For Severe Traumatic Brain Injuries

What are our goals for our medications early in the care of the injured brain?

• Reduce the swelling of the brain
• Prevent seizures
• Treat symptoms of injury to the brain
• Prevent other complications of neurologic injury

What medications do we use for these goals?

Reducing swelling of the brain

We use a medicine or group of medicines that we often call “hyperosmolar therapy” on rounds. These medicines help pull fluid from the brain to make more room for blood as the brain swells. We may give these medicines when we see clinical signs that the brain is swelling or when we have a “pressure monitor” that tells us that the brain is swelling. The two most common medications that we use for swelling of the brain are 3% sodium chloride (also called hypertonic saline) and mannitol. Specific characteristics your loved one’s situation will help us determine which one we give first or if we give them both together.

Reduce the workload on the brain

Sometimes the pressure in the brain can increase when the brain is working hard or when it gets stimulated. Pain medication such as fentanyl or hydromorphone may help calm the injured brain in many ways. Sedative medications such as propofol may also calm the brain, decrease its workload, and help the pressure in the brain decrease. When these medications do not calm the brain enough, and the pressure in the brain continues to increase, we sometimes may use a powerful medication called pentobarbital to put the brain fully to sleep. Pentobarbital is not a drug for all patients, however.

Prevent seizures

When the brain is hurt, several factors from the injury can increase the risk of seizures. Blood, swelling, and the damage itself can irritate the cells in the brain to cause these seizures, even if your loved one has not had a seizure in the past. We can give anti-seizure medications to prevent seizures for the first week after injury. We call it “seizure prophylaxis” on rounds. At Vanderbilt, we give a drug called levetiracetam for one week for this purpose. Unless your loved one actually has a seizure during this one-week time frame, studies tell us that continuing anti-seizure medications after seven days is not very helpful.

Prevent other complications with neurologic injury

Patients with severe brain injury who require a ventilator to help them with breathing are at risk for other complications after their injury, including blood clots, ulcers in the stomach, and pneumonia. We give medications to prevent some of these things. To prevent blood clots, we usually start a blood thinning medication 3 days after an injury to the brain. The blood thinner that we use could be enoxaparin or heparin at low doses. We also given an anti-ulcer medication to prevent “stress-related” ulcers in the stomach while patients are in the intensive care unit. The anti-ulcer medications that we most commonly use could include famotidine, pantoprazole, or omeprazole. We do not give antibiotics to prevent pneumonias, but we do use several different antibiotics to treat pneumonia if it occurs.

Medications As Time Passes

As time passes, medications will change in the care of your loved one. After several days or weeks, we may need medications to slow the heart rate, promote bowel movements, and to help with agitation as the brain heals. One of the medications you might hear us talking about for these purposes would be propranolol. Propranolol is a medication that is sometimes use to decrease blood pressure and heart rate, but in brain injury, it can also help with a common syndrome called “storming”. It is very common and helpful to start this medication in patients in the days and weeks following a brain injury.

Asking for help

Medications can be confusing. Never hesitate to ask questions. Our trauma pharmacist and team members will be happy to explain your medications to you so that you understand what you are getting in the hospital and why.