Acute TBI Treatment
By: Helen Rousso
Acute treatment of a Traumatic Brain Injury (TBI) initiates several metabolic processes that can aggravate the injury. Therefore, management focuses on stabilizing and preventing a secondary injury. Ultimately, the goal is to assess and stabilize the airway and circulation, maintain sufficient blood and oxygen supply to the brain, stop intracranial bleeding and prevent an increase in pressure within the skull.
However, full neuro-monitoring including intracranial pressure measurement are rarely available before the patient’s arrival to the intensive care unit. Mechanical intervention (ventilation support) assists in breathing while alleviating pressure on the brain. Traumatic brain injury (TBI) is a major health and socioeconomic problem that affects all societies. Research shows that worldwide, TBI is a leading cause of death and permanent disability. In the United States alone, there are approximately 1.4 million reported cases of TBI each year.
Unfortunately, there is difficulty in recording the real incidence of TBI’s since many patients refuse to report the incident and seek medical care. Half of those who die from TBI do so within the first two hours of injury, it is now known, however, that all neurological damage does not occur at the moment of impact (primary injury) but rather evolves over the ensuing minutes, hours or days. This secondary brain injury can result in increased mortality and disability.
Consequently, the early and appropriate management of TBI is critical to the survival of these patients. Emergency Medical Services (EMS) personnel are often the first health care providers for patients with TBI. Thus, prehospital assessment and treatment is a critical link in providing appropriate care. Treatment begins in the field and continues during transport by EMS providers who have varied skills, backgrounds and qualifications. Over the past 30 years, EMS has become progressively sophisticated, resulting in improved outcomes, particularly in cardiovascular and trauma resuscitations.
However, many challenges remain, especially in recognition and management of TBI in the prehospital setting. There are three different stages of treatment for traumatic brain injuries. These include the acute phase where the patient is stabilized immediately after the injury; subacute phase, to rehabilitate the patient to their potential to return to the community and the chronic phase to continue rehabilitation and treat any long-term impairment.
Initial treatments will be provided at the scene of the accident by emergency personnel if they are summoned. Occasionally individuals in an accident or athletic injury may determine that it is quicker to transport themselves than it is to wait for an ambulance. However, more commonly an ambulance and paramedics are dispatched to treat the individual at the scene of the accident.
Treatments offered to the patient will vary with the type of injury. Commonly the head of the stretcher or bed will be slightly elevated, and the neck of the individual kept straight. This position can help decrease any intracranial pressure by allowing blood and cerebral spinal fluid to drain using gravity. It is also imperative to maintain the neck and back straight to minimize the risk of further injury to the spinal column that may have been suffered during the trauma.
Paramedics will never give fluids by mouth to an individual who has undergone a dramatic events area. The brain is like a sponge and will absorb any extra fluid that is delivered. Limiting fluids can help control swelling. An IV is started at the scene of the accident to give the paramedics and doctors intravenous access for emergency medication. Emergency medical professionals will also assess the individual’s ability to breathe on their own. If the accident victim is unable to maintain oxygenation of their bodies, then medical professionals will assist until they reach the hospital.
Once admitted to the hospital, professionals will begin treatment of the brain injury. Using imaging studies and clinical assessments they will check for and surgically remove any life-threatening blood clots. Swelling in the brain (edema) is monitored and treated using either clinical evaluation or an intracranial monitor attached to the head.
This swelling can cause an increase in intracranial pressure (ICP) that will squeeze the soft tissue of the brain against the skull. This will damage the brain tissue and cause further harm. A buildup of fluid can also occur within the ventricle of the brain. This is called hydrocephalus and is treated using a shunt. This too is placed within the ventricle and then allows the cerebral spinal fluid to drain in the ventricles to shrink stores normal functions of brain cells.
Seizures can also occur in a week or a month after a traumatic brain injury as the damaged brain cells begin to heal. These seizures can result in minor twitching of a finger or limb or lead to a complete loss of consciousness accompanied by involuntary movements of the entire body. Seizures are very dangerous during the acute treatment phase of a traumatic brain injury, so most patients who have experienced a moderate or severe injury will receive medications for the first few weeks prophylactically.
Another important aspect of the acute care of a traumatic injury is monitoring of other medical problems. Abnormally high or low levels of sodium, calcium, sugar or other chemicals in the blood, which are released during a traumatic event can worsen confusion and precipitate seizures. Individuals who suffer from a traumatic brain injury are also at high risk for infection, such as ammonia, urinary tract infections, and sinusitis.
Medications which may be used to treat the brain injury can include diuretics to decrease the amount of water in the patient’s body, anticonvulsants to prevent seizures, and barbiturates to help control intracranial pressure. Surgeons may also choose to use a shunt or ventricular drain placed in the ventricle to help control cerebral spinal fluid. A ventilator, machine used to support the patient’s breathing, may be used to help control intracranial pressure.
Several surgeries may be required to assist in controlling the increased pressure within the brain. A craniotomy may be done to open the skull if there have been fractures in the bone, large blood clots or swollen brain tissue. Smaller blood clots will be removed to help relieve pressure or to place an intracranial pressure monitor. A bone flap removal is when a piece of bone is removed from the skull to make room and relieve tension that is caused by swollen brain tissue.
Once patients are stabilized in the acute setting, they will be transferred to a subacute dramatic brain injury treatment center where their rehabilitation will be initiated. At the specialized care facilities, medical staff will fully evaluate the patient’s impairments, disabilities, and probability of recovery. Doctors will also outline a course of treatment, and healthy patients and their families build the right team of medical professionals necessary for successful rehabilitation.