Caring for Patients with TBI

By: Robert Janek
Wednesday, April 29, 2015
Specialty: 

Traumatic Brain Injury (TBI) is the leading cause of death and disability in Americans aged 1 to 44. Most often resulting from falls at home, work or play, TBI accounts for 52,000 deaths each year. It also accounts for at least 5.3 million people (2 percent of the US population) currently living with disabilities.

The above statistics are from the Brain Trauma Foundation (BTF). Peter B. Letarte, MD, FACS, is a longtime member of the BTF advisory board and helped write two of its national TBI Guidelines. Board-certified in Neurosurgery and certified in Neurocritical Care, Dr. Letarte has been diagnosing, treating and teaching about TBI for the past 30 years — with the United States Navy, the National Highway Transportation and Safety Administration (NHTSA), the Veterans Administration, and Loyola University. Earlier this year, he joined Akron General Health System.

“Getting the best outcome you can in TBI really revolves around the pre-hospital care, the neuro and trauma surgery and intensive care around that, and then rehab,” Dr. Letarte says. “It all has to be done seamlessly and well. And it has to be done by people who deal with the brain every day.”

Farid Muakkassa, MD, Medical Director of Trauma Services at Akron General, agrees. With 22 years of experience as a trauma surgeon, he’s the veteran on the team he leads.

“It’s the team that makes the difference, and that team at Akron General includes board-certified trauma surgeons who are also board certified in intensive care, neurosurgeons, intensivists and neurointensivists, anesthesiologists, radiologists, interventional radiologists, rehab physicians, therapists, and specially trained nurses,” says Dr. Muakkassa.

As an American College of Surgeons (ACS) verified Level I Trauma Center, Akron General has the resources to take care of all injuries regardless of severity. According to Dr. Muakkassa, the trauma team’s capabilities to diagnose and treat head trauma — from the time of injury all the way to rehabilitation — go well beyond the ACS requirements.

Pre-hospital Management

Obtaining medical treatment within 60 minutes — aka “the golden hour” — often makes the difference for critically ill or injured patients in terms of mortality and morbidity. Emergency ground and air transport services speed delivery of patients to Akron General from 26 Ohio counties, mostly in the northeast quadrant of the state. The healthcare providers on board are all specially trained.

TBI-Dr Farid Muakkassa 250
Farid Muakkassa, MD, is Medical Director of Trauma Services at Akron General.

“We have been involved for many years in educating paramedics and EMTs about trauma life support,” says Dr. Muakkassa, pointing out that his teaching curriculum follows the BTF’s Guidelines for pre-hospital care of patients with TBI.

“I’ve done a lot of teaching on pre-hospital best practices for dealing with and protecting the injured brain. That’s what my work with Navy corpsmen involved,” says Dr. Letarte. Protecting the injured brain — and preventing it from injury — was also the focus of his research with NHTSA and the University of Pittsburgh, where he did his fellowship training in Neurotrauma.

According to BTF, following the guidelines for pre-hospital management of TBI results in correct identification of TBI, optimal treatment in the ambulance or air transport, and direct transfer to a TBI trauma center.

BTF has published in-hospital TBI guidelines, too. Their application reportedly reduces ICU length of stay, decreases death and disability by 30 to 50 percent, and increases neurological outcome upon discharge by 30 to 50 percent.

“The ‘basics’ is trauma life support,” Dr. Muakkassa explains. “BTF guidelines, which we follow at Akron General, go beyond these.”

In addition to better patient outcomes, there are cost savings, as well. According to the CDC, if all trauma centers in the United States adopted the BTF Guidelines, the projected savings would be $3.8 billion.

Trauma and Intensive Care

Once the TBI patient enters Akron General’s Trauma Center, a rapid, systematic approach to examination of the entire body, as well as neurological function, is initiated. CT scans, now recommended over X-ray by the CDC, are obtained to detect skull fractures and blood in the brain.

Based on motor responses, verbal responses and eye opening, a Glasgow Coma Scale (GCS) score is assigned. Patients with a GCS score of 13–15 are considered to have mild TBI or concussion; 9–12, moderate TBI; 3–8, severe TBI. Those with moderate to severe TBI are often taken directly from the Trauma Center to one of Akron General’s four Neuro ORs. Equipped with intra-operative MRI (iMRI) and CT (iCT), they are considered to be truly state-of-the-art.

Patients with TBI who do not need immediate surgery may be admitted to Akron General’s 10-bed Neuroscience ICU, which features a portable CT scanner and continuous EEG monitoring. A six-bed step-down unit is utilized for patients who still require frequent neurologic monitoring, but do not need ICU-level cardiopulmonary monitoring or care.

“The Neuro ORs and the Neuro ICU are fantastic,” says Dr. Letarte. “But the real advantage that Akron General has is its superb staff. The trauma team is highly trained in trauma. They are well versed in the issues, and can identify them quickly and get things going quickly. And that’s what makes the difference in outcomes.”

The majority of TBI patients — 75 to 90 percent, according to the CDC — have mild TBI or concussion. CT scans usually show no abnormalities, and symptoms may not occur for days or weeks.

“Mild TBI is difficult to diagnose,” Dr. Muakkassa says. “But if you can detect and treat it, you’re giving the patient the best possible functional outcome. That’s why we use the Montreal Cognitive Assessment (MOCA) tool administered by our occupational therapist — to examine a patient suspected of having mild TBI and determine, for example, if there’s any attention deficit, language disturbances or short-term memory loss.”

Neurorehabilitation

Both doctors agree good follow-up care is essential for patients with TBI. For those with severe disabilities, that means neurorehabilitation. And that’s where Edwin Shaw Rehabilitation Institute takes the lead. A member of Akron General Health System, Edwin Shaw is accredited by The Joint Commission and by CARF in seven inpatient and outpatient services, including brain injury programs for adults and for children.

“You’ll notice that the military and the VA have focused their resources for TBI on neurorehabilitation, because that’s where quality of life is really determined,” says Dr. Letarte.

He emphasizes that the entire continuum of care for patients with TBI, from pre-hospital to the trauma center to surgery and intensive care, is essential to limit the damage from TBI. Then rehab is of primary importance. Having a highly trained and experienced team, he points out, makes all the difference.

“The analogy I use is the Titanic. If they had closed the doors on the Titanic, it wouldn’t have sunk. But no one knew to do that,” Dr. Letarte explains. “You have to have someone who knows what to do with TBI and limit the damage and stop the devastating injuries from being worse than they need to be. But then when it’s all over, you need rehab to help people reintegrate their lives and get back to doing the most they can do. If you talk to the victims of head injury, that’s their focus for the long run.”


For more information about trauma services at Akron General, visit akrongeneral.org. To learn more about Edwin Shaw Rehabilitation Institute, visit edwinshaw.org.