Traumatic brain injury medical therapy: Difference between revisions
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{{Traumatic brain injury}} | {{Traumatic brain injury}} | ||
{{CMG}} {{JE}} {{Deekshitha}} | |||
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==Overview== | ==Overview== | ||
Acute traumatic brain injury (TBI) is a medical and surgical emergency and requires prompt treatment. The treatment is based on the type of TBI and nature of the injury. But the primary focus of the treatment for all types is to prevent cerebral edema and to maintain intracranial pressure (ICP) within normal limits. <ref>Smith TR. Neurosurgery. In: Doherty GM. eds. Current Diagnosis & Treatment: Surgery, 15e. McGraw-Hill; Accessed April 25, 2021. https://accessmedicine.mhmedical.com/content.aspx?bookid=2859§ionid=242161973</ref> | |||
==Medical Therapy== | ==Medical Therapy== | ||
*Traumatic brain injury is a medical emergency and requires prompt treatment.<ref name="pmid28933211">{{cite journal| author=Galgano M, Toshkezi G, Qiu X, Russell T, Chin L, Zhao LR| title=Traumatic Brain Injury: Current Treatment Strategies and Future Endeavors. | journal=Cell Transplant | year= 2017 | volume= 26 | issue= 7 | pages= 1118-1130 | pmid=28933211 | doi=10.1177/0963689717714102 | pmc=5657730 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28933211 }} </ref> | |||
**Airway management and [[Hyperventilation]]. This is usually achieved by intubation and mechanical ventilation. Carbon dioxide is more permeable across blood-brain barrier than oxygen. Excessive carbon dioxide in serum leads to increased risk for cerebral edema. Hyperventilation will achieve CO2 wash out and hence decreases the risk of cerebral edema<ref>Gouvea Bogossian E, Peluso L, Creteur J, Taccone FS. Hyperventilation in Adult TBI Patients: How to Approach It?. Front Neurol. 2021;11:580859. Published 2021 Jan 28. doi:10.3389/fneur.2020.580859</ref>. | |||
**[[Seizure]] prophylaxis. Traditionally, patients who sustained a TBI has higher risk for a seizure. However, the evidence behind the practice of initiating prophylactic antiepileptic medication is mixed<ref>Nichol H, Boyd J, Trier J. Seizure Prophylaxis Following Moderate to Severe Traumatic Brain Injury: Retrospective Investigation of Clinical Practice and the Impact of Clinical Guidelines. Cureus. 2020;12(4):e7709. Published 2020 Apr 17. doi:10.7759/cureus.7709</ref>. If started the medication can be stopped in one week if no evidence of seizure<ref>Zaman, Anwar MD; Dubiel, Randi DO; Driver, Simon PhD; Bennett, Monica PhD; Diggs, Vincent MPH, CPH; Callender, Librada BS Seizure Prophylaxis Guidelines Following Traumatic Brain Injury: An Evaluation of Compliance, Journal of Head Trauma Rehabilitation: March/April 2017 - Volume 32 - Issue 2 - p E13-E17 | |||
doi: 10.1097/HTR.0000000000000243 </ref>. | |||
**Hyperosmolar therapy. This is again to decrease cerebral perfusion. The principle behind hyperosmolar fluid infusion is to encourage diuresis and reducing intracranial pressure. Traditionally, mannitol, 3% saline are the choice of fluids. The evidence is again mixed and this practice is controversial<ref>Asehnoune, K., Lasocki, S., Seguin, P. et al. Association between continuous hyperosmolar therapy and survival in patients with traumatic brain injury – a multicentre prospective cohort study and systematic review. Crit Care 21, 328 (2017). https://doi.org/10.1186/s13054-017-1918-4 | |||
[[Barbiturate]]s can be used to decrease ICP; [[mannitol]] was thought to be useful, but it appears likely that the studies suggesting that it was of use<ref>Cruz J, Minoja G, Okuchi K. (2001) Improving clinical outcomes from acute subdural hematomas with the emergency preoperative administration of high doses of mannitol: a randomized trial. ''Neurosurgery''. Volume 49, Issue 4, Pages 864-871. PMID 11564247</ref><ref>Cruz J, Minoja G, Okuchi K. (2002) Major clinical and physiological benefits of early high doses of mannitol for intraparenchymal temporal lobe hemorrhages with abnormal pupillary widening: a randomized trial. ''Neurosurgery''. Volume 51, Issue 3, Pages 628-637; discussion 637-638. PMID 12188940</ref><ref>Cruz J, Minoja G, Okuchi K, Facco E. (2004) Successful use of the new high-dose mannitol treatment in patients with Glasgow Coma Scale scores of 3 and bilateral abnormal pupillary widening: a randomized trial. ''Journal of Neurosurgery''. Volume 100, Issue 3, Pages 376-383. PMID 15035271</ref> may have been falsified.<ref>Roberts I, Smith R, Evans S. (2007) [http://www.bmj.com/cgi/content/full/334/7590/392 Doubts over head injury studies.] ''BMJ''. Volume 334, Issue 7590, Pages 392-394. PMID 17322250</ref> | </ref>. | ||
