Question

Roald Dahl novelist, poet and screenwriter, served as a fighter pilot during World War II. In 1940, he crashed his plane and suffered TBI Traumatic Brain Injury. Explain and present the information on cause, symptoms, and outcome. Then suggest steps that may be (or might have been) taken to assist him.

Answer 1

Traumatic Brain Injury

Traumatic brain injury is a form of acquired brain injury wherein a mechanical force causes damage to the brain. It may lead to a temporary or permanent impairment of cognitive, motor and psychosocial functions along with a diminished consciousness. The causes of trauma include road traffic accidents, accidental falls, a blow to the head during assault and in rare circumstances heavy objects accidentally striking the head. In Dahl's case, a plane crash caused TBI. Some cases involve firearms. Narcotics and alcohol are often implicated in motor vehicle accidents. The patients may present with

• Persistent headache or headache that worsens.
• Vomiting or nausea.
• Convulsions.
• Loss of consciousness
• Dilation of one or both pupils of the eyes.
• Clear fluids draining from the nose or ears.
• Inability to awaken from sleep

TBI is often complicated by Coup and contrecoup contusions, Skull fractures, Hematomas, Intracranial hemorrhage. After the primary insult has occurred, raised intracranial pressure and cerebral edema further contribute to the axonal injury. In severe cases, very high intracranial pressure might lead to hydrocephalus and herniation of the brain from the foramen magnum, which can be potentially fatal.

The initial Glasgow Coma Score and the severity of the TBI help to predict the likelihood of death from the injury. Moderate and Severe TBI have poorer outcomes. The mortality rate is 17 per 100,000. The extent of cognitive deficit depends on the severity of the injury.

Eye-opening	Motor response	Verbal response
Spontaneous = 4	Follows commands = 6	Oriented to person, place, and date = 5
To speech = 3	Makes localizing movements to pain = 5	Converses but is disoriented = 4
To painful stimulation = 2	Makes withdrawal movements to pain = 4	Says inappropriate words = 3
No response = 1	Flexor (decorticate) posturing to pain = 3	Says incomprehensible sounds = 2
	Extensor (decerebrate) posturing to pain = 2	No response = 1
	No response = 1

The following steps might have been taken to assist him. Imaging modalities like CT and MRI hadn't been invented in 1940. But a skull X-ray would have revealed any major skull fractures.

• Assessment of vitals, airway, and GCS
• Immobilization of the cervical spine
• Fluid resuscitation
• Monitoring of Intracranial Pressure (ICP)
• Bolus hyperosmolar therapy (HTS) of 3% saline for high ICP
• Decompressive craniectomy if high ICP persists
• Definitive management of other injuries
• Prophylactic antiepileptic drugs to prevent convulsions