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Avoiding missed diagnosis of mild traumatic brain injury

Published on October 31, 2017   29 min

A selection of talks on Neurology

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0:00
Thank you for the invitation today. My talk is called Avoiding Missed Diagnosis of Mild Traumatic Brain Injury. My name is Dr John Bedolla. I'm an assistant professor at the University of Texas Dell Medical School, I'm a national director of risk for US Acute Care Solutions, and I'm a crash rescue physician at the Circuit of the Americas.
0:20
So, we'll start off with some definitions. The definition of TBI according to the CDC is "a disruption in the normal function of the brain that can be caused by a bump, blow or jolt to the head or penetrating injury". You should note that this does not require a loss of consciousness.
0:38
So what counts as TBI? Any loss of consciousness up to 30 minutes, any loss of memory for events immediately before or after the accident for as much as 24 hours, any alteration of mental state at the time of the accident, such as feeling dazed, disoriented or confused, or focal neurologic deficits that might or might not be transient, loss of consciousness exceeding 30 minutes, post-traumatic amnesia lasting longer than 24 hours or a Glasgow Coma Scale falling below 13 after 30 minutes.
1:12
How do we stratify TBI on arrival? The method that we use when a patient arrives is we calculate their Glasgow Coma Scale, and that is going to give us an estimate of how likely they are to have a serious brain injury based on their clinical appearance. So, mild is defined as a Glasgow Coma Scale of 13 to 15, and that would be characteristically someone who is completely normal except they might not be spontaneously opening their eyes, or they might not spontaneously speak. They would only open their eyes or speak if you speak to them, and they might not move spontaneously or do anything, unless you stimulate them. But otherwise they're fairly close to normal, so they've only lost one or two points in each one of their dimensions. So, the three dimensions of the Glasgow Coma Scale is: your eyes, what your eye movements are, what your speaking is and what your motion is. So, you've lost a little bit of function in one or two of those, but you're still awake, alert and protecting your airway. A moderate TBI, or traumatic brain injury, is a Glasgow Coma Scale of 8-13, and that's someone who is significantly more impaired on arrival. They might have a more severe impairment of either their speech and be very incoherent, or they might really not localize very well and be able to reach and do very coordinated movements. And they might keep their eyes closed no matter what you do or not really be able to focus their eyes on anything. A Glasgow Coma Scale of less than eight is severe, and that's someone who's very much, very severely impaired, and that's someone that, as a clinician, you would intubate on arrival. So, there's a term that you've probably heard a lot called the concussion, and concussion essentially equates to mild traumatic brain injury.
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Avoiding missed diagnosis of mild traumatic brain injury

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