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Initial Rehabilitation Interventions in the Acute Hospital Setting and Transitioning to the Next Level of Care

Brian D. Greenwald and Christine Greiss

INTRODUCTION

Moderate-to-severe traumatic brain injury (TBI) carries an overall mortality of 20% to 50% with 85% of those deaths occurring within the first 2 weeks of injury [1,2]. For those who survive, significant risk of disability remains. Initial TBI treatment goals are focused on decreasing its significant mortality and prevention of negative sequelae and disability.

Initial rehabilitation interventions in the acute hospital setting involve shifting focus from life-saving measures and medical stabilization to optimization of the medical milieu in the context of central nervous system (CNS) recovery and preservation or restoration of function. One mechanism to achieve neuroprotection is through pharmacological management, employing medications that are thought to promote neuro-recovery and minimize neural depression. Optimal trauma care should include rehabilitation considerations from the first day of injury on [3]. A physiatrist may be actively involved in more specialized treatment including evaluating and treating disorders of consciousness, arousal, attention, memory, executive function, and agitation [3]. Early rehabilitation or physiatry consultation and formal intervention programs are associated with decreased acute hospital length of stay and improved functional outcomes [3]. The following topic areas represent commonly encountered acute hospital considerations for patients with TBI.

AGITATION

•   Agitation occurs in 33% to 50% of moderate-to-severe TBI patients at some point during the acute hospital course [4–6].

        Search for the cause of agitation, which may include seizures, pain, hypoxia, recent medication changes, or infection.

        Implement environmental modifications—lower lights, turn off TV and radio, decrease visitations, and/or number of visitors in the room.

        Minimize use of restraints because they can increase agitation and cause harm.

        Pharmacological treatment should be kept to a minimum; use the lowest dose possible to address symptoms, and taper as tolerated (see also Chapters 36 and 37) [5,7].

             For restlessness, consider trazodone, carbamazepine, or valproate [7].

             For aggression, consider beta-blockers (metoprolol and other beta selective agents are preferred) or valproate [7,8].

             For emotional lability, consider selective serotonin reuptake inhibitors, dextromethorphan/quinidine, or valproate [7].

             To manage psychotic features, consider quetiapine, risperidone, olanzapine, or other atypical antipsychotics. Typical neuroleptics should be avoided owing to dopamine blockade [5].

             Use of Ativan or other benzodiazepines should be discouraged to the extent possible, because not only do they cause sedation and amnesia, they are associated with risk of paradoxical agitation and delay cognitive recovery by causing adverse effects on neuroplasticity [5].

CONTRACTURES AND SPASTICITY (see also Chapter 51)

•   The first stage of treatment involves aggressive range of motion, stretching, and exercise [10]. Initial interventions should be initiated in the intensive care unit. Repeatedly reassess and modify approach as warranted based on evolving clinical condition.

•   Treatment should be geared toward functional improvement and pain relief.

•   Splinting or serial casting of extremities should be considered whenever appropriate.

•   Pharmacological therapies (e.g., dantrolene, baclofen) may be considered. Close patient monitoring is required, because tone-lowering medications can have negative effects on cognition.

NUTRITION/SWALLOWING STATUS (see also Chapter 26)

•   TBI results in catecholamine excess acutely, leading to hypermetabolism, increased energy expenditure, and increased protein loss; as a result, TBI patients have increased caloric requirements [10–13].

•   Early nutritional support decreases morbidity and mortality, shortens hospital length of stay, and may decrease disability [10].

•   Brain Trauma Foundation (BTF) Guidelines for the Management of Severe TBI recommend that patient’s feeding requirements be met by the first week after TBI [11].

•   Swallow mechanism may be impaired in up to 82% of TBI patients [14]. Note that 12% of patients with swallowing disorders may have normal gag reflex and 77% have good voluntary cough reflex [15].

•   TBI patients may have impaired gastric emptying secondary to vagus nerve damage, elevated levels of endogenous opioids, or use of medications such as narcotics.

        If using enteral nutrition, check feeding residuals periodically.

        Promotility agents such as erythromycin may be considered.

        Metoclopramide should be used sparingly if at all because of its dopamine antagonist activity.

BOWEL AND BLADDER (see also Chapter 30)

•   Injury to frontal lobes can cause loss of cortical control over bowel and bladder.

•   Incidence of urinary incontinence is 62% [16] and that of urinary retention is 9% [10]. Note associated increased risk of urinary tract infection and skin ulcer development.

        Urinary incontinence treatment options include timed voiding programs and use of anticholinergic agents; close monitoring is required because of potentially negative effects on cognition.

        Urinary retention treatment may include intermittent catheterization or Foley catheter placement.

•   Constipation can also be present secondary to immobility and medications.

        Bowel treatment options include use of a timed bowel program, fiber supplementation, maintenance of adequate hydration, and selected medication use (e.g., stool softeners, stimulant suppositories).

PAIN (see also Chapter 38)

Pain is a common cause of agitation; evaluating for etiology may be difficult due to patient confusion or decreased consciousness.

Related posts:

Selected Somatic Disorders Associated With Mild Traumatic Brain Injury: Fatigue, Dizziness and Balance Impairment, and Whiplash Injury Heterotopic Ossification Resources for Traumatic Brain Injury Survivors and Caregivers Ethical Considerations Complementary and Alternative Medicine in Traumatic Brain Injury Developing a Life Care Plan

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