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Successful outcome in severe traumatic brain injury: a case study.

Abstract: This case study describes the management of a 54-year-old male who presented to the Hospital of the University of Pennsylvania (HUP) with a traumatic brain injury (TBI) after being assaulted. He underwent an emergent bifrontal decompressive hemicraniectomy for multiple, severe frontal contusions. His postoperative course included monitoring of intracranial pressure, cerebral perfusion pressure, partial pressure of brain oxygen, brain temperature, and medical management based on HUP's established TBI algorithm. This case study explores the potential benefit of combining multimodality monitoring and TBI guidelines in the management of severe TBL

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Traumatic brain injury (TBI) patients require a multidisciplinary approach among all members of the healthcare team, including physicians, nurses, respiratory therapists, speech therapists, physical/occupational therapists, and nutritionists. This case study demonstrates how a successful outcome can be achieved when a TBI patient is treated under the guidance of an algorithm designed specifically for the management of this population. Our facilty, the Hospital of the University of Pennsylvania (HUP), established a TBI algorithm based on the American Association of Neurologic Surgeons Guidelines for the Management of the Severely Brain Injured Patient (Bullock et al., 2000), which incorporates surgical management and multimodality monitoring (MMM). These guidelines help healthcare providers address patients' complex needs while executing the established standard of care.

Once an initial injury to the brain has occurred, the cascade of events that follows includes altered cerebral perfusion, increased intracranial pressure, and cerebral hypoxia, which all increase the risk of ischemia. The goal of MMM is to prevent secondary injury to the fragile brain. Critical care nurses play a pivotal role in the successful management of brain-injured patients. This article presents and discusses the implementation of a TBI algorithm as a guideline for neuroscience nurses in caring for TBI patients.

Background

TBI occurs when a blow, jolt, or penetration to the head damages brain tissue. Severity can range from mild concussion to coma and death. This type of injury is a major public health problem and a common cause of death and disability in the United States. It is estimated that 1.5 million people sustain a TBI each year in the United States, and approximately 50,000 people die from TBI, accounting for one-third of all injury deaths (Centers for Disease Control [CDC], 1996). An estimated 5.3 million Americans are living with disabilities from TBI ("CDC report shows prevalence of brain injury," 1999). Impairments include cognitive, physical, and psychological disabilities. The loss of potential income, the cost of acute care, and the ongoing expenses of rehabilitation and medical care are considerable. It is estimated that TBI costs society an estimated $48.3 billion each year (Guerrero, Thurman, & Sniezek, 2000).

In 2003, 929 patients were seen in the emergency department (ED) at the HUP Level I Trauma Center. Brain injuries from blunt trauma numbered 892 and there were 37 penetrating head traumas. The average patient age was 42 years. Of the 929 patients seen, 473 were admitted and the average length of stay was 8 days, of which 2 were spent in the intensive care unit (ICU). Overall, 871 patients survived and were discharged either from the ED or after inpatient hospitalization; 58 patients died.

Case Presentation

Initial Presentation

A 54-year-old male was traveling with his family and was discovered by his wife in a highway service area restroom beaten; he was disoriented, walked with an unsteady gait, and had profuse bleeding from both ears. He was airlifted to the HUP Level I Trauma Center and admitted to the trauma resuscitation area. His Glasgow Coma Scale (GCS) score on admission was 15 (4 = eye opening, 5 = verbal, 6 = motor). A rigid cervical collar was placed and spinal precautions were initiated. During the emergent head computed tomography (CT), he had a generalized seizure and lost consciousness. He was returned to the trauma resuscitation area for intubation. The head CT revealed bifrontal and bitemporal contusions with associated subarachnoid hemorrhage (SAH) and left-side subdural hematoma (SDH) with a right midline shift (Fig 1). The patient was transported to the HUP Neurotrauma Surgical Intensive Care Unit (NTSICU).

[FIGURE 1 OMITTED]

Upon arrival to the NTSICU, the patient's GCS score was 5 (1 = eye opening, 1 = verbal, 3 = motor) and he was becoming more bradycardic, from 45-55 beats per minute. His pupils were unequal (left was larger than right), and intermittent seizure activity was noted. Lorazepam (Ativan) and a phenytoin (Dilantin) bolus were given to control seizure activity. After 30 minutes in the ICU, his left pupil became nonreactive and he was taken for an urgent head CT, which demonstrated bifrontal and bitemporal hemorrhagic contusions with increasing hemorrhage along with increasing diffuse SAH. Left uncal herniation and descending transtentorial herniation were noted. Mannitol was given and he was taken emergently to the operating room (OR).

