Pathophysiology and pharmacological management of traumatic brain injury

Traumatic Brain Injury

Pathophysiology

Traumatic brain injury, continues to remain an enigma and treatment is elusive, causing death and disability across the globe. Luckily, significant progress has been made in helping improve short-term outcome in victims facing a severe brain injury. Unfortunately, it is still not possible to get back the victims to their normative level of brain functioning. Injuries to the brains caused by forceful impact may cause tissue distortion. Clinically, outcome depends on the mediating the cellular changes and bimolecular changes caused due to the injury. Secondary brain injuries lead to alteration in the functioning of the cell through disruption of homeostasis, excitotoxicity, free radical generation, and depolarization. It may also propagate injury through intracranial hypertension, edema formation, blood- brain barrier disruption and ischemic injury. To help improve the outcome in patients suffering from traumatic injuries, it is necessary to understand evolution of therapies and processes that are known to help limit secondary brain injury (Greve & Zink, 2009).

2. Standard of Practice

The newly developed Canadian guidelines can help aid healthcare professionals to implement best practices, meant to help challenged population (experiencing post concussive symptoms (PPCS) which follows a mild traumatic brain injury (MTBI) also referred to as concussion or mild head injury. This head disorder has become common today and there is increased public awareness through reportage of concussion in sport prevention and media attention on injuries associated with military blast (Marshall, Bayley, McCullagh, Velikonja, & Berrigan, 2012)

Studies on MTBI hospital treated cases and those presented to family physicians have been estimated to be between 653 and 493 per 1000 people in Ontario. It is now expected that cases of patients experiencing MTBI will recover within months or even days. According to the Centers of disease control and prevention (CDC), 15% of the patients diagnosed with MTBI experience persistent disabling problems. Such cases are few, especially if we look at the high incidences of MTBI. (Marshall, Bayley, McCullagh, Velikonja, & Berrigan, 2012).

a. Evidence-based pharmacological treatment and how they affect management of the disease in the community.

In spite of the massive investment by the government and commercial entities in the past decades, TBI (Traumatic brain injury) remains the main source of mortality and disability in both developing and developed countries. There are over 500 researches funded by The U.S. Department of Defense Neurotrauma Research portfolio. The research aims at developing interventions that will mitigate the effect of trauma and improve quality of life outcome. The portfolio looks at the need for the best pharmacological approaches that can be used to treat TBI and its symptoms. USAMRMC (The U.S. Army medical Research and Material Command) established the Neutrauma Pharmacology Workgroup whose goal is to develop pharmacological treatments aimed at improving TBI clinical outcomes (Arrastia, et al., 2014).

Pre-clinical studies have focused on testing the drug's efficacy in animals. It targets secondary injury including growth factors, calcium channel blockers, free radical scavengers, N- methyl D-aspartate (NMDA) magnesium sulfate and corticosteroids. Phase II clinical trials evaluate efficacy of combinations, such as PEG-SOD (polyethylene glycol conjugated superoxide dismutase) nimodopine, triamcinolone and moderate hypothermia, (Xiong, Mahmood, & Chopp, 2010).

It should be noted that all approaches and compounds which have been tested in phase III trials have not shown any efficacy. The efficacy of using neuroprotective to treat TBI is uncertain. In some cases, manitol has effectively reduced brain swelling after TBI but it is not known whether it can actually manage severe TBI. Also, it has been proved that excessive administration of mannitol is harmful. Mannitol passes from bloodstream to the brain hence increasing the pressure which worsens swelling. Data on the effectiveness of pre-hospital administration is so far insufficient. (Xiong, Mahmood, & Chopp, 2010).

b. Clinical guidelines that can be used to assess, diagnose patient education.

According to the Emergency Department, diagnosis of the mild TBI is critical in successful management of patients, most of whom may be unaware that they have sustained TBI. When there is evidence of direct trauma, injury to the head especially after an accident mTBI should be suspected. Some patients may present post traumatic amnestic state where they may show GCS score of 15/15 and may not be able to form an intelligible memory pattern.

