Discussion: Traumatic Brain Injury
Discussion: Traumatic Brain Injury
Traumatic Brain Injury (TBI) is physical injury to brain tissue that temporarily or permanently impairs brain function. A head injury results from a blow or jerk to the head or penetration by a bullet or foreign object, which impedes normal brain functioning. The purpose of this paper is to discuss TBI, including the pathophysiology, pharmacological treatments, clinical guidelines, impact on patients, families, and communities, and strategies to implement best practices for managing the disease.
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Pathophysiology of Traumatic Brain Injury
Brain injury occurs when a mechanical force is applied directly or indirectly to the brain. A direct injury transpires when a force is produced by a blow to the head. On the other hand, an indirect injury occurs when a force is applied to another body part and has a rebound effect on the brain. The brain responds to forces applied to it by moving within the rigid cranial vault. It can also rebound or rotate on the brainstem, resulting in diffuse axonal injury (Crupi et al., 2020). Besides, the brain may get bruised or lacerated/torn as it shifts over the inner surfaces of the cranium, which are usually irregularly shaped and sharp. The damage to the brain mostly occurs in the frontal and temporal lobes.
[elementor-template id="165244"]Any TBI can result in cerebral edema and reduced brain circulation. The cranial vault has a fixed size and is filled by non-compressible cerebrospinal fluid and brain tissue (minimally compressible). Therefore, any swelling or an intracranial hematoma lacks space to expand, resulting in increased intracranial pressure (ICP) (Crupi et al., 2020). The brain cells then become anoxic and cannot metabolize adequately, resulting in ischemia, infraction, irreversible brain damage, and brain death.
Evidence-Based Pharmacological Treatments in Texas
Treatment of TBI in Texas is usually supportive. Management of moderate and severe injuries usually includes improving ventilation, oxygenation, and brain perfusion. Antipyretics and cooling blankets are used to control fever and avoid shivering, which prevents increased ICP and reduces metabolic demand (Crupi et al., 2020). Antibiotics are administered to patients with ICP monitoring devices insitu. In addition, Anticonvulsants are administered to prevent seizures. Patients with TBI complications like increased ICP are administered osmotic diuretics to alleviate cerebral edema and Dobutamine and IV fluids to maintain cardiac output and improve cerebral perfusion (Crupi et al., 2020). The supportive treatment interventions affect TBI management by maintaining adequate ventilation, oxygenation, and brain perfusion, which prevents secondary brain insult and complications.
Clinical Guidelines for TBI
The 2019 3rd edition of the Guidelines for the Management of Severe Traumatic Brain Injury (TBI) outlines evidence-based recommendations to guide treatment. The guidelines recommend monitoring of ICP and advanced neuromonitoring for only patients with no contraindications to invasive neuromonitoring and without brain death. The recommended threshold guidelines include targeting a threshold of below 20 mm Hg in ICP treatment and maintaining a minimum cerebral perfusion pressure (CPP) of 40 mm Hg (Kochanek et al., 2019). Regarding treatment, the guidelines recommend bolus hyperosmolar therapy (HTS) of 3% saline for patients with ICP, with doses from 2-5 mL/kg over 10-20 minutes. A bolus of 23.4% HTS is recommended for refractory ICP. Bolus administration of midazolam and fentanyl should be avoided during ICP crises to prevent cerebral hypoperfusion. In addition, the guidelines recommend draining CSF using an external ventricular drain to manage increased ICP. Prophylactic treatment is also recommended to reduce the occurrence of early posttraumatic seizures.
The guidelines recommend putting patients on moderate hypothermia (32-33°C) to control ICP, but this is not recommended over normothermia for enhancing overall outcomes. High-dose barbiturate is recommended in hemodynamically stable persons with refractory ICP. Corticosteroids are not recommended for patients with increased ICP. In addition, Decompressive craniectomy is recommended for herniation, neurologic deterioration, and refractory intracranial hypertension (Kochanek et al., 2019). With regard to nutrition, early initiation of enteral nutritional support is recommended to reduce mortality and improve outcomes. Besides, Transgastric jejunal feeding is recommended to decrease the incidence of ventilator-associated pneumonia.
How TBI Affects Patients, Families, and Populations in Communities
Despite the degree of injury, a person with TBI may experience short-term or long-term cognitive, physical, emotional, and financial consequences, as well as their families and the community. A majority of TBI survivors have cognitive impairments with thinking difficulties. The cognitive impairments disrupt the patient’s ability to function effectively at work, school, and personal life (Andelic et al., 2019). Besides, patients with mild TBI are often disoriented and have short-term memory loss. TBI further affects patients since they lose sensation for temperature, pain, touch, and position sense, preventing them from responding appropriately to environmental stimuli. In addition, TBI affects a patient’s planning and organization skills, and many patients encounter difficulty planning and organizing daily activities (Andelic et al., 2019). They also have self-awareness deficits, problems identifying their behavior, and are usually unaware of how others perceive them.
