Evidence-Based Reviews

Traumatic brain injury: Choosing drugs to assist recovery

Author and Disclosure Information

Some agents can worsen neurobehavioral symptoms.


 

References

Choosing medications for patients with traumatic brain injury (TBI) requires caution; some drugs slow their recovery, and no standard post-TBI treatment exists.

As consulting psychiatrist on a TBI rehabilitation team, I am asked to manage enduring cognitive and emotional problems—aggression, apathy, learning disabilities, dementia—in patients with moderate to severe head injuries. This article describes how we apply available evidence to treat neurobehavioral symptoms in these patients.

Case: An iraq war casualty

The physical medicine and rehabilitation service asks for help in managing agitation, anxiety, and nightmares in Mr. N, age 20, a U.S. combat soldier. While on patrol 2 months ago in Iraq, he suffered a penetrating right frontoparietal brain injury from an improvised explosive device.

Mr. N has undergone a right temporoparietal craniectomy with debridement, ventriculostomy placement, and scalp flap closure. He has had seizures and then pancreatitis—thought to be caused by divalproex prescribed to treat the seizures. Divalproex was replaced with phenytoin at our hospital, and the pancreatitis resolved.

How serious an injury?

TBI ranges from self-limited concussion to devastating, permanent CNS impairment and life-long disability. Brain injuries from sudden impact—from assaults, falls, motor vehicle accidents, combat, or sports—can cause diffuse axonal injury and confusion or unconsciousness, even without radiographic evidence of cerebral bleeding, edema, or mass effect.

No hierarchy or nomenclature is universally accepted for TBI. The term “concussion” is generally used for milder injury and TBI for more-severe injuries.

Concussion. The American Academy of Neurology defines concussion as a trauma-induced alteration in mental status that may or may not involve loss of consciousness. Confusion and amnesia—the hallmarks of concussion—may occur immediately after the head trauma or several minutes later.1 This definition recognizes three concussion grades:

  • Grade 1: confusion lasts
  • Grade 2: confusion persists >15 minutes but without LOC
  • Grade 3: concussion with LOC. The confusional state is marked by disorientation, delayed verbal and motor responses, inattention, incoordination, emotional lability, and slurred or incoherent speech.
TBI. The severity of an injury with LOC is usually determined by four factors: the patient’s initial Glasgow Coma Scale (GCS) score in the emergency department (Table 1),2 neuroimaging, duration of coma, and duration of posttraumatic amnesia (PTA).
  • Mild TBI: GCS 13 to 15, LOC 1,3
  • Moderate TBI: GCS 9 to 12, LOC 30 minutes to 7 days, and PTA 24 hours to 7 days.
  • Severe TBI: GCS ≤8, LOC, and PTA >7 days,4 or any focal neuroimaging abnormalities.3
Table 1

Using Glasgow Coma Scale scores to evaluate brain injury severity

ComponentResponseScore
Best eye responseNo eye opening1
Eye opening to pain2
Eye opening to verbal command3
Eyes open spontaneously4
Best verbal responseNo verbal response1
Incomprehensible sounds2
Inappropriate words3
Confused4
Oriented5
Best motor responseNo motor response1
Extension to pain2
Flexion to pain3
Withdrawal from pain4
Localizing pain5
Obeys commands6
GCS total score ≥12 is mild injury, 9 to 11 is moderate, and ≤8 is severe (90% of patients with scores ≤8 are in a coma). Coma is defined as not opening eyes, not obeying commands, and not saying understandable words. Composite scores with eye, verbal, and motor responses (such as E3V3M5) are clinically more useful than totals.
Source: Reference 2.

Case continued: ‘They’re hurting me’

Mr. N meets criteria for severe TBI. He is periodically agitated and aggressive and refuses to return to physical therapy, complaining that rehabilitation nurses are intentionally hurting him. He occasionally hits the staff and throws things. His medications include:

  • phenytoin, 100 mg every 6 hours for seizure prophylaxis
  • lamotrigine, 50 mg bid for seizure prophylaxis
  • zolpidem, 5 mg as needed at bedtime for pain
  • methadone, 10 mg/d for pain
  • oxycodone, 5 mg every 4 hours as needed for breakthrough pain.
Mr. N’s recovery 2 months after injury is rated as Rancho level IV, indicating that he remains confused and agitated. He requires maximal assistance with bed mobility and transfers, upper and lower extremity dressing, and rolling his wheelchair with both feet. He is incontinent of bowel and bladder.

Assessing progress

For patients such as Mr. N, TBI recovery progress is measured with the Rancho Los Amigos Scale.

The original Rancho scale—developed in 1972 by staff at the Rancho Los Amigos rehabilitation hospital in Downey, CA—described eight levels of cognitive and adaptive functioning, from coma and total care through normal cognition and independence. A 1997 revised version separates the highest cognitive functioning level (VIII, purposeful, appropriate function) into three parts, expanding the scale to 10 levels (Table 2).5

Of course, not all TBI patients begin recovery at Rancho level I, and unfortunately not all achieve level X. Some experience dementia caused by head trauma, with persistent memory impairment and cognitive deficits in language, apraxia, agnosia, or executive function.6

Pages

Recommended Reading

School-Based Project Improves Girls' Coping Skills
MDedge Psychiatry
Antidepressants Raise Suicide Risk, Data Show
MDedge Psychiatry
Depression Contagion: Parents Can Affect Children
MDedge Psychiatry
Children With Anxiety, Depression More Likely to Use Ecstasy
MDedge Psychiatry
Tool Helps Spot Bipolar Prodrome in Children : Questionnaire asks patients to rate 39 symptoms that can emerge before the first manic episode.
MDedge Psychiatry
Dearth of Evidence in Guiding Tx Of Bipolar Depression in Teens
MDedge Psychiatry
Quetiapine May Help Manage Depression in Bipolar Adolescents
MDedge Psychiatry
Children Suffer Long Term When Parent Has a Stroke
MDedge Psychiatry
Olfactory Deficits May Be a Signal for Early Psychosis
MDedge Psychiatry
Lamotrigine Effective Add-On for Seizures : Adjunctive treatment reduces frequency of primary generalized tonic-clonic seizures.
MDedge Psychiatry