Traumatic Brain Injury (Part 3)

By: Carine Human

In Part 1, Traumatic Brain Injury (TBI) was explored, along with the types of TBI and their symptoms. Traumatic Brain Injury Part 2 focused on the effects of TBI and how TBI is diagnosed and the symptoms of moderate and severe brain injury. Part 3 will explore the various treatment options for patients who have suffered TBI.

Treatment Options for Traumatic Brain Injury
Rest and medication usually is necessary for mild TBI to relieve headache. For moderate to severe TBI, intensive care in a hospital is required. In the case of bleeding and/or swelling in the brain, it could become an emergency that requires surgery. There are times when a patient does not need surgery, but must be safely monitored by nurses and physicians in an intensive care unit.
Immediate treatment is aimed at resuscitating and supporting the critically ill patient, as well as to minimise secondary brain injury and complications and eventually facilitate the patients transfer to a recovery or rehabilitative environment. There are thus far only measures to control brain swelling and despite significant research, there still is no way to eliminate swelling from happening.

Neurocritical care
The intensive care of patients who have suffered life-threatening TBI, is referred to as Neurocritical Care. Often patients with severe TBI are comatose or paralyzed and they may also have other injuries. Their care is usually overseen by a specialist trained physician who coordinates the complex neurological and medical care. Patients must be monitored and woken every hour for nursing assessment of their mental status or brain function.
Patients are usually connected to several machines, tubes, and monitors. This equipment provides information about the functioning of the body and helps to guide care. Certain function may also be taken over by some equipment, such as breathing (ventilator), nutrition (feeding peg, intravenous feeding) and urination (dialysis) until the body is able to manage these functions again.
 
The appearance of a TBI patient may be shocking to families or loved ones as their appearance will be altered because of facial injury and equipment that is used for monitoring. Several tubes, lines, and equipment may be used to closely monitor heart rate, blood pressure, and other critical body functions.

Methods of monitoring
Intracranial pressure (ICP) monitor. A catheter is inserted through a small hole in the skull and placed inside the ventricle (fluid-filled area deep within the brain) to measure pressure inside the head. If pressure become too high, immediate intervention is necessary.
Brain oxygen monitor (Licox). A catheter is inserted through a small hole in the skull and positioned within the brain tissue and measures the oxygen level and temperature within the brain. To maximise the brain's oxygen level, adjustments in the amount of oxygen given to the patient are often made.
 Ventilator.  A ventilator is a machine that helps a patient breathe. The ventilator is connected to the patient by the endotracheal (ET) tube, which is placed into the patient's mouth and down into the trachea, or windpipe. The tube enables the machine to push air into and out of the lungs, thereby helping the patient breathe.
Feeding tube. When patients are ventilated, or have a decreased level of alertness, they may unable to eat or get adequate nutrition. A nasal-gastric feeding tube is inserted through the patient's nose and passed down the throat into the stomach, which delivers liquid nutrition as well as any medication that may be required.
Seizures and EEG monitoring. A seizure is an abnormal electrical discharge from the brain and approximately 24% of patients who suffer a TBI will have a seizure that may remain undetected unless they are monitored by an electroencephalogram (EEG). Seizures that are invisible to the human eye are non-convulsive seizures and because these seizures are serious, all patients with a severe TBI are monitored with continuous EEG for 24 to 72 hours after injury.


Medication
After a head injury it may be necessary to keep the patient sedated with medications, which can be turned off quickly to awaken the patient and check their mental status. Patients often have other injuries, pain medication is administered to keep them comfortable.
Controlling intracranial pressure is important and hypertonic saline is a medication used to control pressure within the brain and works by drawing the extra water out of the brain cells into the blood vessels and filtered out by the kidneys.
Patients are given an anti-seizure medication (levetiracetam or phenytoin) to prevent seizures from occurring.
Prevention of infection is vital, but the risk remains, and any device placed within the patient has the potential to introduce a microbe and should an infection be confirmed by tests, it will be treated with antibiotics.

Surgery
Should skull fractures or bleeding vessels need repair, or blood clots be removed or extremely high intracranial pressure be relieved, surgery is needed. Such surgery is referred to as a craniotomy and it involves cutting a hole in the skull to remove a bone flap so that the surgeon can access the brain and the flap is replaced in its normal position and secured to the skull with plates and screws upon repair of the damage or relief of swelling.
Decompressive craniectomy involves removing a large piece of bone so that the brain can swell and expand and is typically performed when extremely high intracranial pressure becomes life threatening. The exposed brain is covered by a special biologic cover and the skin is closed and the bone flap is stored in a freezer for up to 3 months and replaced during a procedure called cranioplasty once the swelling has resolved and the patient has stabilized from the injury.

Other surgical procedures that may be performed to aid in the patient's recovery are a Tracheotomy, which involves making a small incision in the neck to insert the breathing tube directly into the windpipe to which the ventilator will then be connected. Sometimes a Percutaneous Endoscopic Gastrostomy Tube (PEG) inserted directly into the stomach through the abdominal wall as a feeding tube.

Not all head injuries are the same and recovery from a brain injury can take weeks, months, or even years and many family members express feelings of helplessness when their loved one is in the ICU.

It is important to understand that too much stimulation can agitate the patient and raise his or her blood pressure. Also, as patients recover, they need help understanding what has happened to them during this "time lapse". Recovery of consciousness is a gradual process - not just a matter of waking up. Progress is tracked in three areas: movement, thinking, and interacting.

Rehabilitation
Patients are usually discharged from the hospital when their condition has stabilised and they no longer require intensive care. A social worker will work closely with the family as preparations are made for a return home or for transfer to a long-term care or rehabilitation center.
Recovering from a brain injury depend on on the brain's plasticity, or the ability for undamaged areas of the brain to take over functions of the damaged areas and on regeneration and repair of nerve cells, but most importantly, on the patient's hard work to relearn and compensate for lost abilities.

Physical therapy helps patients rebuild and maintain strength, balance, and coordination.
Occupational therapist helps patients to perform activities of daily living, such as dressing, feeding, bathing, toileting, and transferring themselves from one place to another and provide adaptive equipment if a patient has difficultly performing a task.
Speech therapy helps patients by monitoring their ability to safely swallow food and helping with communication and cognition.
Neuropsychology helps patients relearn cognitive functions and develop compensation skills to cope with memory, thinking, and emotional needs.
It is critical that family members seek and receive support (family, friends, support groups, counseling) in dealing with their own emotional responses to caring for a head injured loved one.

Prevention
Tips to reduce the risk for a head injury or TBI:
-    Always wear a helmet when riding a bicycle, motorcycle, skateboard, or all-terrain vehicle and sports.
-    Never drive under the influence of alcohol or drugs.
-    Always wear your seat belt and ensure that children are secured in the appropriate child safety seats.
-    Avoid falls in the home by keeping unsecured items off the floor, installing safety features such as non-slip mats in the bathtub, handrails on stairways, and keeping items off stairs.
-    Avoid falls through exercise to increase strength, balance, and coordination.
-    Store firearms in a secured and locked cabinet with bullets in a separate location.