Traumatic brain injury medical therapy

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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.

Medical Therapy

• Traumatic brain injury is a medical emergency and requires prompt treatment.
  • 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.
  • 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. If started the medication can be stopped in one week if no evidence of seizure.
  • 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.
  • 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 may have been falsified.

Contraindicated medications

Recent intracranial trauma is considered an absolute contraindication to the use of the following medications:

• Alteplase
• Prednisolone

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