Helping a patient recover from severe traumatic brain injury
Following a car accident, an 18-year-old man from Virginia was flown to Duke with polytrauma, including severe traumatic brain injury (TBI). He was immediately admitted to the neuro-ICU because his other injuries—rib fractures, hemopneumothorax, and pelvic fractures—were not as significant as his TBI.
For the first several days, Duke neurologists and neurosurgeons worked together to control the pressure and swelling in his head using mannitol and hypertonic saline. When the swelling persisted, the team administered pentobarbital to induce coma. To prepare him for the recovery process, he also underwent tracheostomy, and a feeding tube was inserted.
After 12 days, the swelling had resolved enough for the patient to be taken out of a coma. But he soon developed severe paroxysmal sympathetic hyperactivity. For the next two weeks, he was administered high-dose opioids, muscle relaxers, and blood pressure medications to try to treat the sympathetic storming.
“Paroxysmal sympathetic hyperactivity is typically associated with poor outcome,” notes critical care specialist Christa Swisher, MD, who cared for the patient. “But younger patients tend to do better because their brains are still plastic enough that they can rewire themselves around the injured areas, so we used a more aggressive approach with him.”
Slowly, the patient began to recover. By the end of his second week in the neuro-ICU, he began to open his eyes. Soon after, he began tracking objects with his eyes. During that time, physical therapists started working with him to prevent muscle contractures and help him with his passive range of motion.
Neurology fellow Christian Hernandez, MD, checked in with the patient daily, focusing not only on caring for the patient but also his family. “Severe TBI is often really hard for a patient’s family to process, and it’s understandably very hard for them not to look ahead,” he says. “But recovery takes a lot of time—it’s a matter of inches, maybe millimeters sometimes—so I remind them to take it one day at a time. I’ll tell them, ‘This is what our goals are today. This is what I’m worried about today. This is what I’m encouraged by today. Tomorrow is a different day, and we’ll talk again.’”
After six weeks at Duke, the patient was well enough to move to an intensive rehabilitation facility, and six weeks later he returned home. By six months after the accident, the patient was talking, dressing himself, sitting and eating at the dinner table with his family, walking with assistance, and swimming in the pool with his siblings.
The patient’s outcome is better than anticipated, and his condition continues to improve, Hernandez says, highlighting an important point for anyone caring for patients with TBI: “We shouldn’t be so pessimistic. It can be easy to say, ‘This looks bad. We should talk about comfort measures.’ But I think we do this way too soon. In the absence of a few clear signs, we really don’t know a patient’s prognosis. We need to be realistic, but, as this case illustrates, patients do recover. We’ve seen it happen. We’ve made it happen.”