Chapter 23: Patient Management for Traumatic Brain Injury

INTRODUCTION

Moderate to severe traumatic brain injury (TBI) is a leading cause of morbidity and mortality in the United States and worldwide, with an annual incidence of 60 to 100 per 100,000.^1–4 In 2010, there were 715.7 per 100,000 emergency department (ED) visits related to TBI, with 91.7 per 100,000 TBI-related hospitalizations, and 17.1 per 100,000 TBI-related deaths.⁵ It is estimated that over 5 million people in the United States are living with TBI-related disability,⁶ and by 2020, TBI will be the third leading cause of disability in the world,⁷ with the annual cost of providing acute and rehabilitation care for individuals in North America projected to be in the billions of dollars.⁸ These statistics are especially troublesome because the incidence of TBI is highest among young males between the ages of 15 and 24,^1,8,9 leading to decades of disability and lost productivity. Despite the improvement in mortality rate, many survivors are left with lifelong impairments in physical, cognitive, and psychosocial functioning. Management of these individuals is challenging, given the varying severity of illness and baseline comorbidities.

This chapter will focus on patient management in TBI; key points will be reviewed, and the reader is encouraged to review the references for a more detail examination of the topic.

PHARMACOLOGIC INTERVENTIONS FOR COMMON PROBLEMS IN PATIENTS WITH TRAUMATIC BRAIN INJURY

This section will review frequent problems associated with traumatic brain injury and their most common pharmacologic treatments. For many of these problems, limited or no high level evidence exists to support common management strategies often used by physicians. Despite the paucity of data, clinical recommendations regarding medication management are based on the best data available. Often, when no data exist, extrapolation of data from studies not specific to patients with brain injuries is utilized. When the decision to start a medication has been made, the old adage by many experts in the field of brain injury medicine, “start low and go slow” truly applies. “Go slow” takes into account dosing adjustments and timing of adjustments. Not waiting long enough to allow a medication to fully take effect and increasing dosing prior to this may lead to side effects or other adverse consequences. Patience and understanding the pharmacodynamics of the medication may lead to an adequate response to the symptom being treated at the lowest possible dose.

PHARMACOLOGIC INTERVENTIONS FOR MOOD DISORDERS IN THE BRAIN-INJURED PATIENT

Antidepressant medications are frequently used in the management of brain-injured patients. The content of this section will focus on commonly used drug classes: selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants, and benzodiazepines. They have been used in this patient population for depressive disorders, anxiety, and behavior disorders. This section is organized by drug class and their potential indications.

Depression incidence ...