Treatment of Traumatic Brain Injury - Coursework Example

Introduction Severe or temperate Traumatic Brain Injury (TBI) is normally managed if the case is reported not long after the damage. However, it will be hard to bring back the damage that result from trauma if at all there is a delay in bringing the patient for treatment. The interventions involved during treatment in Traumatic Brain Injury include Pre-Hospital approaches, Surgical approaches, Non-Surgical approaches and Experimental approaches. Apart from these approaches, there is normally primary care provided to the patient diagnosed with Trauma Brain Injury which include efficient oxygen supply to both the brain and the rest of the body, ensuring sufficient blood flow in the body as well as managing pressure. In most cases, patients diagnosed with temperate injuries in brain usually get neckline and skull X-rays. This helps the medical specialist to comprehend whether the spinal and bone have been fractured. On the other hand patients diagnosed with severe brain injuries normally get rehabilitation which entails physical therapy, language therapy, occupational therapy and social support. Prognosis of Traumatic Brain Injury Before looking at the treatment in Traumatic Brain Injury, it is very vital to understand the prognosis of the condition. Data from various hospitals shows that, majority of patients diagnosed with severe brain injuries usually go for surgery approach as a way of treatment (Marion et al, 1997). This treatment involves removal of damaged tissues, for instance, damaged blood vessels or bruised tissues. Otherwise, the disability that results from TBI depends on the intensiveness of the injury. Some of these disabilities normally affect mental conditions for instance thinking and reasoning, sensory system (hearing, smell or touch) as well as behavior. Social unsuitability and personality adjustments are the primary behavior outcomes that are easily realized from a severe brain injured patient. Also, there is high possibility of an individual to acquire Persistent Vegetative State (PVS) for more than a month if he or she has experienced severe Traumatic Brain Injury (TBI). Evidence on TBI Treatment Approaches A study by Cicarone et al (2002, p. 1681) identifies evidence-based cognitive rehabilitation in patients diagnosed with Traumatic Brain Injury (TBI). The study shows substantial heterogeneity that exists among treatment approaches which in most cases it is difficult to determine their boundaries. However, specialists are advised to provide comprehensive diagnostic basis as a core prerequisite in choosing the management approach of the condition. Actually, it is necessary for specialists to replicate the intervention which has already been established effectively in order to specify an effective approach for different patients. Otherwise, speculating the treatment may often not effectively explain plausible treatment approach to TBI (McCrea, 2008, p. 4). According to Cicarone et al (2002), Evidence-Based Approaches in treatment of Traumatic Brain Injury (TBI) helps medical specialists to develop effective strategies of treatment that will reduce the intensity of primary and secondary damage. It also encourages diverse therapies in management of brain trauma as well as developing better healing function of the patient. Treatment of Traumatic Brain Injury According to Rosenfeld (2012), Traumatic Brain Injury is among the major global health problem. Patients with TBI are classified on the basis of clinical signs of the disease as mild, temperate/moderate or severe basing on Glasgow Coma Scale. Treatment is divided into the following clinical approaches; a) Pre-Hospital Approach The importance of pre-Hospital approach intervention is to avoid hypotension and hypoxemia since they can largely contribute to secondary injuries which will perhaps lead to poor outcome. Research by Holcomb and Young (2009) shows that most patients diagnosed with Traumatic Brain Injury with hypotension were associated with poor outcomes after treatment. In a study by Legome and Shockley (2011, p. 58), the incident rate of Traumatic Brain Injury in rural areas was high compared to the incident rates in urban areas. This implies that there was high mortality rate in the rural population compared to urban population in Colorado. High mortality rates that result from TBI in rural settings is normally associated with delay in gaining access to definitive pre-hospital services. Brain Trauma Foundation, founded by United States government (1998), has emphasized the importance of pre-hospital management of TBI. Pre-Hospital Assessment The first step in pre-hospital assessment is to determine the intensity of brain injury sustained by a patient. If the patient outcome interprets present severe level of consciousness (LOC) as well as amnesia, this will prompt the need for referral to neurosurgical intervention. Physical examinations in pre-hospital assessment include; securing airway hyperventilate, examination of cervical spine, exposure, disability, assessment of oxygen supply (should be at SaO2>90%) and assessment of blood pressure (should be 90 mmHg) (Finkelstein, Corso & Miller, 2006). Traumatic Data Coma Bank (TDCB) established that hypotension and hypoxemia would lead to poor outcome in a patient diagnosed with TBI, and a single incident of pre-hospital hypotension (Oxygen saturation 90mmHg. Also, close monitoring of pulse oximetry blood pressure and cardiac performance is very