Traumatic Brain Injury (TBI)

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Questions to Ask Your Doctor about Traumatic Brain Injury (TBI)
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Treatment

There are three stages of treatment for TBI:

1. Acute—to stabilize the patient immediately after the injury;
2. Subacute—to rehabilitate and return the patient to the community; and
3. Chronic—to continue rehabilitation and treat the long-term impairments.

Acute Treatment
Initial acute treatment focuses on saving the victim's life. Rescue or emergency personnel unblock airways, assist breathing, and keep blood circulating. Cardiopulmonary resuscitation may be as necessary. Treatment then focuses on stabilizing the patient. Hospital personnel then take over, working to maintain the body fluid levels and prevent or treat infections and other complications.

Several types of TBI require surgery. Surgery may be performed within hours or days of the injury, if a blood clot causes increased intracranial pressure (ICP). Some clots must be removed; others must not be removed because of the danger of disturbing them. Subdural hematomas and intracerebral hemorrhages may also increase ICP, sometimes necessitating surgery.

During acute treatment, swelling in the brain (edema) is monitored and treated. Brain edema can have dire consequences, causing increased pressure inside the head (intracranial pressure or ICP). Because the skull is hard, ICP can compress or squeeze the soft brain tissue against it, preventing blood from circulating adequately in the brain tissue and causing damage to brain cells. Most edema subsides within a few days or weeks, but a few minutes or hours of excessive ICP can cause permanent damage.

To manage this condition, a device called an ICP monitor can be inserted through the skull to provide physicians with a constant pressure reading. If the ICP rises too high, medications are administered to draw fluid out of the brain and into blood vessels, decrease the brain's metabolic requirements, and increase blood flow to the injured tissues. The patient also can be placed on a ventilator to ensure an adequate supply of oxygen (hyperventilation), which is necessary to promote healing. When brain swelling is particularly severe, elevated pressure can only be relieved temporarily by surgically removing a portion of the skull. This allows swollen tissues to bulge out reducing the risk for pressure-induced damage.

A buildup of fluid inside the brain is also a concern in acute treatment. If the fluid-containing spaces in the brain (ventricles) experience blockage, a neurosurgeon must insert a tube called a shunt to drain the fluid build up (hydrocephalus). This allows the ventricles to shrink and restores normal function to brain cells. Elevated ICP due to swelling, hydrocephalus, or blood clots significantly impacts recovery from TBI.

Seizures may occur seconds, weeks, or years after TBI. A seizure can be a minor twitching of one finger or limb, or a complete loss of consciousness accompanied by involuntary movements of the entire body. Seizures can be particularly dangerous during this time, so most patients with moderate to severe TBI receive antiseizure medication for at least the first few weeks.

Another important aspect of acute care is the prevention of other medical problems. One concern is the development of abnormally high or low levels of sodium, calcium, sugar, or other substances in the blood that can worsen confusion and precipitate seizures. TBI patients also are at high risk for infections, including pneumonia, urinary tract infections, and sinusitis, which must be treated promptly and aggressively.

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