In such a case, the patient should be monitored in order to rule out life threatening complication including intracranial hemorrhage and prepare the patient for possible delayed complications. This is done in order to monitor and rule out any life threatening complications (ONF, n.d.).

Acute mTB complication remains a matter of great concern and most of the patients may not experience any complications. Unfortunately, most of the patients will experience acute post mTB. Therefore, education on anticipated symptoms is vitalin the recovery process. Provision of information and instructions for the follow-up has been shown to be one of the most effective strategies that can help prevent the development and persistent of the post mild TBI. The family physician must make regular follow-ups and monitor the progress and assure the patient that specialist referral can be made if needed. The health care provider must also explore and document risk factors which may delay recovery. (ONF, n.d.).

c. Standards of managing the disease within the community and national practices

After the TBI patient has been hospitalized, he must receive rehabilitation care in different settings. He should be provided with rehabilitation especially if the medical condition needs skilled nursing care. These services can be accessed from hospitals, skilled nursing facilities, and inpatient rehabilitation facilities. The care setting selected should be based on functional recovery insurance coverage, geographic availability, and independence. (CDC & NIH, 2015).

About 30 million injury related patients visit hospitals, emergency departments(ED) or die. 16% of them are TBI as primary and secondary diagnosis. Of those who die, one-third die as a result of TBI. (CDC & NIH, 2015). Each state needs to determine the policy to ascertain and account for brain deaths.

3. Characteristics of resources

Headache is one of the most common symptoms associated with brain injury. Being aware of TBI related symptoms such as sustained sports injuries and those involved in conflicts in Afghanistan and Iraq. Note that post-traumatic headaches (PTH) is poorly understood and may be classified as secondary syndrome as far as International of Headaches Disorders is concerned (Hoffman, et al., 2011).

Behaviors exhibited in classroom may be related to cognitive deficits. This may be seen in their level of attention, speed of processing ideas, memory, visual spatial problems, receptive language and how they learn.

In the initial phase of recovery from TBI, the parent must focus on the recovery of the child (Mayfield, 2009). The family may experience stress but must remain hopeful to recover fully. Stressors may mask dysfunction or family problems. The parents should be hopeful that things will normalize as soon as they return home. Most parents believe that if the children spend more time with the family, the recovery will be quick. They hope for quick recovery as time passes but recovery becomes a problem especially if the child sustained severe head injury (Mayfield, 2009).

a. Disparities in management of TBI on an international and national level

The issues of gender, class and ethnicity have been cited in discussions about brain injury treatment as well as care. This has added disparity in level of care in states (Stone, 2014). Pertinently, according to the recent study that was published in neurorehabilitation, it found out that minorities have a lower rate of success when it comes to treating traumatic brain injuries as compared to Caucasians.

The available data suggest that the minority populations are at a traumatic brain injury risk hence the notable disparities in the outcomes. One of the questions that needs to be asked is why cultural issues and socioeconomic and discrimination play a role. Thus it is necessary to have a shift in treatment paradigm (Stone, 2014).As a worldwide condition, TBI has longtime consequences on the lives of individuals. Unfortunately, many countries have limited speech --language pathology thus TBI victims receive limited services.

According to WHO, TBI will be a leading cause of death and disability in the 2020. Research shows that differences in socio --economic status, cultural influences, and education system make the management of TBI difficult in some countries. Underdeveloped countries have fewer services and least understand the condition while fewer professional are actually able to provide treatment. (Davee, 2014).

4. Three factors that help patients manage Brain Injury

Medicaid/Medicare

Traumatic Brain Injury patients and their families face a wide range of financial issues. When someone experiences traumatic brain injury, it may change life as effort is focused on recovery and survival. Brain related treatment can be costly. Medicare, one of the programs financed at the federal level, can be a helpful source in this context. It is attached to social security and focuses on the older population (TFF, n.d.). This is a health insurance program for people aged 65 years or those who are under 65 years but face certain disabilities or those suffering from stage renal diseases.

