ABPMR Brain Injury Medicine cheat sheet
ABPMR Brain Injury Medicine · Keep the key ideas within reach.
Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury
Glasgow Coma Scale severity: severe 3-8, moderate 9-12, mild 13-15.
Post-traumatic amnesia: mild <24 hours, moderate 1-7 days, severe >7 days.
Rancho Los Amigos levels I-VIII; IV = confused/agitated, V = confused/inappropriate non-agitated, VI = confused/appropriate, VII = automatic/appropriate, VIII = purposeful/appropriate.
Disorders of consciousness: coma = no wakefulness or awareness; vegetative state/unresponsive wakefulness = wakefulness without awareness; minimally conscious state = reproducible command following, intelligible speech, or purposeful behavior.
Cerebral perfusion pressure = mean arterial pressure minus intracranial pressure; adult guidelines target ICP <22 mmHg and CPP 60-70 mmHg.
CT is first-line for acute traumatic brain injury; MRI susceptibility-weighted imaging detects diffuse axonal injury and FLAIR detects cortical contusions.
Phenytoin or levetiracetam reduces early seizures in the first 7 days but does not prevent late post-traumatic epilepsy.
Avoid definitive prognostication before 72 hours and until confounders such as sedation, seizures, hydrocephalus, and metabolic derangement are excluded.
Brain death requires coma, absent brainstem reflexes, and apnea, with all confounders excluded.
Neurobehavioral, Cognitive, and Psychiatric Sequelae of Brain Injury
Agitation peaks in the first weeks after severe traumatic brain injury and usually resolves by 4-6 weeks; the Agitated Behavior Scale tracks severity.
Depression affects 25-50% within the first year; selective serotonin reuptake inhibitors are first-line, and bupropion is avoided when seizure risk is present.
Apathy is reduced goal-directed behavior without dysphoria and is common with frontal or basal ganglia injury; dopaminergic agents may help.
Pseudobulbar affect is treated with dextromethorphan-quinidine or a selective serotonin reuptake inhibitor; episodes are incongruent with mood.
Memory rehabilitation uses external aids such as notebooks and phones, errorless learning, and spaced retrieval for prospective memory.
Executive dysfunction responds to metacognitive strategy training more than to repetitive drill practice.
Psychosis and severe agitation may be ictal; obtain EEG when presentation is episodic or atypical.
Sleep-wake disturbance is common; use CBT for insomnia and circadian scheduling before sedating medications.
Medical and Neurologic Complications and Comorbidity Management
Heterotopic ossification commonly affects hip, shoulder, and elbow; alkaline phosphatase is elevated, triple-phase bone scan is sensitive early, and plain films lag 2-4 weeks.
Spasticity: focal treatment is botulinum toxin; generalized treatment is oral baclofen or tizanidine, or intrathecal baclofen; monitor sedation and withdrawal.
Post-traumatic hydrocephalus triad: gait disturbance, urinary incontinence, and cognitive decline; shunt symptomatic cases.
Early seizure occurs at 7 days or less; late seizure after 7 days defines epilepsy; prophylaxis beyond 7 days is not recommended.
Paroxysmal sympathetic hyperactivity causes paroxysmal tachycardia, hypertension, fever, diaphoresis, and dystonia; treat triggers, then propranolol, clonidine, gabapentin, or bromocriptine.
Hyponatremia: SIADH is euvolemic with low urine output; cerebral salt wasting is hypovolemic with high urine sodium; treat with fluid restriction versus saline.
DVT risk is high after traumatic brain injury; use mechanical prophylaxis plus low-molecular-weight heparin once intracranial hemorrhage is stable.
Pituitary dysfunction is screened at 3-6 months with morning cortisol, free T4, IGF-1, and gonadal hormones.
Anosmia from CN I injury and CN VI palsy are common cranial nerve deficits after traumatic brain injury.
Rehabilitation Interventions, Functional Recovery, and Assistive Technology
Functional Independence Measure: 18 items scored 1-7, total 18-126; lower scores indicate greater assistance needed.
Early intensive rehabilitation improves functional outcome; therapy dose and task specificity matter.
Constraint-induced movement therapy improves upper limb function in selected patients with adequate cognition and minimal pain.
Memory rehabilitation uses external aids and errorless learning; executive rehabilitation uses metacognitive strategy training.
AAC ranges from low-tech boards to eye-tracking speech-generating devices; match access method to residual motor control.
Manage spasticity before or alongside gait training to optimize biomechanics and prevent contracture.
Driving: screen vision, cognition, and perception; obtain a formal behind-the-wheel evaluation when deficits persist.
Vocational rehabilitation with supported employment and work hardening improves return-to-work rates.
Special Populations, Including Pediatric and Geriatric Brain Injury
PECARN age-specific rules identify children at very low risk of clinically important traumatic brain injury and avoid unnecessary CT.
Pediatric Glasgow Coma Scale verbal score is age-adjusted: cooing/babbling, words, and oriented conversation.
Abusive head trauma: subdural hemorrhage, retinal hemorrhages, and encephalopathy; inconsistent history warrants reporting.
Older adults on anticoagulants need liberal CT after minor head trauma and rapid reversal of anticoagulation.
Aging with traumatic brain injury increases risk of dementia, parkinsonism, and late seizures.
Concussion: no same-day return to play; use a stepwise 24-hour progression.
Pregnancy after traumatic brain injury: avoid valproate and certain anticonvulsants; coordinate with obstetrics.
Pediatric plasticity does not prevent diffuse deficits in attention, memory, and behavior after severe injury.
Systems of Care, Ethics, Advocacy, and Medicolegal Issues
Levels of care: acute trauma care, inpatient rehabilitation, day treatment, outpatient therapy, and home or community programs.
Inpatient rehabilitation admission requires 24-hour medical and nursing availability, intensive therapy (typically 3 hours daily), and realistic functional goals.
Medicare inpatient rehabilitation facility 60% rule: at least 60% of patients must have a qualifying condition.
Surrogate decisions use substituted judgment first and best interests when prior wishes are unknown.
Symptom validity tests such as the Test of Memory Malingering detect invalid performance; low scores suggest exaggeration, not definitive malingering.
Decisional capacity requires understanding, appreciation, reasoning, and expression of choice.
Ethical conflicts invoke autonomy, beneficence, nonmaleficence, and justice; request ethics consultation for disputes.
Advocacy includes insurance appeals, guardianship planning, and access to assistive technology.