vital during pre-hospital approach (Holcomb and Young, 2009, p. 59). A case control study of 1092 TBI patients showed that paramedics intubation maintained survival in selected victims (Ketzleb, 2009). However, the findings from a prospective cohort study in San Diego hospital showed that patients who underwent pre-hospital intubation were at high risk of mortality (Legome and Shockley, 2011). Generally, Pre-Hospital approach tends to focus largely on maintaining oxygen saturation at > 90% (airway management), sustaining fluid pressure at > 90 mmHg and assessment of the degree of injury using GCS and select appropriate referral for severe Traumatic Brain Injury of the victims ( Rosenfeld, 2012, p.1089). b) Surgical Approaches According to Rosenfeld (2012, p. 1092), surgical approach in managing traumatic brain injury helps in improving end results for patients diagnosed with severe brain injury. The study by Servadei et al (2007, p.163) shows that surgical approach is mostly common in post-traumatic intracranial hematomas patients despite less evidence. High Intracranial Pressure (ICP) is the most common cause of poor outcome (disability or death) of severe brain injury. When high intracranial pressure is experienced in patients with bilateral brain inflammation, medical treatment perhaps may not be the appropriate approach to manage the condition. However, a set of broad maneuvers that involve cerebrospinal fluid drainage, moderation of hypocapnia (Pco2 between 30 mmHg and 35 mmHg) and maintenance of osmotic therapies are applied during surgical approach. These are the first line measures in managing intracranial pressure. Sometimes the fist line measures fail to control intracranial pressure (Sahuquillo and Arikan, 2006), therefore second surgical measures are considered if the CT scan contains the evacuable lesions. The second level surgical measures include deep hyperventilation, barbiturates and decompressive craniectomy (Servadei et al, 2007, p.165) and should be considered for patients with intensive brain injury resulting from high intracranial pressure. The introduction of CT scanning to detect intracranial lesions following the occurrence of brain injury in a patient has maintained the incidence of TBI patients between 2.7% and 4% (Bullock, R et al, 2006, p. 52). It is important to note the significant of GCS over age in determining the outcome of the patient undergoing surgery. An analysis by Uzan et al (1998) shows that the use of GCS in predicting the outcome is far much better that the use of age for patients undergoing EDH surgery. For instance, in a case of 284 patients diagnosed with severe TBI, GCS acted as a significant factor in determining the outcome at six months. The results showed that patients that had subdural hemorrhage and a GCS between 3 and 5 (74%) had highest mortality compared to patients with GCS between 6 and 8 (9%). Bullock, MR, Ghajar, J et al (2006) pointed out that fist level and second level surgical measures that are used to perform decompressive craniectomy involve the removal of skull and creating a cavity in the durameter. Despite the effort of trying to reduce the rate of mortality in severe brain injured patients, open cavities in the durameter subjects the victim to Hospital pneumonia (Polman, Heimans, et al.1986). Therefore clinicians are challenged to use antibiotics through the veins of the patient in order to fight germs that may cause hospital pneumonia (American Thoracic Society, 2005, p.390). This approach also takes into account regenerative treatment whereby an injured patient is transplanted with stem cell to repair injured brain (Rosenfeld, 2012, p.1092). These cells (transplanted cells) substitute affected neurons as well as reducing brain inflammation. However, the process is quite challenging during early management of Traumatic Brain Injury. c) Non-Surgical Approach Non-Surgical approach normally focus on adjustments in neurologic outcomes (sensory nerves, motor index score), medical complications, (hospital-pneumonia, pressure ulcers, re-hospitalization) and functional results (rehabilitation or length of stay of a patient diagnosed with traumatic brain injury). According to U.K Report on National Clinical Guideline (2009) brain injuries contribute a significant proportions in most emergency departments (ED) as well as pre-hospital and ambulance service. In United Kingdom for example, out of all patients attending ED department, about 6.6% are diagnosed with head injuries. This statistics account to about 15% head injuries reported per year with 93% in GCS 15. The guidelines in this approach have developed several aspects to manage brain injury. These aspects include imaging, referral to neurosurgical department and neuro-intensive care of patients diagnosed with TBI as well as rehabilitation (National Clinical Guideline, 2009, p. 2). Apparently, the approach tends to optimize early intervention of head injury especially after CT scanning. The key objective of non-surgical approach it to focus on early diagnosis and the treatment of traumatic brain injury to facilitate reduction in mortality that is most likely caused by secondary injuries (Brambrink and Kirsch, 2011, p. 99). In this process therefore, approaches to protect Spinal Cord of patients are integrated. Actually, this will help the specialist to take actions as soon as possible especially when there is urgent need of transfer of patients with SCI to hospital. Indicators of referral Patients with signs of