TBI disrupts families’ sense of coherence and ability to move forward in a moderately predictable manner. It significantly affects family relationships, lifestyles, and quality of life. Whiffin et al. (2021) explain that uninjured family members are at risk of developing stress, depression, and anxiety due to increased strain and ineffective family functioning. Although caring for a family member with TBI is physically demanding, it is seeing the changes in cognition, personality, and behavior that cause the greatest burden to family members. The healthcare costs related to the treatment and rehabilitation of TBI put a financial strain on most families (Whiffin et al., 2021). The community is also affected since patients become economically unproductive, resulting in loss of labor. Resources channeled towards the treatment and rehabilitation of patients further financially affect the health systems in the community.
Strategies to Implement Best Practices for Managing TBI in the Current Healthcare Organization
Strategies that can be used to implement best practices when managing TBI patients in our organization include early enteral nutritional support, Cognitive rehabilitation therapy, and teaching Self-management. TBI patients will be initiated on early enteral nutritional support to improve immunity, correct systemic metabolic disorders, and improve clinical outcomes (Yang et al., 2021). Small-lumen nasogastric or nasoduodenal tubes will be inserted to support continuous or intermittent feeding. Cognitive rehabilitation therapy is a training approach that seeks to help TBI patients regain function in vital areas necessary to return to independence and improve their quality of life (Samuelson et al., 2020). It entails the repetitive exercise of standardized cognitive tests of increasing complexity, targeting particular cognitive domains. Patients with TBI will be taken through cognitive rehabilitation therapy to reinforce, strengthen, and restore their impaired skills.
Teaching Self-management will include providing the patient and family with written and verbal instructions during discharge. Patients will be educated on seizure precautions and approaches to adapt to sensory dysfunction. Besides, patients and families will be educated on issues linked with personality or behavior problems that can arise and how to cope with them (Andelic et al., 2019). In addition, the nurse will emphasize the importance of regular follow-up visits with therapists for monitoring and early detection of health status or complications.
Conclusion
TBI can occur due to direct or indirect injury to the head, which causes the brain to move within the rigid cranial vault and increase ICP. Treatment aims in moderate and severe TBI include improving ventilation, oxygenation, and brain perfusion. TBI affects patients’ occupational and social functioning and causes psychological and financial distress to their families. Approaches that can be applied to implement best practices when managing TBI patients include early enteral nutritional support, cognitive rehabilitation therapy, and teaching self-management.
References
Andelic, N., Løvstad, M., Norup, A., Ponsford, J., & Røe, C. (2019). Editorial: Impact of Traumatic Brain Injuries on Participation in Daily Life and Work: Recent Research and Future Directions. Frontiers in Neurology, 10, 1153. https://doi.org/10.3389/fneur.2019.01153
Crupi, R., Cordaro, M., Cuzzocrea, S., & Impellizzeri, D. (2020). Management of Traumatic Brain Injury: From Present to Future. Antioxidants (Basel, Switzerland), 9(4), 297. https://doi.org/10.3390/antiox9040297
Kochanek, P. M., Tasker, R. C., Bell, M. J., Adelson, P. D., Carney, N., Vavilala, M. S., … & Wainwright, M. S. (2019). Management of pediatric severe traumatic brain injury: 2019 consensus and guidelines-based algorithm for first and second tier therapies. Pediatric Critical Care Medicine, 20(3), 269-279. doi: 10.1097/PCC.0000000000001737
Samuelson, K. W., Engle, K., Abadjian, L., Jordan, J., Bartel, A., Talbot, M., Powers, T., Bryan, L., & Benight, C. (2020). Cognitive Training for Mild Traumatic Brain Injury and Posttraumatic Stress Disorder. Frontiers in Neurology, 11, 569005. https://doi.org/10.3389/fneur.2020.569005
Whiffin, C. J., Gracey, F., & Ellis-Hill, C. (2021). The experience of families following traumatic brain injury in adult populations: A meta-synthesis of narrative structures. International Journal of Nursing Studies, 123, 104043. https://doi.org/10.1016/j.ijnurstu.2021.104043
Yang, L., Liao, D., Hou, X., Wang, Y., & Yang, C. (2021). Systematic review and meta-analysis of the effect of nutritional support on the clinical outcome of patients with traumatic brain injury. Annals of Palliative Medicine, 10(11), 11960-11969. doi: 10.21037/apm-21-3071
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