Rehabilitation After Traumatic Brain Injury

Blessen Eapen, David X. Cifu

• Publisher: Elsevier
• Year: 2018
• ISBN:
  9780323544573
• Topic: Medicine
• Subtopic: Physiotherapy, Physical Medicine & Rehabilitation

Covering the full spectrum of rehabilitation after traumatic brain injury, this practical reference by Drs. Blessen C. Eapen and David X. Cifu presents best practices and considerations for numerous patient populations and their unique needs. In an easy-to-read, concise format, it covers the key information you need to guide your treatment plans and help patients relearn critical life skills and regain their independence.

• Covers neuroimaging, neurosurgical and critical care management, management of associated complications after TBI, pharmacotherapy, pain management, sports concussion, assistive technologies, and preparing patients for community reintegration.
• Discusses special populations, including pediatric, geriatric, and military and veteran patients.
• Consolidates today's available information and guidance in this challenging and diverse area into one convenient resource.

Chapter 1

Acute Management of Traumatic Brain Injury

Aditya Vedantam, MD, Shankar P. Gopinath, MD, and Claudia S. Robertson, MD

Abstract

Improvements in the acute management of traumatic brain injury (TBI) have contributed to superior outcomes for patients with TBI in recent years. The development of guidelines by the Brain Trauma Foundation and American College of Surgeons has helped establish a framework for the treatment of the head injured patient. Management of the patient with TBI begins in the field with effective prehospital care and rapid transport to a well-coordinated team at a trauma center. Prevention of hypoxia and hypotension is the cornerstone of preventing secondary brain injury in the acute phase. The availability of neurosurgical expertise for emergent surgical intervention is essential. Advances in critical care have also played a major role in improving outcomes after TBI. Optimizing blood pressure and ventilation is essential, and the use of intracranial pressure monitoring can guide the maintenance of adequate cerebral perfusion pressure. Acute management of TBI is not restricted to the cranial injury but rather involves monitoring all organ systems. Maintaining normothermia, providing early nutrition, appropriate blood transfusions, deep vein thrombosis prophylaxis, and treatment of infections are necessary steps for optimal neurologic recovery. The treatment plan for the individual patient with TBI is created using a combination of evidence-based guidelines and clinical judgment. Overall, the management of the patient with TBI requires a team approach, and neurologic recovery is a multifactorial process assisted by optimization of local and systemic physiology.

Keywords

Decompressive craniectomy; Head injury; Intracranial pressure; Neurocritical care; Traumatic brain injury; Ventriculostomy

Introduction

Traumatic brain injury (TBI) is an important cause of morbidity and mortality, accounting for more than 1.4 million annual cases in the United States and an estimated 10 million cases globally.¹ The adherence to well-researched trauma guidelines as well as an efficient trauma system has contributed to improved outcomes after TBI.² Our understanding of the pathophysiology of TBI has also improved over the years, and this has helped refine the acute clinical management of patients with TBI. Advances in critical care have also played a major role in improved outcomes for patients with TBI.

In this chapter, we describe current management protocols for acute TBI, particularly moderate and severe TBI. Although the Brain Trauma Foundation (BTF) has provided updated evidence-based guidelines for the management of TBI, the lack of high-quality evidence for many of the interventions has limited the strength of recommendations. The American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) has published a best practices document for the management of TBI that provides practice recommendations for clinicians taking care of patients with TBI. We have incorporated recommendations from both the BTF and ACS TQIP in this chapter and discuss prehospital care, evaluation, and acute critical care management of patients with TBI.

Prehospital Care

Prehospital care in the United States is often initiated by emergency medical service providers, who are trained to provide basic emergency care in the field. The evaluation and treatment of the patient with acute TBI begins with a rapid assessment and interventions for airway, breathing, and circulation. Maintaining an airway in the unconscious patient may require interventions ranging from a laryngeal mask airway to intubation. Supplemental oxygen to avoid hypoxemia (cyanosis, <90% oxygen saturation) is recommended.³ The avoidance of hypotension (systolic blood pressure <90 mm Hg) is also important,⁴ and a peripheral intravenous line or intraosseus line may be required to administer isotonic fluids en route to the trauma center. Recording a Glasgow Coma Scale (GCS) score (Table 1.1) in the field provides an important baseline assessment for these patients and should be repeated at frequent intervals to identify an improvement or deterioration in the neurologic status. Based on the GCS, TBI has been classified as mild (13–15), moderate (9–12), and severe (<9) TBI. It is important to recognize that the initial GCS can change as a result of secondary insults. Patients with an initial moderate TBI can potentially deteriorate rapidly to GCS consistent with a severe TBI. Therefore treatment protocols should not be established based solely on the initial GCS. In addition to the GCS, the size and reaction of pupils to light should be recorded after resuscitation. All patients should be rapidly evaluated for active blood loss from open injuries and signs of polytrauma. The patient should be rapidly transferred to a trauma center with available computed tomography (CT) imaging and neurosurgical care. Cervical immobilization should be performed with a hard cervical collar during transport. Continuous monitoring of blood pressure and pulse oximetry should be instituted during transport with additional intravenous fluid resuscitation using bolus doses of isotonic fluids if necessary. An organized trauma care system and the development of protocols for prehospital providers can streamline and reduce delays in prehospital care. The importance of avoiding early hypoxemia and hypotension in the prehospital setting for patients with acute TBI cannot be overemphasized.

Table 1.1

Glasgow Coma Scale—Calculated by Adding up the Scores for Eye Opening, Verbal Response, and Motor Response

Components	Score
Eye Opening (E)
Spontaneous	4
To voice	3
To pain	2
No eye opening	1
Verbal Response (V)
Oriented	5
Confused	4
Inappropriate words	3
Incomprehensible sounds	2
No verbal response	1
Motor Response (M)
Obeys commands	6
Localizes stimulus	5
Withdraws from stimulus	4
Abnormal flexion	3
Abnormal extension	2
No motor response	1

The minimum score is 3, and the maximum score is 15.

Evaluation of the Patient With Acute Traumatic Brain Injury

Once the patient is brought to the emergency room at the trauma center, a rapid clinical evaluation by the trauma team is essential. Clinical history on the mechanism of injury, GCS, and pupil examination in ...