Nursing Considerations

Initial and repeated nursing assessments of patients with severe TBI are essential to detect neurological changes. Nonreactive pupils require prompt reaction by nurses to prevent impending herniation. Mannitol is an osmotic diuretic that increases plasma osmolality, causing a subsequent reduction of osmotic pressure. HUP's guideline prescribes a 0.25-1.0 g/kg intravenous (IV) bolus until intracranial pressure (ICP) <20 mm Hg or serum osmolality reaches 320 mOsm/L. The fluid and electrolyte shifts that occur can cause severe hypovolemia and arrhythmias; therefore, it is important for nurses to monitor the electrocardiogram (ECG), blood pressure, and fluid intake and urine output every hour in addition to serum sodium and potassium levels. Variables that can affect cerebral oxygen demands are fever, shivering, seizures, pain, and agitation. To control oxygen demand, seizures are treated with 4 mg of IV lorazepam over 2-5 minutes and may be repeated every 10-15 minutes as needed to a maximum dose of 8 mg (Lexi-Comp Online, n.d.). Benzodiazepines as a class may cause respiratory depression and hypotension; the patient was already intubated and his blood pressure was tolerating the medication bolus. Per HUP procedure, a loading dose of 15-18 mg/kg of phenytoin was given to reach a therapeutic level of 10-20 mg/mL. During administration of these medications, nurses need to continuously monitor ECG, blood pressure, and respiratory effort to ensure hemodynamic and respiratory stability are maintained.

Surgery and Immediate Postoperative Care

Upon arrival to the OR, a report of the patient's past medical history and current medical issues was given to the perioperative nurse and anesthesia physician assigned to the case. The perioperative nurse was then responsible for proper positioning to avoid skin and tissue injury and the implementation of thromboembolic stockings and external sequential compression devices. A bifrontal craniectomy was performed for evacuation of a left SDH with subsequent alleviation of ICP. During the surgical procedure the brain was visualized to be swollen and the subfrontal regions severely contused. The dura was left open and covered with a dural closure product, Duragen (Integra LifeSciences, Plainsboro NJ). Prior to departing the OR, a triple lumen bolt that accommodates a brain tissue oxygen probe, a brain tissue temperature probe, and a fiberoptic intracranial pressure monitoring device catheter (Integra LifeSciences, Plainsboro, NJ) was inserted.

After surgery, the patient was returned to the NTSICU unreversed from anesthesia and neuromuscular blockade; he remained intubated. A clinical exam was performed; the external sequential compression devices were connected and turned on, and he was placed in reverse Trendelenburg to promote cerebral venous drainage. His GCS score was 3 and pupils were 2 mm bilaterally with slight reaction to light. The brain oxygen and brain temperature (bT) probes were connected to their corresponding cables, which attached to the LICOX stand-alone bedside monitor. The partial pressure of brain oxygen ([P.sub.bt][O.sub.2]) was 21 mm Hg (normal range is 25-45 mm Hg) and ICP was 12 mm Hg. Over the next 2 hours he awoke and became agitated, withdrawing his right side to painful central stimuli. His [P.sub.bt][O.sub.2] increased to 30 mm Hg. Despite the decompressive craniectomy, however, his ICP climbed and remained above 20 mm Hg. Midazolam (Versed) and sublimaze (Fentanyl) were ordered for sedation and ICP control. His serum osmolality was 320 mOsm/L and mannitol could no longer be given. His ICP continued to climb despite analgesic administration. Concerned about secondary brain injury, the team decided to administer further chemical sedation. A continuous infusion of propofol (Diprovan) and sublimaze for sedation and pain were started with a goal to lower the ICP to <20 mm Hg. Prepared for the sedation-related hypotension, his nurse had a phenylephrine (Neosynephrine) infusion ready by the bedside. As the patient became hypotensive during the initiation of sedation, the phenylephrine infusion was started with a goal to maintain a cerebral perfusion pressure (CPP) >60 mm Hg. His hydration status was assessed and he demonstrated adequate hydration with a central venous pressure of 8 mm Hg. Over the next 6-12 hours the ICP decreased from a range of 19-24 mm Hg to a range of 17-19 mm Hg. Once the ICP was controlled, he was taken for a repeat head CT that demonstrated marked improvement of the descending transtentorial herniation. He was taken back to the NTSICU where MMM was continued. Because the loading dose (1000 mg) of phenytoin had already been given, he was continued on a maintenance dose of 5-6 mg/kg/day in three divided doses. His phenytoin level was checked to maintain a therapeutic level of 10-20 mg/ml. An international normalized ratio (INR) level of 1.6 was corrected to 1.3 with two units of fresh frozen plasma.

