning, organizing,
problem solving,
selective attention,
personality and “higher
cognitive functions”
including behavior and
emotions

28. Knowing the Brain’s Anatomy
 Parietal Lobe (2)
 Controls
sensation, touch, pressure, judg
ment of
texture, weight, size, shape
 Right side damage may cause
visuo-spatial deficits
 Left side damage may interrupt
person’s ability to understand
spoken/written language

29. Knowing the Brain’s Anatomy
 Temporal lobe (2)
 Distinguishes different smells and
sounds; sorts new information;
major role in short-term memory
 Right side injury may cause issues
with visual memory (people,
photographs)
 Left side injury may case issues with
verbal memory (recalling names,
certain words, phrases)

30. Knowing the Brain’s Anatomy
 Occipital lobe
 Process visual
information, colors,
shapes

31. Knowing the Brain’s Anatomy
 Cerebellum
 Coordinates movement, balance
and muscle coordination
 Damage may result in ataxia
and can interfere with a person’s
ability to walk, talk, eat and
perform self care tasks

32. Knowing the Brain’s Anatomy
 Brain stem
 Connects brain to spinal cord
 Neurological functions include those
necessary for survival (breathing,
digestion, heart rate, blood pressure)
and for arousal (awake and alert)
 Most cranial nerves come from the
brainstem
 Pathway for all fiber tracts passing up
and down from the peripheral nerves
and spinal cord to the highest part of
the brain

33. Knowing the Brain’s Physiology
 Neurons - cells that constitute nerve tissue; Have the
property of transmitting and receiving nerve impulses
 Dendrites - branching protoplasmic processes that
conduct impulses toward the body of a nerve cell
 Glial cells - does not conduct electrical
impulses, but supports them and
insulates neurons

34. Knowing the Brain’s Physiology
 Forebrain
 Anterior of the three primary
divisions of the developing
vertebrae brain or the
corresponding part of the
adult brain including the
cerebral hemisphere and the
thalamus and hypothalamus

35. Knowing the Brain’s Physiology
 Midbrain
 Middle division of the
three primary divisions of
the developing vertebrae
brain; or
 Corresponding part of the
adult brain that includes a
ventral part containing the
cerebral peduncles and a
dorsal tectum containing
corpora quadrigemina and
surrounds the aqueduct of
sylvius connecting the 3rd
and 4th ventricles

36. Knowing the Brain’s Physiology
 Hindbrain
 posterior division of the three
primary divisions of the
developing vertebrae brain or
the corresponding part of the
adult brain that includes the
cerebellum, pons, and
medulla oblongata

37. Knowing the Brain’s Physiology
 Thalamus
 serves as a relay station to and
from the cerebral cortex, and
functioning especially sensation
and arousal

38. Knowing the Brain’s Physiology
 Hypothalamus
 Temperature control issues,
edema, vomiting, nausea,
irritability, psychiatric
problems, rage, laughing,
crying, excessive sexuality,
antisocial behavior,
hallucinations, coma,
somnolence, excessive
salivation, bradycardia

39. Knowing the Brain’s Physiology
 Pituitary gland
 regulates the many hormones
that control various functions
and organs in the body
 Controlled by hypothalamus

40. Knowing the Brain’s Physiology
 Adrenal glands (suprarenal
glands)
 Responsible for releasing
hormones in response to stress
- corticosteroids-cortisol-
catecholamines-epinephrine.

41. History
 CDC – Many healthcare providers fail to recognize the
potential impact of mild TBI
 No physical injury
 Facial injury – increases suspicion of head/brain injury
 X-ray/MRI/CT normal
 Delay in treatment
 Didn’t hit head, wasn’t unconscious

42. Rehabilitation
 Critical care / stabilization
 Acute care
 Acute rehabilitation
 Sub-acute rehabilitation
 Long term / Post acute rehabilitation
 Specialized rehabilitation
 Continuing support

43. Glasgow Coma Scale
Involves three determinants:
- Eye opening
- Verbal responses
- Motor response (movement)

44. Glasgow Coma Scale
Scoring
Score 13 – 15 Mild brain injury
Score 9 – 12 Moderate brain injury
Score 8 or less Severe Brain injury

45. Other Scales
 Rancho Los Amigos scale
 Mayo-Portland Adaptability Inventory

46. Imaging
 X-ray
 CT
 MRI
 fMRI
 EEG
 PET scan
 SPECT scan
 MMPI

47. Testing
 Neuropsychological Testing
 Blood Tests
 Ultrasound
 Thermography
 Cerebrospinal fluid analysis
 Electronystagmography (ENG)

48. Testing
 Evoked potentials (a/k/a evoke responses)
 Auditory evoked potentials
 Visual evoked potentials
 Intrathecal contrast –enhanced CT scans
(cisternogrphy)
 Diffusion tensor imaging (DTI)
 Fractional anistrophy (FA)
 QEEG brain topography

49. Testing
 Quantitative EEG
 Cerebral Angiography
 Transcranial doppler ultrasound

50. Help! I need somebody…..
Brain Injury Association of
America
(703) 761-0750
www.biausa.org
Brain Injury Association of
Indiana
(317) 356-7722
www.biausa.org/indiana
Brain Injury Association of
Ohio
(614) 481-7100
www.biaoh.org
Brain Injury Alliance of
Kentucky
(502) 493-0609
www.biak.us