The federal government, does not fund the Medicaid program, another likely aid. Each state provides up to half the of the Medicaid program fund. In some states counties are required to contribute some funds. This is not the case for Medicare program since the Medicaid is normally need- based social protection program and not an insurance program (TFF, n.d.)

Access to care

If the care is protocol driven, it greatly reduces mortality and cost in TBI especially when the Brain Trauma Foundation guidelines are followed. The guidelines recommend specialized surgical and medical care which can be delivered at a trauma center. Adherence to the guidelines reduces the cost and improves outcome in TBI. The Brain Trauma Foundation guideline improves the care for all TBI patients at the centers (Sharma, Gomez, deMestral, Hsiao, Rutka, & Nathens, 2014).

B. How TBI impacts on families, patients and the entire population

When a member of a family suffers from TBI, familial life changes completely, causing variety of problems to family members. These include financial difficulties, communication problems, and lack of family members support. Family members may become anxious, angry, guilty, and frustrated. (Novack, n.d.).

1. Financial costs of TBI on families, the population and patient on diagnosis

The study shows that the estimated cost due to brain trauma deaths was 20.7 million USD in 2009; in 2013 98% of the cost was related to productivity (indirect costs) while 2% related to direct medical expenses (Kavosi, Jafari, Hatam, & Enaami, 2015).

C. Best practices in managing TBI

Protocolized approaches and Multi-model, which involves hemodynamic support, fluid management and other aspects of therapy, can help prevent secondary brain injury. It requires optimizing cerebral oxygenation. It also requires effort from a multidisciplinary team such neurosurgeons, neurointensivists, therapists, respiratory therapist and bed side nurses. (Haddid & Arabi, 2012).

1. Strategies to use in implementing best TBI practices

Physical therapy intervention strategies

i. Intervention and assessment tools have evolved especially for TBI assessment with adolescent and children. The oculomotor screen is used in the study. The head turns with a metronome set, which replicates the movement and velocity that is aligned with day-to-day living patterns of the patient. (Hugentobler, Vegh, Janiszewski, & Yates, 2015).

ii. Evidence-based strategy

For individuals with a TBI and their families, the effect of their damage can be extraordinary and lifelong. Having the right frameworks, administrations and support set-up can alleviate its effect on those affected. An evidence-based, and proactive way to deal with services is to create a practice by building up an all-encompassing system for individuals with a TBI (concentrating on adults with a moderate to extreme TBI) (ACC, 2016).

The strategy was produced with contribution from key partners. The procedure included meeting customers, families and caregivers to better comprehend their encounters; working with administration providers and restoration experts to gain a better understanding of the part they play in treatment and recovery; counseling with client associations and undertaking documentation, and evidence-based research reviews (ACC, 2016).

ii. Compensatory Strategy Training

Compensatory strategy concentrates on amplifying the abilities of the person with TBI by either adjusting the ambience/environment, and/or providing interior and outer makeovers, and gains by in place-aptitudes to overcome shortages caused by TBI (ASHA, n.d.).

Evaluation Method

i. The addition of exercise protocol and Brock string greatly improves occulomotor intervention and screening for the population. (Hugentobler, Vegh, Janiszewski, & Yates, 2015).

ii. The theory-based evaluation factors along the proposed causal pathway will be supplemented by different segments that structure a portion of the procedure assessment; these are: 1) an evaluation of intervention constancy and whether it achieved the objectives; 2) perception of accomplishment of receipt and delivery, and elements that added to this; and 3) view of adequacy and attainability of the deliverables of the intervention (Bosch et al., 2014).

iii. Compensatory procedures can incorporate both inward (e.g., mental aids, symbolism, affiliation) and outside (e.g., memory helps, PDAs, logbooks) techniques. Outer procedures including assistive innovation may bolster an assortment of subjective open weaknesses, including consideration, memory, route, time administration, association, and passionate capacity (ASHA, n.d.).