Nursing Considerations

When the patient arrived from the OR the nurse connected the [P.sub.bt][O.sub.2] and temperature probes to their respective cables. Ten to 120 minutes are required for the brain tissue to stabilize after the microtrattma of inserting the [P.sub.bt][O.sub.2] probe into cerebral white matter. During this time the accuracy of the [P.sub.bt][O.sub.2] is not guaranteed (Integra NeuroSciences/ GMS, 2002). If the [P.sub.bt][O.sub.2] is <20 mm Hg and there is a question of probe accuracy, reliability, or validity the nurse performs a 100% [O.sub.2] challenge on the ventilator for 2-5 minutes. If the [P.sub.bt][O.sub.2] does not increase, a head CT is obtained to check for proper catheter placement. If the [P.sub.bt][O.sub.2] increases with the [O.sub.2] challenge, the nurse refers to the Brain Hypoxia Module (Fig 2) within the TBI algorithm to determine the cause and systematically manage the patient with the neurosurgical team. (Table I explains the components of the Brain Hypoxia Module.) Because propofol was started, the nurse monitored its effects on blood pressure and CPP. Continuing to follow the TBI guidelines, a phenylephrine drip was initiated to maintain CPP >60 mm Hg. Phenylephrine must be administered via a central line to prevent extravasation and skin necrosis.

[FIGURE 2 OMITTED]

The nurse also recognized that the patient was at risk for deep vein thrombosis (DVT) and continued the use of antiembolism stockings and external sequential compression devices. When the head CT results showed the areas of hemorrhage were stable, subcutaneous heparin was added. Venous thromboembolism is a common, life-threatening complication in critically ill patients and those undergoing neurosurgery procedures. Mechanical and pharmacologic methods have been shown to significantly reduce the risk of thromboembolism.

Forty-Eight Hours Later

Propofol infusion was stopped daily at 5 am for a neurological assessment. During 6 am team rounds, the patient did not follow commands; his GCS score was 3; and his ICP was >20 mm Hg. During these 48 hours, the [P.sub.bt][O.sub.2] began to desaturate to 21 [+ or -] 2 mm Hg and ICP remained <20 mm Hg on propofol and sublimaze infusions. His Pa[O.sub.2] was 169 mm Hg on 30% Fi[O.sub.2] and hemoglobin was 11.6mg/mL. Frequent hypotensive events caused a decrease in CPP and consequently a decrease of oxygen supply to the patient's brain. During these periods of [P.sub.bt][O.sub.2] desaturation, his CPP was 50 [+ or -] 3 mm Hg requiring a titration of his phenylephrine infusion to maintain a CPP >60 mm Hg. With titration, the [P.sub.bt][O.sub.2] increased to 30 mm Hg. A head CT at this time showed extensive hemorrhagic contusions in the frontal and temporal lobes bilaterally, with an overall increase in mass effect with increased compression of the frontal horns of the lateral ventricles and narrowing of the basilar cisterns. It also showed an evolving infarct in the medial left temporo-occipital region.

Nursing Considerations

During [P.sub.bt][O.sub.2] desaturation the nurse immediately and systematically must determine its cause by following the HUP Brain Oxygen Algorithm for brain tissue oxygen <20 mm Hg (Fig 3 explains low [P.sub.bt][O.sub.2] and Fig 4 explains high [P.sub.bt][O.sub.2]). Inadequate [P.sub.bt][O.sub.2] is affected by either an increased [O.sub.2] demand by the brain or a decreased [O.sub.2] supply to the brain. The four factors that cause a decrease in [O.sub.2] supply are anemia, hypovolemia, hypoxia, and hypotension. The patient's hemoglobin was 11.6 mg/ mL; CVP was 8 mm Hg; and Pa[O.sub.2] was 169 mm Hg on 30% Fi[O.sub.2]. Because the patient was hypotensive, there was a decreased cerebral perfusion pressure and consequently a decreased [O.sub.2] supply to the brain. The nurse increased the phenylephrine to increase CPP and maximize [O.sub.2] delivery. Thoracic and lumbar spines were cleared and the nurse elevated the head of the bed to 30[degrees] to facilitate venous drainage and decrease the incidence of ventilator-associated pneumonia.

