Second edition

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intoxication is a very common factor, being found in from
one-third to one-half of all cases (Corrigan 1995). Although
multiple forms of brain injury may occur, this syndrome
refers primarily to cases occurring with sudden ‘acceleration–deceleration’,
as during a motor vehicle accident or a
fall or blow to the head; trauma due to gunshot wounds and
crush injuries are not considered here. This chapter will discuss
the clinical features and treatment of the various
aspects of traumatic brain injury, the etiology of these clinical
features, and the differential diagnosis between traumatic
brain injury and concussion.
Clinical features and treatments
In considering the clinical features (and their treatments)
of traumatic brain injury, it is convenient to divide them
into two groups, namely an acute phase and a chronic phase.
The acute phase, from a neuropsychiatric point of view, is
often dominated by a delirium; as the confusion clears,
patients gradually enter into the chronic phase, which in
turn may be characterized by numerous sequelae, including
cognitive deficits that may, at times, be severe enough
to constitute a dementia.
ACUTE PHASE
Almost all patients with significant traumatic brain injury
will sustain a loss of consciousness, of variable duration,
immediately after the injury. Those who do survive will
typically emerge into a delirium. This delirium, in addition
to such characteristic symptoms as confusion, disorientation,
and decreased short-term memory, is also often
marked by hallucinations, delusions, and, especially, agitation,
which is seen in the majority of cases (Rao and
Lyketsos 2000; van der Naalt et al. 2000).
It must be borne in mind that although the delirium in
such cases is generally due to the intracranial injuries directly
caused by the trauma, that other factors, as discussed in
Section 5.3, may also be involved as the hospitalization proceeds.
Toxicity from such medications as opioids, baclofen,
anticholinergics, metoclopramide, and even amantadine
must be considered, along with metabolic factors, such as
hyponatremia, hypoglycemia, hypomagnesemia, and systemic
effects of infections, such as pneumonia. Other metabolic
factors to consider relate to the frequency with which alcoholism
is involved, and include Wernicke’s encephalopathy
due to thiamine deficiency and delirium tremens. Consideration
may also be given to the effects of global cerebral
ischemia secondary to severe hypotension and, in those with
fractures of long bones, to the fat embolism syndrome.
Treatment of patients during the acute phase is, at least
initially, generally undertaken in either a trauma unit or an
ICU. Neurosurgical treatment may be required for evacuation
of epidural or subdural hematomas or large contusions
or intracerebral hemorrhages, and serial CT scans
are obtained. In comatose patients, intracranial pressure
7.5 Traumatic brain injury 289
monitoring is often indicated, and treatment with intravenous
sedation, mannitol, and other agents may be
required to reduce pressure. Intubation is often required,
and pneumonia is a frequent occurrence.
Treatment of delirium, in all cases, involves simple environmental
measures designed to reduce confusion. These
include, whenever possible, having the patient in a quiet
room, with a window. Large calendars and digital clocks
should be in full view, and the nurse’s call button should be
readily available. Sleep is essential and consequently the
room should be darkened and very quiet at night, and all
non-emergency procedures (e.g., vital signs, weights, baths,
laboratory testing) should be forbidden during the sleeping
hours. Restraints may occasionally be required and can be
life-saving. For patients prone to get out of bed unsupervised,
keeping the bedrails up may be sufficient; if not, or if
these are impractical, utilizing a ‘low-boy’ bed, surrounded
by mats, may help prevent injury. In some cases, roundthe-clock
sitters may be required.
In cases where these environmental measures are ineffective,
pharmacologic treatment may be considered with either
an antipsychotic or, in certain emergent cases, lorazepam.
Antipsychotics are indicated for treatment of hallucinations
or delusions, and are also effective for agitation. A secondgeneration
agent, such as risperidone, is often used, and, in
practice quetiapine and olanzapine are also utilized. Initial
doses should generally be low, for example 0.5–1 mg of
risperidone, 12.5–25 mg of quetiapine, and 2.5–5 mg of olanzapine.
The first-generation agent haloperidol is also often
used, with initial doses of 2–5 mg. Repeat doses, in approximately
similar milligram amounts, may then be given every
hour or so until the patient is calm, limiting side-effects
occur, or a maximum dose is reached: rough guidelines for
dose maxima are 5 mg for risperidone, 150 mg for quetiapine,
20 mg for olanzapine, and 20 mg for haloperidol. In
cases when the patient responds satisfactorily, a regular daily
dose is ordered for the next day (with the total daily dose
approximately equivalent to the total required initially),
divided into two or three doses. Provision is also made for
further as-needed doses, with the total daily dose being
adjusted according to the amount needed in p.r.n. doses. The
eventual maintenance dose is then continued until the
patient has been stable for a significant period of time, at
which point it may be gradually tapered. Lorazepam is very
commonly used, and given the rapidity of its effectiveness
when given intravenously, has a place in emergent situations;
however, given that lorazepam may also worsen confusion, it
is appropriate to substitute another agent as soon as this is
practical. If lorazepam is used, one may give anywhere from
0.5 to 2 mg i.v. every hour as needed until the patient is calm,
limiting side-effects (such as sedation) occur, or a maximum
of approximately 12 mg is reached.
Once patients have been stabilized, general rehabilitation
efforts may be started, including physical, speech, and
occupational therapy. Eventually, most patients are transferred
to a specialized rehabilitation facility, where these
general efforts are continued.