Traumatic Brain Injuries: Treatment

Last Wednesday we looked at the basics of severe traumatic brain injury (TBI). Remember, the basis of treating TBI is manipulation of the three components within the skull: the brain, the blood, or the cerebrospinal fluid (CSF).

1. Manipulating Brain Tissue:

Removing brain tissue is an option and may be done to tissue that has died. Recovery of the patient is dramatically influenced by what part of the brain was removed.

Another management strategy is to put the brain at rest by placing the patient in a medically induced coma. You may have heard about this in relation to Gabrielle Gifford's care. Medication is used to heavily sedate the patient. Typically, the patient is on continuous EEG monitoring to ensure a minimal amount of brain activity is present. The purpose of the coma is to reduce the metabolic demands of the brain in hopes of keeping swelling down and allowing the brain time to heal.

Additionally, a diuretic, typically Mannitol, can be given to draw water out of swollen brain cells.




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2. Manipulating Blood Flow:

This can entail a couple of areas. Remove blood that has collected in the brain. Sometimes when the brain is injured, blood vessels within the brain are ripped open. Two types of bleeding can occur between the brain and the skull: a subdural or epidural hematoma. A subdural hematoma occurs from veins. An epidural hematoma occurs from an artery. Depending on the size of the hematoma, a neurosurgeon may choose to operate and remove it. Sometimes bleeding occurs within brain tissue. This type of bleeding can be small and more diffuse. Although a risk for the patient it may not be an option to surgically remove it.

Another way to manipulate blood flow is to manipulate the size of the blood vessels inside the patient's head. This can be done by increasing the rate of the patient's breathing on the ventilator thereby decreasing their blood level of carbon dioxide. When this level is lower, the blood vessels inside the patient's brain shrink in diameter. This therapy is controversial and if done, only a mild drop in carbon dioxide levels is the goal.

Lastly, the blood pressure can be manipulated. A certain blood pressure or blood flow to the brain must be maintained in order to keep the brain alive. This is called the cerebral perfusion pressure (CPP) and is calculated by using the patient's blood pressure and their intracranial pressure (ICP). Reducing the blood pressure is an option but you must maintain the cerebral perfusion pressure as well. This can be a challenging balancing act.

3. Manipulating CSF:

A drain is placed to remove excess cerebrospinal fluid.

4. Removing a portion of the skull.

I know, this isn't one of three but it is a viable option for management of brain swelling. A portion of the skull is removed (hemicraniectomy) to allow the brain room to swell. The portion of the skull that is removed is preserved by freezing so that is can be re-attached at a later point once the swelling has eased.

Have you had a character in your novel with a traumatic brain injury? If so, what type and why did you choose it?