[FIGURES 3-4 OMITTED]

TBI patients have an increased calorie and protein requirement. A nasoentric postpyloric feeding tube was placed during the patient's second day of hospital stay for initiation of total enteral nutrition (TEN). However, because of the patient's need for a phenylephrine infusion, the neurosurgical team decided to hold enteral feedings because of the possibility of decreased gut perfusion.

Days 3-4

Propofol infusion was stopped and the sublimaze infusion was decreased while keeping ICP <20 mm Hg. Eight hours later the patient began to localize with his right upper extremity and his GCS score was 7 (1 = eye opening, 1 = verbal, 5 = motor). His left side was markedly weaker and he could only flicker it in response to painful central stimuli. A head CT showed a small focal infarction of the left thalamus, with an evolving left posterior cerebral artery infarction. His ICP remained <20 mm Hg and the phenylephrine was decreased to maintain CPP >60 mm Hg. During this time his temperature became elevated to 102.1[degrees]F. The nurse administered antipyretics and instituted cooling measures to decrease the brain tissue oxygen demand. Blood, urine, and sputum cultures were sent for laboratory testing and a chest X ray was performed to locate a source of infection.

Nursing Considerations

Fever increases the demand for oxygen--the nurse administered acetominophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs) and implemented ambient cooling methods. The nurse readdressed the patient's nutritional status with the team and consulted the hospital's clinical nutrition service. HUP's policy is to identify one port on the central line solely for total parenteral nutrition (TPN) to decrease the risk for bloodstream infection; this caused a delay in TPN administration because the ports had been emergently used for propofol and phenylephrine. A new central line was placed and an infusion of sodium-free TPN was started.

Days 5-8

During this time the patient began to stabilize. His laboratory values and hemodynamic status normalized, and he was weaned off phenylephrine on day 5. His [P.sub.bt][O.sub.2] values were >32 mm Hg; his brain temperature was 37.6[degrees]C-38.7[degrees]C. His ICP and [P.sub.bt][O.sub.2] remained stable and he was weaned off propofol infusion. During this time his GCS score was 9 (2 = eye opening, 1 = verbal, 6 = motor) and he began to intermittently follow commands with his right hand. After [P.sub.bt][O.sub.2] and ICP were stable for 24 hours, the monitoring system was discontinued. During the following day the patient began to open his eyes, use his voice, and make eye contact with his family.

Days 9-10

Stable pulmonary function and adequate peripheral oxygenation permitted successful extubation to 6L nasal cannula. The patient had minimal verbalization and confused conversation but no stridor was heard and, though weak, he did have a cough. The primary nurse arranged for speech and swallow consults to safely evaluate the patient's ability to take food and decrease his risk for aspiration. The speech pathologist detected mild dysphagia and cleared the patient for a mechanical soft diet. However, because the patient was consuming inadequate calories to support his nutritional needs, TPN was continued until a calorie count demonstrated sufficient calorie intake. Activity was increased so that the patient was out of bed twice daily and the nurse taught him and his family passive range-of-motion (ROM) exercises, which involved the family in his care. The patient's wife, a retired physical therapist, actively participated in the activities of daily living and ROM exercises for his limbs. Because of a short-term memory loss, the patient required frequent reorientation by the nurses and his family. A clock and an orientation board with day, date, place, and the name of the nurse caring for him was placed in his room. The staff also encouraged his wife to bring in pictures of his family and things he enjoyed to facilitate his memory

Outcomes

The patient was transferred out of the NTSICU to the surgical floor 10 days after his injury and underwent aggressive physical therapy. He had difficulty with gross motor function, particularly with controlling movements of his arms and legs; however, he could ambulate with moderate assistance. Short-term memory problems were apparent, but the patient was alert and oriented to person, place, and time. After a total hospital stay of just 3 weeks, the patient and his wife flew back home (Florida), where he attended an inpatient rehabilitation program. In April 2005, the patient underwent a cranioplasty, and according to his wife, he is slowly returning to the tasks he once loved. His wife noted that not only does he walk without assistance, but he also runs 1/4 mile, shops for groceries, and one day plans to teach classes in a local dental school. She is amazed by his determination and progress to date, and most of all she reports that his kind smile and laugh have returned along with his sense of humor.

