Traumatic Brain Injury

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This week’s article I will be discussing Traumatic Brain Injury. It isn’t as popular or common as diabetes or high blood pressure, but it is definitely more debilitating and life altering if you experience it. Most traumatic brain injuries fall within one of four categories: concussion, brain contusion, penetrating brain injury or anoxic brain injury. Before we jump into the topic let me explain my fascination with trauma and particularly traumatic brain injury.

While I was completing my final year of pharmacy school in Memphis, I had the opportunity to spend one month in the Trauma Unit at the Med (now Regional One Medical Center) in Memphis. At that time, it was the only level one trauma unit in the Southeast region meaning that it had its own dedicated surgical suites, lab, rooms, one to one nurse ratio, and its own pharmacist to closely and quickly monitor/change drug dosages depending upon the patient’s condition. Out of all of my rotations, this was the one I loved the most. I loved the fast pace environment, the rapidly changing patients, and the ability to literally save a person’s life with my knowledge. Most disease states are slow, like diabetes. It can take years, decades even to see the result of an intervention such as a dietary or medication change, but with trauma, the result is almost immediate. Either your patient is dead, or he/she will live to see another minute.

 As a student in this fast pace environment I arrived to the trauma unit around 430 am each morning. I was expected, as the medical students were, to catch up on any changes that had occurred during the night with my patient, brief the resident on those changes and make recommendations if needed. The resident usually arrived an hour after the students and the attending usually arrived an hour or two after that so that we would round as a group on each patient by 7:30 or 8am each morning. During rounds questions were lobbed at us like direct missiles. Either we diffused them mid air or they took us out and we were resolved to the cafeteria for most of the remaining hours playing catch up on the newest studies and literature available to treat our patients. The head trauma patients were certainly the most interesting of all our patients because while the initial trauma usually involved a concussion (head hitting a windshield) or a penetrating brain injury (gunshot wound), the secondary brain injury was usually the result of an anoxic event(the brain didn’t get enough oxygen).  A delicate equation existed in the trauma unit CPP=MAP-ICP. Cerebral Perfusion Pressure= Mean Arterial Pressure minus Intracranial Pressure. In other words the more oxygen your brain got depended upon how high we could push your blood pressure and how low could we keep your intra cranial pressure. As a pharmacy student, it was my role to try to keep that equation balanced with medication and within the confines of the hospital formulary (ie as cheap as possible because most of our patients did not have insurance). 

I quickly became a big fan of hypertonic saline..that is basically a super salty IV solution that would pull fluid off the brain while raising blood pressure. It was cheap, it was effective, and it was readily available, unlike some of the other medications. Almost every head trauma patient I saw that month was given at least one bag of hypertonic saline to minimize the secondary anoxic brain injury. One patient that had stayed with me that month was a female that was just a couple of years younger than me. She was an undergraduate student at Mississippi State University in Starkville when she and some sorority sisters were out riding the back roads of Mississippi at midnight when the car they were driving struck a cow in the road. She was ejected from the car and landed in a nearby field. The other occupants had much less severe injuries and were treated and released from the trauma unit. She was unfortunate though. The team I was on started her immediately on the hypertonic saline solution. She had several lacerations to her body and internal bleeding. Her first couple of days in the trauma unit was mostly spent in surgery to repair lacerations to her vital organs. Once she had made it through those surgeries it was time to concentrate on her closed head injury (her head had obviously hit to windshield and the ground at a tremendous speed and force which caused her brain to collide with her skull resulting in a concussion first, then a contusion, then and anoxic brain injury from the swelling). While the team did all we could to lower the pressure inside her skull we knew that with time the brain cells that weren’t receiving oxygen would die off and she might never be the same.  We kept that equation at the top of her white board in her room and monitored it every 15 minutes. Her family and friends helped with her healing process by placing pictures, playing music, and surrounding her with familiar smells (her favorite perfume). All of those things truly helped in her recovery by stimulating different parts of the brain.

During my last shift in the Trauma Unit, my patient that I had worked so hard to save was finally able to breathe on her own. She couldn’t walk, but she could point towards specific objects, recognize faces, and move her upper body on command. I followed up on her until my graduation seven months later and she had been moved to a rehabilitation center, then home, then back to a rehabilitation center. She was certainly lucky to be alive, but would never again be the vibrant young woman she once was. I like to think that she finished college and is doing great, but honestly I don’t know. Traumatic brain injuries have a way of affecting the rest of your life. No matter how far in time you get away from it, the effects still linger in either an altered speech or funny walk. The best we can all do is try to prevent the injury from happening by wearing our seatbelt or wearing a helmet if riding a bike or motorcycle. Luckily, physical therapy and occupational therapy can help you attain a new normal. I sure hope that was the case with my patient!

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