Neurocritical Care In Head Injury

Traumatic brain injury (TBI)

when moderate to severe, may often require emergency surgery, blood transfusion and prompt treatment of complications. Up to 40% of head injury patients are in the age group of 21-45 years. With immediate and optimal neurocritical care facilities, favourable outcomes such as improved survival rates and reduced disability can be achieved. Good neuro-rehabilitation is key to successful recovery after any head injury. The goals of neurocritical care crucial for patients with TBI are several, all of which are aimed at prevention of secondary insult to the brain. Protection of airway and breathing. Respiratory care, prevention and treatment of aspiration due to poor consciousness, pneumonia and other issues needs great care and vigilance. The patient’s may require insertion of a breathing tube and ventilator which will protect the lungs and also help in reducing the pressure in the brain. Those recovering over longer periods may require a tracheostomy, a tube inserted in front of the neck into the windpipe (frequently done under anesthesia as a bedside procedure in the ICU), which is usually temporary. Blood pressure and heart function. These have to be maintained, sometimes with additional medications and intravenous fluids. Electrolytes and urine production are often deranged and need to be corrected. Pain relief and sedation. Headache or pain due to other injuries such as fractures should be addressed immediately and adequately. Restlessness due to the brain injury or pain should be controlled to prevent self harm and provide effective critical care. Nutrition. Feeds have to be started at the earliest to ensure continued gut function even when the patient is critically ill. This is the safest way to preserve gut health, prevent malnutrition and fight infection. Nutrition is provided via tube feeds directly into the stomach when patients are unable to swallow food. Those with swallowing difficulties undergo intensive swallow and speech therapy until they are no longer dependent on tube feeds for nutrition. Intravenous nutrition is reserved for those patients whose gut health does not permit digestion or absorption. Prevention of infection. Immunity takes a hit during critical illness. TBI patients often have many invasive tubes in their body that puts them at risk for various infections like pneumonia, meningitis, bloodstream infections, urinary tract infections, abdominal infections and skin or soft tissue infections. Specific ICU protocols are in place to prevent and treat each of these conditions. Prevention of Ulcers. Stress and medications frequently can lead to erosions or ulcers due to acidity in the stomach. Prevention and early identification of these are a part of neurocritical care practice. Prevention of thromboembolism. Patients who remain immobile and bed-bound for more than a few days may develop blood clots in the veins of the body, commonly the leg veins, which sometimes lead to painful swollen legs or sudden spread of the clots to the heart and cause heart failure which can be fatal if not identified and treated early. For prevention of the formation of these clots, special inflatable sleeves attached to a pressure pump are wrapped around the patient’s legs to promote continuous blood circulation. Once the risk of neurosurgical bleeding is no longer present, blood thinner injections are started for prevention of clot formation that may be converted to tablets in case of long term immobilization. Early mobilisation and physiotherapy. These help in prevention of pressure injuries (bed sores), chest infection and joint contractures. Early mobilisation also helps improve the state of consciousness with more sensory stimulation. Psychosocial support for the family and the patient. Neurointensivists are sensitive to the emotional state of the patients’ families and often provide the necessary support, confidence, resources and guidance on how they need to deal with the challenging circumstances they are faced with. Families need to rebuild their lives and restructure their routines to fit in the needs of their loved ones recovering from TBI. Hand-holding during this crucial phase has helped many families emerge victorious on the other side of this mishap that sometimes causes irreparable damage. Here at People Tree Institute of Neurosciences, patients are at the centre of the neurocritical care programme that begins as soon as the patient enters the emergency room, continues through the emergency surgery, into the neurocritical care unit and transitions into the long term acute care (LTAC) and neuro-rehabilitation programmes. As more and more patients benefit from these efforts, the motivation to do more as a team has grown stronger.