Managing Medical Complications of Brain Injury. Katie Turpin, NP-C
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1 Managing Medical Complications of Brain Injury Katie Turpin, NP-C
2 Objectives: 1. Describe the role of the medical team in a setting focused on therapy/rehabilitation. 2. Identify common disabilities or after effects of TBI that affect success of therapy. 3. Identify medical interventions to treat disabilities or after effects of TBI.
3 Overview Traumatic Brain Injury (TBI) as defined by CDC: A disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head, or penetrating head injury. Centers for Disease Control and Prevention Website (
4 Combined rates for ER visits, hospitalizations and deaths related to TBI have risen over the last decade 521 per 100,000 in per 100,000 in 2010 TBI related deaths have decreased ER visits have risen Hospitalizations stable Deaths decreased from 18.5 per 100,000 in 2001 to 17.1 per 100,000 in 2010 Centers for Disease Control and Prevention Website (
5 Stroke A leading cause of long term disability 610,000 people suffer a stroke every year in the US Patel, Early Diagnosis of Post stroke Spasticity and Treatent Options. US Neurology. 2009
6 Rehabilitation Importance TBI consequences: Family disruption/stress Loss of income Large financial expense over lifetime Goal to return to a maximum degree of level of functioning Khan, Baguley, Cameron, Rehabilitation after traumatic brain injury. Rehabilitation Medicine. 2003
7 Medical Management of TBI Complications Routine management of chronic conditions such as HTN, DM, hypothyroidism Management of conditions resulting from TBI such as seizure disorder, TBI
8 Medical Management of TBI Complications, continued Management of conditions resulting from TBI that directly affect progress of therapy and overall recovery/prognosis Pain Dysautonomia Behavioral changes Spasticity
9 Pain Managment Identify source Musculoskeletal Muscle spasms Neuropathic Medications Oral Topical
10 Pain management, continued Medications Gabapentin Muscle relaxant Cymbalta Acetaminophen Opiates NSAIDS Topical analgesic
11 Dysautonomia Loss of balance between the sympathetic and parasympathetic nervous systems Results in increased activity of sympathetic nervous system Diagnosis of exclusion Lemke, D, Sympathetic Storming After Severe Traumatic Braine Injury. Critical Care Nurse. 2007
12 Dysautonomia, continued Autonomic nervous system discharges a large amount of neurotransmitters Paroxysmal elevation of ANS: Tachycardia, Tachypnea, Elevated temperature, Diaphoresis Associated with muscle overactivity Posturing, Dystonia, Rigidity, Spasticity Baguley, I. Current Understanding of Dysautonomia After Severe Acquired Brain Injury. ACNR
13 Dysautonomia, continued Occurs in 11-15% of people with severe TBI Triggers Pain Infection Environmental stimuli Nursing Vigilance Calms Neuro Storm. Nurse.com Baguley, I. Current Understanding of Dysautonomia After Severe Acquired Brain Injury. ACNR
14 Dysautonomia, continued Treatment Focuses on symptom management to reduce adverse effects of prolonged sympathetic nervous system activity Rule out other causes Eliminate external stimuli Treat internal stimuli Medically manage symptoms
15 Dysautonomia, continued Medical treatment Can cause a diminished level of responsiveness Prevent secondary injury Cell death Contractures Skin breakdown Malnutrition Cardiac damage Lemke, D. Riding Out the Storm: Sympathetic Storming after Traumatic Brain Injury. J Neurosci Nursing
16 Dysautonomia, continued Medication Opioids (Morphine, oxycodone) Suppresses sympathetic outflow Bromocriptine Reduces hyperthermia and diaphoresis Chlorpromazine Rapidly reduces core temperature Lemke, D. Riding Out the Storm: Sympathetic Storming after Traumatic Brain Injury. J Neurosci Nursing
17 Dysautonomia, continued Beta blockers (Propranolol, labetalol) Suppresses sympathetic outflow, slows neuronal activity Treats tachycardia and HTN Clonidine is an alternative: lowers circulating plasma levels of epinephrine and norepinephrine Dantrolene Decreases release of calcium, interfering with muscle contraction Treats posturing, dystonia Can cause drowsiness Lemke, D. Riding Out the Storm: Sympathetic Storming after Traumatic Brain Injury. J Neurosci Nursing
18 Behavioral Changes No FDA approved treatments for TBI related cognitive impairment Memory impairment Difficulty with concentration Lack of initiation; amotivational Reduced insight; impulsivity Altered emotional control Depression, anxiety Wortzel, H and Arciniegas, D. Treatment of Post-Traumatic Cognitive Impairments. Curr Treat Options Neurol. 2012
19 Behavioral Changes, continued Aggression and agitation Up to 30% of TBI cases Depression 10-60% of TBI cases Treatment SSRI s Mood stabilizers Carbamazepine Sodium valproate Talsky, et al, Pharmacological interventions for traumatic brain injury. BC Medical Journal Khan, Baguley, Cameron, Rehabilitation after traumatic brain injury. Rehabilitation Medicine. 2003
20 Behavioral Changes, continued Minimal responsiveness or amotivational Treatment Psychostimulants Methylphenidate Improved concentration at 1 month, but not at 3 months Antiparkinsonian drugs Amantadine Improved arousal and LOC Modafinil Improved memory and daytime somnolence Talsky, et al, Pharmacological interventions for traumatic brain injury. BC Medical Journal. 2010
21 Behavioral Changes, continued Memory deficits Donepezil Improved long term cognitive outcomes Early administration Talsky, et al, Pharmacological interventions for traumatic brain injury. BC Medical Journal. 2010
22 Muscle Spasticity Muscle hypertonia during movement Increased resistance to muscle stretch with either flexion or extension Hypertonicity, clonus, muscle spasms May lead to permanent contractures Thibaut et al, Spasticity after stroke: Physiology, assessment and treatment. Informa Healthcare Patel, Early Diagnosis of Post stroke Spasticity and Treatent Options. US Neurology. 2009
23 Muscle Spasticity, continued Treatment PT Orthoses/splinting Medications
24 Spasticity, continued Medications, continued Baclofen Benzodiazepines Gabapentin (high dose) Tizanidine Dantrolene Thibaut et al, Spasticity after stroke: Physiology, assessment and treatment. Informa Healthcare. 2013
25 Spasticity, continued Invasive medications Phenol injections Botox injections Intrathecal baclofen pump Surgical interventions Tendon release Thibaut et al, Spasticity after stroke: Physiology, assessment and treatment. Informa Healthcare. 2013
26 Summary Physical rehab and medical care converge during post TBI care Goal is to return to highest level of functioning and independence as possible
27
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