brain skull fracture, loss of consciousness, persistent headache (severe), vomiting, coagulopathy and GCS < 15 during initial assessment are recommended for referral. On the other hand, those who show signs of confusion (probably after clinical observation), suspected head injury and full consciousness (GCS 15/15) are recommended for head CT. Neuro-intensive care As pointed out before, non-surgical approach focus on length of stay (LOS) and neuro-intensive care unit. Therefore, if the outcome from the CT scanning shows a fresh intracranial lesion and if the clinical features of the patient suggest neuroscience assessment, then managing that patient in Intensive Care Unit (neuro-intensive care) is highly recommendable (National Clinical Guideline, 2009, p.5). Like Pre-Hospital approach, non-surgical approach also uses Hyperbaric and diving medicine (Gracia, Putnam and Dean, 2010) in managing patients’ outcome. Rosenfeld (2012, 1089) illustrated that normobaric and hyperbaric hyperoxia improves energy production (mitochondria functions) in the brain cells and thus there will be high formation of Adenosine Triphosphate. Sustainability of oxygen level in the brain cells may be difficult since oxyhaemoglobin is highly saturated in plasma. Also the intracranial pressure will hardly be maintained by the homeostatic functions in the brain. Non-surgical therapeutic hypothermia reduces cerebral metabolic disorder, forms free radicals and connects excitatory neuro-transmitters. This will improve neurobehavioral results at this stage of intervention (Rosenfeld, 2012). However, this approach largely depends on time (the clinical procedures in non-surgical approach works effectively if a patient is diagnosed with fresh TBI). A big challenge is how to maintain body when therapeutic hypothermia is used to improve that outcome of TBI patient. Rehabilitation Patients subjected to neuro-intensive care unit due to mild or severe (depending on the GCS) are recommended to have rehabilitation procedures as part of comprehensive treatment (Xiong, 2010). Patient together with his/her family should select the best approach for rehabilitation; home-base, hospital-outpatient, hospital-inpatient, day-care or school-based rehabilitation (for children). Actually, rehabilitation is offered to the survivor depending on his/her needs. These needs are individually modified on the grounds of occupational therapy (daily living activities), speech therapy, physiatry, psychology and social support (Brambrink and Kirsch, 2011). Experimental approach Neuroprotection is an important strategy for treating Traumatic Brain Injury in this approach (Narayan et al, 2002). However, there are no effectual neuroprotective means endorsed from various trials (experiments) that have been done. Perhaps it may be because of variability in intervention approaches as well as heterogenic population. Also, experimental approach uses drugs which aim a sole pathophysiological method which is normally experienced during secondary injury in brain (Stoica et al, 2009). Recent studies shows have discovered that traumatic brain injury (TBI) stimulates neurogenesis, spinal sprouting as well as angiogenesis (Richardson, et al, 2007). These processes later may lead to unprompted function recovery. Therefore, experimental approach is argent of treatment that that uses comprehended trials to improve the outcome of a patient with severe or mild brain injury. Clinical trials in this approach normally target protection of neurons thus becoming a potential therapy of managing Traumatic Brain injury. Various trials show that neorogenesis normally occur in the subventricular zone (SVZ) in all mammals. Therefore, during brain injury, new neurons are developed from the neural stem cells (NSCs) especially in adults’ brain (Zhao et al, 2008). When TBI generates cell proliferation, hippocampal in this case, new developed neurons that stay alive after 10 weeks of TBI normally divide and grow into mature neurons (Sun eta la, 2007). Axonal remodeling is another agent in experimental approach. If brain neurons show a sense of survival after brain injury, perhaps there will be a natural motor remodeling in brain (Oshima et al, 2009). Therefore, this treatment is important to functional recovery of the brain since it promotes axonal plasticity (Smith et al, 2007). Angiogenesis on the other side present an integrative molecular understanding in neurovascular roles which are normally important in the development of neurogenic rehabilitation processes for patients with traumatic brain injuries (Yang et al, 2010). In conclusion, pre-clinical, clinical and experimental studies are very important in treatment and management of Traumatic Brain Injury (TBI). Prior to any intervention, beneath from, pre-hospital to surgical treatment, clinical data at every stage gives preferably several brain intervention models that will improve the outcome (reduce in mortality and morbidity). Therefore, comprehensive pharmacokinetic data especially in the argents of TBI treatments in various approaches, combined with effective therapies will likely to account positive outcomes in patients with TBI. Experimental approach is an interesting treatment in clinical medicine whereby, specialists enjoys that nature of useful argents as that enhances redevelopment of brain tissues after the injury. Bibliography American Thoracic Society (2005). Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. 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