Management of Traumatic Brain Injury
- 690 Downloads
Traumatic brain injury (TBI) is a complex disease process that requires constant attention as one manages the associated body systems. Even though an “isolated” brain injury may be the cause for admission to the hospital, the injured brain cannot be thought of in isolation from the remainder of the body. All body systems, from cardiac to pulmonary, need to be addressed as one moves from the initial to the long-term management of the TBI. The multiple issues are best addressed with a dedicated neurocritical care team that is in continuous communication with the neurosurgical team throughout the course of treatment. To date, no pharmacologic treatment has led to improved outcomes after TBI, but it is becoming increasingly clear that advances in the critical care of TBI patients are contributing to better results.
During resuscitation of the TBI patient, medical management in its simplest form strives to return measurable vital signs and laboratory values (eg, intracranial pressure, mean arterial pressure, blood glucose, PaO2, or PaCO2) to their normal range. The initial goal is to maintain or reestablish normal homeostasis.
The initial injury to the brain is irreversible by any medical modalities available today. After the initial resuscitation, medical maneuvers are directed at limiting secondary damage to the brain. Secondary brain injury occurs in response to inflammatory changes, expanding hematomas, cellular swelling, seizures, and systemic complications (ie, hemodynamic or pulmonary changes, fever, pain); vulnerable surrounding brain tissue can be damaged through alterations in cerebral perfusion and metabolism. Treatments to address these issues include, but are not limited to, analgesics, sedatives, anticonvulsants, hyperosmotic agents, and hypothermia.
The future of TBI care likely lies in the areas of better injury classification to guide therapeutic interventions, management of secondary injury, improved technology for intracranial monitoring, and regeneration/rehabilitation. Studies focusing on signaling pathways, neural stem cells, and reparative medications are all in the early stages of development; their use is currently experimental at best.
There are few areas in medicine where clinicians have the opportunity to impact a patient’s life to the degree seen in the management of TBI. Although parts of the proverbial puzzle certainly remain unsolved, it is the remarkable recoveries that patients make with the therapeutic modalities available today that keep management of TBI one of the most exciting areas in medicine.
KeywordsTraumatic Brain Injury Traumatic Brain Injury Patient Decompressive Craniectomy Neurocritical Care Traumatic Axonal Injury
Dr. Shutter has received research support from UCB Pharma, the US Department of Defense, and the National Institutes of Health. No other potential conflicts of interest relevant to this article were reported.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance, •• Of major importance
- 1.Centers for Disease Control and Prevention: Traumatic brain injury. Available at http://www.cdc.gov/ncipc/tbi/TBI.htm. Accessed December 29, 2009.
- 2.Langlois JA, Rutland-Brown W, Thomas KE: Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2006. Available at http://www.cdc.gov/ncipc/pub-res/TBI_in_US_04/TBI%20in%20the%20US_Jan_2006.pdf. Accessed December 29, 2009.
- 9.••Brain Trauma Foundation: Guidelines for Management of Severe Traumatic Brain Injury, edn 3. New York: Brain Trauma Foundation; 2007. Available at http://www.braintrauma.org/site/DocServer/Guidelines_Management_2007w_bookmarks.pdf?docID=621. Accessed December 29, 2009. The Brain Trauma Foundation guidelines are a comprehensive guide for management of traumatic brain injury. Solutions to questions about patient care and level of evidence of current therapies are available from this source and can be used for patient care.
- 11.Vasile B, Rasulo F, Candiani A, Latronico N: The pathophysiology of propofol infusion syndrome: a simple name for a complex syndrome. Intensive Care Med 29(9):1417–1425.Google Scholar
- 12.Szaflarski JP, Sangha KS, Lindsell CJ, Shutter LA: Prospective, randomized, single-blinded comparative trial of intravenous levetiracetam vs. phenytoin for seizure prophylaxis. Neurocrit Care, published online Nov 9, 2009.Google Scholar
- 14.Brain Trauma Foundation: Guidelines for Prehospital Management of Traumatic Brain Injury. New York: Brain Trauma Foundation, 2000.Google Scholar
- 38.SyNAPSe (Study of the Neuroprotective Activity of Progesterone in Severe Traumatic Brain Injuries). http://www.synapse-trial.com/. Accessed December 29, 2009.
- 40.A phase 2a dose escalation study with SLV334 in patients traumatic brain injury. http://clinicaltrials.gov/ct2/show/NCT00735085. Accessed December 29, 2009.
- 42.The DECRA Trial: early decompressive craniectomy in patients with severe traumatic brain injury. http://clinicaltrials.gov/ct2/show/NCT00155987. Accessed December 29, 2009.
- 43.Randomised Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of Intra-Cranial Pressure. http://www.rescueicp.com/. Accessed December 29, 2009.
- 44.Surgical trial in traumatic intracerebral haemorrhage. STITCH (Trauma). Available at http://research.ncl.ac.uk/trauma.STITCH/documents/Summary.pdf. Accessed December 29, 2009.