**Medically induced [[coma]] and [[Therapeutic hypothermia]] are other practices which are used to reduce cerebral perfusion and hence decrease ICP. However, the long term effects of medically induced coma are unknown. | |||
*Medical care usually begins when [[paramedic]]s or [[emergency medical technician]]s arrive on the scene of an accident or when a TBI patient arrives at the emergency department of a hospital. Because little can be done to reverse the initial brain damage caused by trauma, medical personnel try to stabilize the patient and focus on preventing further injury. Primary concerns include insuring proper [[oxygen]] supply, maintaining adequate blood flow, and controlling [[blood pressure]]. Since many head-injured patients may also have [[spinal cord injury|spinal cord injuries]], the patient is placed on a back-board and in a neck restraint to prevent further injury to the head and spinal cord. Medical personnel assess the patient's condition by measuring [[vital signs]] and reflexes and by performing a neurological examination. They assess the patient's level of consciousness and neurological functioning using the [[Glasgow Coma Scale]]. Depending on the patient's mental and respiratory status, patient may need intubation and mechanical ventilation. | |||
*[[Barbiturate]]s can be used to decrease ICP but mental status should be monitored; [[mannitol]], 3% normal saline was thought to be useful, but it appears likely that the studies suggesting that it was of use<ref>Cruz J, Minoja G, Okuchi K. (2001) Improving clinical outcomes from acute subdural hematomas with the emergency preoperative administration of high doses of mannitol: a randomized trial. ''Neurosurgery''. Volume 49, Issue 4, Pages 864-871. PMID 11564247</ref><ref>Cruz J, Minoja G, Okuchi K. (2002) Major clinical and physiological benefits of early high doses of mannitol for intraparenchymal temporal lobe hemorrhages with abnormal pupillary widening: a randomized trial. ''Neurosurgery''. Volume 51, Issue 3, Pages 628-637; discussion 637-638. PMID 12188940</ref><ref>Cruz J, Minoja G, Okuchi K, Facco E. (2004) Successful use of the new high-dose mannitol treatment in patients with Glasgow Coma Scale scores of 3 and bilateral abnormal pupillary widening: a randomized trial. ''Journal of Neurosurgery''. Volume 100, Issue 3, Pages 376-383. PMID 15035271</ref> may have been falsified.<ref>Roberts I, Smith R, Evans S. (2007) [http://www.bmj.com/cgi/content/full/334/7590/392 Doubts over head injury studies.] ''BMJ''. Volume 334, Issue 7590, Pages 392-394. PMID 17322250</ref> | |||
* | |||
===Contraindicated medications=== | ===Contraindicated medications=== | ||
{{MedCondContrAbs | {{MedCondContrAbs | ||
|MedCond = Recent intracranial trauma|Alteplase}} | |MedCond = Recent intracranial trauma|Alteplase}} | ||
*[[Prednisolone]] | |||
<nowiki>[[Category:Needs review]]</nowiki> | |||
==References== | ==References== | ||
Latest revision as of 01:55, 15 December 2021
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Joanna Ekabua, M.D. [2] Deekshitha Manney, M.D.[[3]]
Overview
Acute traumatic brain injury (TBI) is a medical and surgical emergency and requires prompt treatment. The treatment is based on the type of TBI and nature of the injury. But the primary focus of the treatment for all types is to prevent cerebral edema and to maintain intracranial pressure (ICP) within normal limits. [1]
Medical Therapy
- Traumatic brain injury is a medical emergency and requires prompt treatment.[2]
- Airway management and Hyperventilation. This is usually achieved by intubation and mechanical ventilation. Carbon dioxide is more permeable across blood-brain barrier than oxygen. Excessive carbon dioxide in serum leads to increased risk for cerebral edema. Hyperventilation will achieve CO2 wash out and hence decreases the risk of cerebral edema[3].
- Seizure prophylaxis. Traditionally, patients who sustained a TBI has higher risk for a seizure. However, the evidence behind the practice of initiating prophylactic antiepileptic medication is mixed[4]. If started the medication can be stopped in one week if no evidence of seizure[5].
