Opened in 2014, Mission Hospital's Neuroscience & Spine Institute stands as the premier neurosurgical facility in Orange County

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 responses.

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 accident.

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.