Traumatic Brain Injury (TBI) – Mission Protocols
Mission Hospital’s traumatic brain injury protocol uses the latest
in technology and medications for the treatment of traumatic brain injury.
Our TBI protocol is based on recommendations from the Brain Trauma Foundation
(BTF). The team uses the latest tools to monitor brain pressure and oxygen
in the brain, heart pressure, and oxygen levels in the whole body. The
goal is to keep the brain as quiet as possible and to control the swelling
that happens after brain injury.
Mission Hospital’s TBI protocol is typically initiated by the trauma
team. First, the team makes sure the patient is getting enough oxygen
through a breathing tube. The oxygen and carbon dioxide levels will be
watched closely and the respiratory therapist and nurse will make changes
on the breathing machine. The neurosurgeon (brain doctor) may place an
Intracranial Pressure (ICP) monitor inside the brain to monitor pressures.
The neurosurgeon may also place a tiny catheter into the brain tissue
to measure the oxygen in the brain tissues. If there is a need to remove
a blood clot from the brain or remove the bone temporarily to relieve
pressure, the neurosurgeon would do this in the operating room.
The goal of the team is to heal the brain. Giving the patient drugs to
put his brain to sleep will help in controlling the pressure inside the
brain. This is known as a drug induced coma. The goal is to quiet the
brain and keep the pressure and oxygen need in a specific range. Commonly
used drugs for these patients include Fentanyl for pain, Versed for keeping
the patient asleep, and Propofol for controlling brain pressure and/or
brain oxygen levels. A drug called Mannitol or a salt solution may also
be used to reduce swelling in the brain. The body commonly responds to
this medication by producing a larger amount of urine. The nurses will
give fluids to replace these lost fluids.
One very important part of the protocol is keeping the blood pressure higher
than normal. The higher pressure helps supply blood to the injured brain.
The team may discuss the mean arterial pressure or the cerebral perfusion
pressure. These pressures are related to the blood pressure and are very
important to monitor. The nurse will be doing calculations with the vital
sign information to monitor the patient’s progress. The nurse, doctor,
and pharmacist will discuss the amount of fluids to be given based on
the heart pressures. Other drugs may be given to raise the blood pressure,
such as norepinephrine and phenylephrine. The nurse will monitor the response
to these drugs and increase or decrease the medication based on the body’s
Monitoring the patient’s temperature is also an important part of
their care. The nurse will work to keep the body temperature slightly
below normal (98.6oF). This colder temperature helps to protect the brain and help in letting it rest.
Due to the severe injury to the brain, the patient may have lung problems.
A pulmonologist critical care doctor (a doctor specializing in the care
of the lungs) may be consulted to help the team care for the patient.
The pulmonologist will be most focused on managing problems of the lungs.
Most of the time, the lung problems happen within five to seven days after
The TBI protocol uses the team’s skills/knowledge, equipment, medications
and fluids to keep the patient’s pressure inside the head and his
oxygen level within normal limits. A majority of the time, the team is
successful in controlling the pressure and keeping the oxygen levels normal.
Over 60 percent1 of Mission Hospital’s TBI patients survive their injury and have
a good outcome or are moderately disabled. There are cases when nothing
that is done by the team can control the effects of the initial brain
injury. In a few cases, the extent of the injury is such that the patient
may have permanent and severe brain damage, or die from their injuries.
Awakening from a severe TBI and rehabilitation is an important process
in helping these patients recover.
Waking Up from Brain Injury: Emerging from Coma
When patients with severe TBI awaken, it is a very slow process. There
are tools that help the team and family to determine how the person is
waking up and what needs to be done to help them recover.
It is natural for family and friends to want to help the person recover
from their injuries. Individual differences will affect the rate and amount
of recovery. Each person will progress at their own rate, depending on
how bad the injury was, what part of the brain was injured and the length
of time since injury. The Rancho Scale of Cognitive Functioning describes
a common course of recovery. Some people will go through each of the levels,
some may move back and forth between 2-3 different levels in the course
of a day, while others may progress to a certain level and stay there. Click
here for some suggestions for family and friends to follow that match each
of the “Rancho” levels.
Specialized therapists work with patients to determine what has been injured
in the brain and how it affects the person’s ability to live and
be independent. Occupational Therapists (OT), Speech Language Pathologists
(SLP) and Physical Therapists (PT) provide care that will help the patient
to improve their ability to use their muscles and prepare them for more
intense rehabilitation. They assist with daily activities like eating,
sitting and walking. OT focuses on activities of daily living and upper
extremity (arms) movements. PT focuses on walking and leg strength as
well as safety in moving. SLP focuses on swallowing abilities and cognitive
abilities (thinking, math skills, judgment, affect, etc). Mission Hospital’s
rehabilitation team includes a specialized doctor in rehabilitation known
as a physiatrist. The physiatrist will see the patient and work with the
therapy team to provide direction on the rehabilitation needs. When the
patient no longer needs to stay in the acute care hospital, a case manager
and rehabilitation team will determine how much activity the patient can
participate in their recovery and work with the family on the next steps
of caring for the patient. There are many choices for care after being
discharge from the hospital including acute rehabilitation units, sub-acute
hospitals, long term care facilities, skilled nursing facilities and possibly home.
1. Palmer S., Bader MK, Qureshi A, Palmer J, Shaver T, Borzatta M, and
Stalcup C. The Impact of using the traumatic brain injury guidelines on
outcomes in a community trauma center.
Journal of Trauma 2001. 50: 657-664.