- Hyperosmolar therapy. This is again to decrease cerebral perfusion. The principle behind hyperosmolar fluid infusion is to encourage diuresis and reducing intracranial pressure. Traditionally, mannitol, 3% saline are the choice of fluids. The evidence is again mixed and this practice is controversial[6].
- Medically induced coma and Therapeutic hypothermia are other practices which are used to reduce cerebral perfusion and hence decrease ICP. However, the long term effects of medically induced coma are unknown.
- Medical care usually begins when paramedics or emergency medical technicians arrive on the scene of an accident or when a TBI patient arrives at the emergency department of a hospital. Because little can be done to reverse the initial brain damage caused by trauma, medical personnel try to stabilize the patient and focus on preventing further injury. Primary concerns include insuring proper oxygen supply, maintaining adequate blood flow, and controlling blood pressure. Since many head-injured patients may also have spinal cord injuries, the patient is placed on a back-board and in a neck restraint to prevent further injury to the head and spinal cord. Medical personnel assess the patient's condition by measuring vital signs and reflexes and by performing a neurological examination. They assess the patient's level of consciousness and neurological functioning using the Glasgow Coma Scale. Depending on the patient's mental and respiratory status, patient may need intubation and mechanical ventilation.
- Barbiturates can be used to decrease ICP but mental status should be monitored; mannitol, 3% normal saline was thought to be useful, but it appears likely that the studies suggesting that it was of use[7][8][9] may have been falsified.[10]
Contraindicated medications
Recent intracranial trauma is considered an absolute contraindication to the use of the following medications:
[[Category:Needs review]]
References
- ↑ Smith TR. Neurosurgery. In: Doherty GM. eds. Current Diagnosis & Treatment: Surgery, 15e. McGraw-Hill; Accessed April 25, 2021. https://accessmedicine.mhmedical.com/content.aspx?bookid=2859§ionid=242161973
- ↑ Galgano M, Toshkezi G, Qiu X, Russell T, Chin L, Zhao LR (2017). "Traumatic Brain Injury: Current Treatment Strategies and Future Endeavors". Cell Transplant. 26 (7): 1118–1130. doi:10.1177/0963689717714102. PMC 5657730. PMID 28933211.
- ↑ Gouvea Bogossian E, Peluso L, Creteur J, Taccone FS. Hyperventilation in Adult TBI Patients: How to Approach It?. Front Neurol. 2021;11:580859. Published 2021 Jan 28. doi:10.3389/fneur.2020.580859
- ↑ Nichol H, Boyd J, Trier J. Seizure Prophylaxis Following Moderate to Severe Traumatic Brain Injury: Retrospective Investigation of Clinical Practice and the Impact of Clinical Guidelines. Cureus. 2020;12(4):e7709. Published 2020 Apr 17. doi:10.7759/cureus.7709
- ↑ Zaman, Anwar MD; Dubiel, Randi DO; Driver, Simon PhD; Bennett, Monica PhD; Diggs, Vincent MPH, CPH; Callender, Librada BS Seizure Prophylaxis Guidelines Following Traumatic Brain Injury: An Evaluation of Compliance, Journal of Head Trauma Rehabilitation: March/April 2017 - Volume 32 - Issue 2 - p E13-E17 doi: 10.1097/HTR.0000000000000243
- ↑ Asehnoune, K., Lasocki, S., Seguin, P. et al. Association between continuous hyperosmolar therapy and survival in patients with traumatic brain injury – a multicentre prospective cohort study and systematic review. Crit Care 21, 328 (2017). https://doi.org/10.1186/s13054-017-1918-4
- ↑ Cruz J, Minoja G, Okuchi K. (2001) Improving clinical outcomes from acute subdural hematomas with the emergency preoperative administration of high doses of mannitol: a randomized trial. Neurosurgery. Volume 49, Issue 4, Pages 864-871. PMID 11564247
- ↑ Cruz J, Minoja G, Okuchi K. (2002) Major clinical and physiological benefits of early high doses of mannitol for intraparenchymal temporal lobe hemorrhages with abnormal pupillary widening: a randomized trial. Neurosurgery. Volume 51, Issue 3, Pages 628-637; discussion 637-638. PMID 12188940
- ↑ Cruz J, Minoja G, Okuchi K, Facco E. (2004) Successful use of the new high-dose mannitol treatment in patients with Glasgow Coma Scale scores of 3 and bilateral abnormal pupillary widening: a randomized trial. Journal of Neurosurgery. Volume 100, Issue 3, Pages 376-383. PMID 15035271
- ↑ Roberts I, Smith R, Evans S. (2007) Doubts over head injury studies. BMJ. Volume 334, Issue 7590, Pages 392-394. PMID 17322250