Medical Management of Acquired Brain Injury

Medical Management of Acquired Brain Injury

Introduction to Acquired Brain Injury

  • Acquired brain injury refers to conditions such as strokes.

  • The presentation aims to discuss both the medical management and pathophysiology of acquired brain injuries.

Goals of Medical Management

  • General Plan: Control, maintain, and restore acute medical health of the patient.

  • Improving Cerebral Perfusion: Re-establishing circulation as necessary is key to recovery.

Oxygen Administration

  • Oxygen may be administered in two ways:

    • Nasal Cannula: A common method for mild support.

    • Mechanical Ventilation: Such as intubation for severe cases.

Medication Administration

  • Tissue Plasminogen Activator (TPA):

    • Described as a “clot buster” used in cases of ischemic strokes.

    • The use of TPA is time-sensitive, effective within 3 to 4.5 hours post-stroke.

Blood Pressure Management

  • Maintaining Blood Pressure and CO2 Levels:

    • Antihypertensive agents may be administered.

    • Permissive Hypertension: Refers to the practice of potentially reducing antihypertensive medications immediately after a stroke, based on patient circumstances.

    • 2013 AHA Guidelines: The ideal blood pressure range is dependent on specific patient conditions.

    • If eligible for TPA:

      • Systolic < 185 mmHg

      • Diastolic < 110 mmHg

    • For patients not receiving thrombolytics:

      • Withhold antihypertensive treatment unless systolic BP > 220 mmHg or diastolic BP > 120 mmHg.

Restoring Homeostasis Post-Stroke

  • Electrolyte and Glucose Management:

    • Important to maintain appropriate electrolyte levels via IV.

    • Blood glucose levels must also be monitored.

  • Stabilization of Edema and Intracranial Pressure:

    • Necessary to avoid detrimental impacts on recovery.

    • Ventriculostomy (VP Shunt):

    • A procedure to drain excess fluid and relieve pressure on cerebral structures.

Management of Complications

  • Seizures: Must be actively managed in the acute post-stroke phase.

  • Infections: Careful monitoring for associated medical factors is necessary.

  • Integumentary System Maintenance:

    • Preventing pressure injuries due to immobility is crucial.

    • Encouragement of movement via physical therapy helps preserve muscle mass and improve cardiovascular health.

    • Bowel and Bladder Function:

    • Initiating movement can assist in proper bowel and bladder function through gravitational aid.

    • Structured bowel and bladder programs may be enacted.

Complications Following Stroke

  • Common complications include:

    • Deep Vein Thrombosis (DVT)

    • Pulmonary Emboli

    • Aspiration

  • Prothrombin Time International Normalized Ratio (PTINR):

    • Measures blood clotting time.

    • A low PTINR = faster clotting; high PTINR = slower clotting.

    • Optimal PTINR levels are determined by the stroke type (ischemic stroke considerations).

Pharmacological Interventions Post-Stroke

  • Thrombolytics:

    • TPA is essential for ischemic strokes within critical time frames but has risks such as bleeding.

  • Anticoagulants:

    • Medications like Warfarin (Coumadin) and Heparin to prevent clot enlargement and new clots.

  • Antiplatelet Therapy:

    • Medications such as Aspirin and Plavix to reduce thrombus formation.

  • Antihypertensive Agents:

    • Includes ACE inhibitors, beta blockers (ending in "-olol"), and diuretics for blood pressure control.

    • Angiotensin II Receptor Agonists: Also assist in controlling blood pressure.

  • Anticholesterol Agents:

    • Statins: Medications like atorvastatin to reduce cholesterol levels and lower stroke risk.

  • Antispasmodics and Antispastics:

    • Antispasmodics (e.g., Flexeril, Diazepam) address muscle spasms.

    • Antispastics such as Baclofen target spasticity post-stroke.

  • Anticonvulsants:

    • Agents like Tegretol, Klonopin, and Phenobarbital for seizure management.

  • Antidepressants:

    • Examples include Prozac and Zoloft.

  • Neurotoxins:

    • Botox used locally to reduce spasticity.

Surgical Interventions for Stroke Management

  • Mechanical Thrombectomy:

    • Surgical removal of large clots within 6 hours of an ischemic stroke; must follow TPA administration.

  • Carotid Endarterectomy:

    • Performed in chronic stages to remove fatty build-up in carotid arteries to reduce risk of future strokes.

  • Management of Hemorrhagic Strokes:

    • Imaging to identify aneurysms; potential interventions such as:

    • Aneurysm Coiling: Tying off or coiling an aneurysm to prevent rebleeding.

    • Resection: Surgery might be needed for at-risk arteriovenous malformations.

Conclusion

  • Post-stroke medical management focuses on:

    • Improving vascular perfusion.

    • Controlling complicating factors (edema, intracranial pressure).

    • Maintaining homeostasis (electrolyte balance, bowel and bladder function).

    • Utilization of pharmacological agents and potential surgical interventions based on individual circumstances.