Summary

TBI patients and their families experience physical and emotional devastation immediately following injury. TBI is life altering, and an MMM approach to patient care requires the participation of a vigilant bedside nurse to detect often subtle neurologic changes. Early detection and rapid intervention of these neurodynamic changes can make a difference in the development and progression of secondary injuries.

This case study demonstrates how neurocritical care management with MMM can control ICP, maximize CPP, and prevent devastating secondary injury. The use of the HUP institutional TBI algorithm in concert with a multidisciplinary approach maximizes the capability of two of the instituion's most valuable resources--the neuroscience nurse and technology--increasing the potential for an excellent outcome in the management of severe TBI.

Acknowledgments

The authors thank Patricia Blissitt, PhD RN, Eileen Maloney Wilensky, MSN RN CRNP, and Peter LeRoux, MD, for their guidance and critical review of this manuscript. In addition, special thanks are extended to the nursing staff in the NeuroTrauma Intensive Care Unit at the Hospital of the University of Pennsylvania for their dedication to the management of TBI patients.

Suggested Reading

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. (2003). Report to Congress on mild traumatic brain injury in the United States: Steps to prevent a serious public health problem, Atlanta: Author.

References

Bullock, R., Chestnut, R. M., Clifton, G., Ghajar, J., Marion, D.W., Narayan, R. K., et al. (2000). Guidelines for the management of severe head injury (2nd ed.). New York: Brain Trauma Foundation.

CDC report shows prevalence of brain injury. (1999). CNN Interactive. Retrieved July 13, 2000, from www.cnn.com/HEALTH/9904/14/ brain.injury

Centers for Disease Control and Prevention. (1996). Traumatic brain injury (TBI): Incidence and distribution. Retrieved September 2004, from www.cdc.gov

Guerrero, J. L., Thurman, D.J., & Sniezek, J. E. (2000). Emergency department visits associated with traumatic brain injury: United States, 1995-1996. Brain Injury, 14, 181-186.

Integra NeuroSciences/GMS. (2002). LICOX [product insert]. Plainsboro, NJ: Author.

Lexi-Comp Online. (n.d.). Retrieved from www.lexi.com/web/index.jsp

Questions or comments about this article may be directed to Stephanie Bloom, Department of Neurosurgery, Clinical Research Division, 3rd Floor Silverstein Building, 3400 Spruce Street, Philadelphia, PA 19104 or via e-mail to blooms@uphs.upenn.edu. She is a research nurse in the department of neurosurgery and a clinical nurse II in the neurosurgical intensive care unit at the Hospital of the University of Pennsylvania in Philadelphia, PA.

Jessica Patterson, RN BSN CCRN, is a neuroscience nurse in the neurotrauma intensive care unit at the Hospital of the University of Pennsylvania in Philadelphia, PA.

Bernadette Coyle, RN BSN CCRN, is a level III staff nurse in the neurotrauma intensive care unit at the Hospital of the University of Pennsylvania in Philadelphia, PA.

Danielle Mouradjian, RN BSN, is a level III staff nurse in the neurotrauma intensive care unit at the Hospital of the University of Pennsylvania, Philadelphia, PA.

Eileen Maloney Wilensky, RN MSN CRNP CCRN CNRN, is director of neurosurgery clinical division at the University of Pennsylvania Medical Center, in Philadelphia, PA
Table 1. Components of Brain Hypoxia Module

Module Explanation

Primary This module applies only to the comatose
evaluation head-injured patient. During this
and monitoring time a postresuscitation Glasgow
 Coma Score and neurological exam is
 recorded and performed guiding
 the direction of the management and
 treatment approach.

Brain hypoxia Used as a guideline to determine
treatment the management approach for those
 patients with a brain oxygen
 level <20 mm Hg.

ICP treatment Includes standard interventions
 aimed at maintaining an ICP <20 mm Hg.

Reevaluation Allows the neurological status of the
 patient to be reevaluated concluding
 to either continue current treatment
 regimen or ultimately withdraw care.

C-spine Used as a guideline for the management
clearance and treatment of a cervical spine
 injury.

Fluid Includes interventions aimed at
resuscitation increasing the mean
 arterial pressure to
 >80 mm Hg and CPP >60 mm Hg.
COPYRIGHT 2005 American Association of Neuroscience Nurses
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Author:Patterson, Jessica; Bloom, Stephanie A.; Coyle, Bernadette; Mouradjian, Danielle; Wilensky, Eileen M
Publication:Journal of Neuroscience Nursing
Geographic Code:1U2PA
Date:Oct 1, 2005
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