Neurotrauma: Treatment, Rehabilitation, and Related Issues

Texas

Preface

As we respond to the compelling need to improve efficiency in the medical management of injured patients, we realize we must keep foremost in our thoughts that quality cannot be sacrificed for efficiency. Thus, an ongoing purpose of this series is to offer a forum for communication between the disciplines involved in the care of neurologically injured patients. This communication allows us to be better informed about broad areas of treatment of the neurologically injured and to be criticized constructively by members of our own and other disciplines. Such scrutiny can only improve patient management and facilitate a collegial approach to multifaceted problems.

The Second Houston Conference on Neurotrauma, from which this volume emanates, brought together experts from diverse backgrounds to discuss, criticize, and improve the management of neurologically injured patients. A unique focus of the conference was to enlarge the spectrum of discussion to include critically important patients who have both brain and spinal cord injuries. We will continue to emphasize information regarding acute care treatment and investigations of brain injury in the same conference in which rehabilitation strategies and approaches are discussed. This full-spectrum, multidisciplinary approach will be increasingly important to those who demand excellence in treatment regimens, because the rehabilitation process actually begins at the patient’s first medical encounter. Ultimately then, we are all rehabilitationists who specialize in small areas of the entire process.

We are indebted to Ms. Anne Brown, Mr. Randy Johnson, Dr. Daniel Morrison, and Dr. Mary Ellen Hayden of the Medical Center Del Oro Hospital, to Don Lehmkuhl of The Institute for Rehabilitation and Research, and to Dr. Dennis Kopaniky, Dr. Judy Hargadine, Ms. Gloria Horner, and Ms. Lou Esposito at The University of Texas Medical School, Houston, for their help in planning the conference and their support in the preparation of this book.

M.E.M. and K.A.W.

Introduction

Steve Bartlett

Head injury is the leading cause of death or long-term disability among trauma victims. Approximately 180 out of every 100,000 Americans sustain a traumatic head injury each year; therefore, nearly 70,000 persons annually will require long-term hospitalization and rehabilitation. Improvements in health care now keep people alive who formerly would have had little chance of survival. Just 5 years ago, fewer than 50,000 Americans survived head injury annually; 20 years ago, a fraction of that number lived to require reintegration into society. According to the National Head Injury Foundation, 2 million Americans are alive today following a severe head injury. These figures are a tribute to advances in emergency resuscitation and transportation, as well as to the growing expertise and better technology available in an ever-increasing number of trauma units.

Unfortunately, parallel advances have not occurred in our support systems or in the technology needed to make a full and productive life possible for these survivors. Health insurance coverage, access to vocational rehabilitation, availability of professionals trained in counseling and independent living skills, access to community services, compatibility of eligibility criteria under federal and state laws, development of public awareness campaigns, and family counseling are all issues that often go ignored but are vitally important to brain-injured persons. Since the incidence of traumatic brain injury is unlikely to diminish, and the number of survivors will undoubtedly increase, we are challenged to improve the services for assisting head-injured patients and their families to create the best possible life following injury. The days of nursing home care and an out of sight, out of mind attitude must end. It is time for social reform because independence for survivors benefits all of us, both economically (approximately 8% of our gross national product is spent on disability programs) and in human terms. That 84% of our disabled citizens are unemployed is a national tragedy. Fortunately, progress toward rehabilitation of brain-injured persons has been rapid in recent years, and, with assistance, independent living and employment may be obtainable objectives. To achieve independence for these individuals is a goal we must set for the next decade.

A number of worthwhile efforts are already under way. The National Council on the Handicapped is reviewing federal legislation to identify disincentives that limit or prevent the employment and independence of disabled persons. Currently the council is reviewing legislation related to disincentives to employment, housing, transportation, and attendant care.

The National Advisory Board on Technology and the Disabled, established by the Secretary of Health and Human Services, is looking to identify constraints on the transfer of technologies to assist the disabled, to identify areas of needed research, to increase public awareness of the need for and use of technologies to aid the disabled, and to identify technical assistance models.

In terms of federal policy, our chief legislative goal should be to remove from federal laws any disincentives to work. These laws too often contribute to the problem and not to a solution. Many persons with disabilities who could work, indeed who want to work, cannot do so because they are unable to get medical insurance because of a preexisting health condition.

Congressional response to the needs of head-injured and other disabled persons is fragmented, but is moving in the proper direction. The Employment Opportunities for Disabled Americans Act (P.L. 99-643) made important reforms in an existing program, Section 1619 of the Social Security Act. Section 1619 allows a disabled person who receives Supplemental Security Income (SSI) benefits to earn over $300 a month and remain eligible for medical coverage through Medicaid. The individual may lose federal cash assistance as his or her income increases but will retain the important medical coverage. The reforms in this law removed a significant disincentive to the increased employment of disabled persons.

Reintegration of disabled persons into the community, besides being humane, is most cost effective than placing them in institutions, and national policy is moving toward that goal. Rather than distinguishing between whether or not persons are in an institution, a group home, or their own home in determining eligibility for federal assistance, Congress is now considering a different approach. The concept of the money follows the client is becoming increasingly popular, so the government would not have a bias—the individual could receive assistance to live in the environment best suitable.

Providing increased opportunities for productive work by disabled persons should continue to be a primary goal of federal policy. During the 99th Congress, I was successful in including supported employment as an acceptable outcome of rehabilitation services under the Rehabilitation Act.

Congress should continue to review existing federal laws which provide disincentives to growth and opportunity for disabled persons, and revise them, while also looking for new ideas and concepts to encourage success.

