Management of TBI

• Alex


  22 years old, sustained a traumatic brain injury from a motor vehicle accident, unconscious with multiple fractures
• Traumatic brain injury


  1. Primary injury

  2. Secondary injury
• Management of neuroinflammation and promotion of neuroprotection of the injured brain have become central in the medical treatment of traumatic brain injury
• In this module you will learn about the medical, surgical, and pharmacologic management of patients with mild, moderate, and severe traumatic brain injury

  
• Initial care and acute management of TBI

  1. Monitor oxygenation, blood pressure, cognitive function using Glasgow Coma Scale, pupillary function, signs of brainstem herniation

  2. Transport to trauma center with CT scanning, neurosurgical evaluation, intracranial pressure monitoring
• Glasgow Coma Scale


  Measure of level of consciousness and injury severity, scores range from 3 to 15 with lower scores indicating lower levels of function

  
• Scores from 13 to 15 indicate a mild brain injury, 9 to 12 a moderate brain injury, and 8 or less a severe injury
• Acute care priorities


  1. Resuscitation

  2. Prevention of secondary insult
• Brain Trauma Foundation guidelines for severe TBI management in acute phase

  • Airway control and ventilation to optimize oxygenation
  • Monitoring and maintenance of cerebral perfusion pressure and blood pressure
  • Monitoring and management of intracranial pressure
  • Fluid management
  • Hyperosmolar therapy
  • Sedation
  • Prophylaxis of infections, deep vein thrombosis, seizures, and hypothermia

  
• Advanced multimodal neuromonitoring is recommended to improve outcomes of TBI, including jugular venous oxygen saturation, focal brain tissue oxygen tension, cerebral microdialysis, and continuous electroencephalography
• Decompressive craniotomy


  Procedure where a large portion of the skull is removed to allow the brain to swell, used when intracranial pressure is elevated over 25 mm Hg for 1 to 12 hours despite other medical interventions
• External ventricular drain


  Neurosurgical procedure to control elevated intracranial pressure, a catheter is inserted through the skull into the anterior horn of one of the lateral ventricles to drain cerebrospinal fluid
• Persons with epidural hematomas often undergo craniotomies with blood evacuation, subdural injuries are frequently treated by removing the blood through bur holes
• Concussion


  A complex pathophysiological process affecting the brain, induced by biomechanical forces
• There are challenges for physicians to diagnose a concussion due to the absence of a valid and reliable diagnostic test or battery of diagnostic tests, and the evolving nature of the clinical presentation
• Medical management of concussion

  Recognize, Remove, and Evaluate framework used by licensed medical personnel during sporting events
• Medications used in TBI management

  • Osmotic agents like mannitol to decrease intracranial pressure
  • Propofol to decrease ICP if other means fail
  • Hypertonic saline
  • Corticosteroids to stabilize brain injury
  • Vasopressors like phenylephrine and norepinephrine to control blood pressure and cerebral perfusion pressure
  • Hemostatic drugs to control intracranial bleeding
  • Anticonvulsants to prevent seizures
  • Hypothermia and progesterone for neuroprotection
  • Carbamazepine, valproate, propranolol, SSRIs for behavior and cognitive functions
  • Amantadine, methylphenidate for motor functions
• Hypothermia


  Frequently used in acute severe TBI because of its possible neuroprotective effect
• Hypothermia


  Associated with improved functional outcome on the Glasgow Outcome Scale

  
• Progesterone


  A hormone that has been shown to reduce cerebral edema and neuronal loss in acute TBI
• Carbamazepine (Tegretol)


  A first line treatment for agitation and aggression
• Valproate


  A first line treatment for agitation and aggression
• Propranolol (Inderal)


  Can help to improve aggression
• Selective serotonin reuptake inhibitors (SSRIs)


  Recommended for persons with depressive symptoms
• Neuroleptic medications


  Used to treat confusion and other neuropsychotic symptoms
• Monoaminergic agonists (amantadine or methylphenidate)


  May increase information processing, aid functional recovery, and prevent permanent functional loss in some patients with attention deficits
• Amantadine


  Recommended for people with disorders of consciousness to improve arousal
• Oral medications for treating spasticity

  • baclofen
  • diazepam
  • dantrolene sodium
  • tizanidine
• Baclofen


  Works at the CNS level and may cause drowsiness
• Baclofen


  Can be delivered intrathecally where the side effect is less
• Dantrolene sodium


  Works directly at the muscle level and is less likely to cause cognitive disturbances but more likely to cause generalized weakness
• Botulinum toxin type A (Botox)


  Commonly used to treat focal muscle hypertonicity
• Diazepam (Valium)


  Used for spasticity or high muscle tone but causes drowsiness, decreased responsiveness, increased muscle weakness, ataxia
• Combine medications with transcranial magnetic stimulation (TMS) and therapeutic exercise


  To achieve greater benefits of tone reduction medications and improve functional outcomes
• Rehabilitation of patients with TBI

  • Occurs across a continuum of care in a variety of settings
  • Once medically stable, patients in a persistent vegetative state may receive ongoing therapy in a nursing home or other long-term care facility
  • Patients beginning to recover from coma with moderate to severe cognitive, behavioral, and physical impairments often continue rehabilitation in either an acute or subacute inpatient rehabilitation facility
  • As patients progress in recovery, they will be discharged to other community-based settings such as home health and outpatient rehabilitation depending on the needs of the individual patient
• Interprofessional team approach


  • Essential to providing the most comprehensive care that will lead to maximizing functional recovery
  • Shown to be effective for improving activity levels and participation in society
  • Individual members collaborate, contributing their expertise in a specific area which enhances the team's overall effectiveness
  • Communication and open-mindedness are key
  • Each team member should develop an approach to treatment that considers information obtained from all other participating disciplines, leading to a consistent and comprehensive approach to care
  • Some members may play more prominent roles depending on the setting and stage of recovery
• Patient and Family


  • Center of the team
  • Information needed on the patient's work, school, financial status, and social history
  • Family members should be interviewed to obtain information about the patient's lifestyle (work/school/leisure), favorite social and recreational activities, etc.
  • Ascertain family dynamics
  • Patient's role in the family
• Physician


  • In acute rehabilitation setting, oversees the care of the patient with a brain injury is usually a physiatrist or neurologist
  • Physiatrist: expertise and training in physical medicine and rehabilitation
  • Neurologist: how the brain may recover and what impairments and activity limitations are likely to be seen given the location and the extent of the injury
  • Both have vast knowledge in neuropharmacology

  
• Speech-Language Pathologist


  • Examines, evaluates, and treats communication, swallowing, and cognitive impairments
  • Collaborates with PT to incorporate strategies for consistency of care in relation to cognitive, swallowing, and communication impairment
  • Devises the most effective and consistent way to communicate with the patient
  • Instructs the team in how the patient's cognitive impairments may impede new learning
• Occupational Therapist


  • Examines, evaluates, and treats the patient's diminished ability to perform ADLs, visual/perceptual impairments, UE functional loss, and sensory integration problems, and will often work with the SLP in treating cognitive impairments
  • Basic ADL includes dressing, self-feeding, bathing, and grooming
  • Instrumental ADL includes home management, housekeeping, grocery shopping, driving, and telephone use
  • May co-treat with the PT with patients who have severe motor control and cognitive deficits
  • Educates the nursing staff on the best ways to assist the patient with ADL