The past five years have seen a change in attitude in the United States toward brain-injured individuals—a positive acceptance of survivors for what they can do. A man in Lubbock, Texas, summed it up in Psychology Today when he observed: Instead of saying these people can’t learn, we now say we haven’t been competent to teach. The fault is not with the severely handicapped, but with us. All of us have a role to play in the care of head-injured persons, and we must work to see that legislative endeavors keep pace with their needs.

I

ACUTE TREATMENT OF BRAIN INJURY

Outline

Chapter 1: Introduction to Acute Treatment of Brain Injury

Chapter 2: Less-Than-Severe Head Injury: Pathology and Outcome

Chapter 3: Protective Effect of Facial Fractures on Closed Head Injuries

Chapter 4: Barbiturate Coma: The Richmond Experience

Chapter 5: Cerebral Protection with Barbiturate-Induced Coma in the Treatment of Severely Brain-Injured Patients

Introduction to Acute Treatment of Brain Injury

Michael E. Miner

Over the past decade, the standard of care for patients with severe brain injuries has become much better defined. Routine monitoring now includes intracranial pressure measurement, well-defined ventilatory support, and increasing scrutiny of cardiovascular function. This has allowed an increase in survival rate that is still improving, in no small measure because the secondary systemic effects of brain injury are better treated. Pneumonia, nutrition, and cardiovascular function are better dealt with today, but brain swelling, ischemia, and intracranial hypertension continue as major problems. Recently, the use of drugs that protect the brain from the secondary effects of injury has been increasingly explored. A very real controversy has developed regarding the role of barbiturates in the treatment of brain injuries. Ward and Becker (Chapter 3), who have made so many important contributions to the care of brain-injured patients, report on their silver bullet approach to the use of barbiturates. They studied the effect of barbiturates on patient outcome when they were given to all patients with severe brain injuries. They found no effect, either beneficial or detrimental. This is a landmark study because it must lead us to believe that it is doubtful whether any single new treatment is going drastically to alter survival after severe brain injury. Instead, we will need to individualize each patient’s care. The contrasting chapter (Miner, Chapter 4) describes a regimen in which barbiturates are used to treat high intracranial pressure after other treatment programs have failed to control intracranial hypertension completely. This is a more specific effect of barbiturates and may be more in line with the concept of individualizing patient care. The complications of high dose barbiturates are also stressed, and both chapters emphasize that the management of these severely brain-injured patients must be performed in a center that works with these patients on a daily basis and has all the facilities available full-time to meet their many needs.

Data from the University of Virginia, reported by Jane (Chapter 1), have greatly benefited the understanding of mild brain injury. Jane and his colleagues have studied the neurologic, psychologic, histologic, and sociologic effects of mild brain injury. Before their work, the clinical course of patients with mild brain injuries was ill defined and often confusing. Jane and his colleagues have defined these patients’ injuries anatomically as well as functionally. Their chapter is of great value in bringing all their data together and placing them in perspective with regard to brain injuries.

Many patients with brain injuries have associated facial fractures. Lee and his colleagues (Chapter 2) have studied these patients from the point of view of their cerebral computerized tomography (CT) scans and neurological examination and have made several interesting observations. Most important, their data support the notion that fractures of the lower portion of the face seem to be protective of the brain. Similarly, fractures of the upper portion of the face are associated with greater injuries to the brain. These data have real implications for automobile design and perhaps the design of protective helmets.

This section is important because it addresses controversies occurring in the clinical care of acutely brain-injured patients, an in-depth analysis of mild brain injuries, and novel information regarding the relationship between facial fractures and brain injury.

Chapter 1

Less-Than-Severe Head Injury: Pathology and Outcome

Austin R.T. Colohan, John A. Jane, Wayne M. Alves and Rebecca W. Rimel

Publisher Summary

The study of patients with less-than-severe head injuries may be a useful model to understand the pathophysiology of head injury. Head injury is one of the greatest health care concerns in the western world. The Glasgow Coma Scale (GCS) has been widely accepted as a means of judging the severity of head injury. Less-than-severe head injuries are a part of the spectrum of mechanically induced damage to the CNS with the basic pathological process being axonal disruption. The experimental pathology of minor head injury in the Philadelphia head injury model relates exclusively to damaged axons seen in the brain stem. Recovery following head injury may involve the recovery of function of damaged neurons by sprouting or the functional use of alternative neural pathways. As understanding of neuronal plasticity and regenerative responses to injury improves with time, the goal of intervention to restore function to damaged neural tissue becomes more attainable.

Head injury is one of the greatest health care concerns in the Western world. The incidence of serious head injuries has been estimated at approximately 2 million per year in the United States alone [1,2]. While head injury is the diagnosis for 400,000 admissions to hospitals annually in the United States [3], estimates suggest that 75–90% are for less-than-severe head injury [4,5]. The Glasgow Coma Scale (GCS) has been widely accepted as a means of judging the severity of head injury [6]. The GCS is a 13-point scale for assessing level of consciousness utilizing three components: eye opening, motor response, and verbal behavior. We have previously defined GCS 3 through 8 as severe head injuries, 9 to 12 as moderate head injuries, and 13 to 15 as minor head injuries [7,8]. This chapter is concerned with the pathology and outcome of moderate and minor head injuries.

The vast majority of head injuries in the United States fall into the less-than-severe category (GCS of 8 or less) [4,5]. A previous analysis of the Charlottesville experience with 1,248 consecutive patients admitted to the University of Virginia with a diagnosis of head injury revealed that 21% had an admission GCS of 8 or less, 24% had a GCS between 9 and 12, and 55% had a GCS of 13 to 15 [7]. Therefore, if our experience is typical, the contribution of less-than-severe injury to the overall problem becomes