Key points for the management of traumatic brain injury in dogs and cats
In veterinary patients, head injury (TBI) is an emergency presentation that commonly occurs after a motor vehicle accident or other blunt or penetrating trauma. During a session at the Fetch dvm360 conference in Kansas City, Danielle Powers, DVM, DACVIM (Neurology), of the Animal Medical and Surgical Center in Scottsdale, Arizona, described the management of TBI in veterinary patients from initial presentation to recovery.
Triage and clinical history
Patients presenting with a TBI should be classified as emergency patients. Airway, breathing, and circulatory status should be stabilized while patient movement is minimized. Powers reminded veterinarians that many of these patients present in shock and that their mental status can be significantly improved by treating this phenomenon. Ideally, the neurological evaluation should be performed before the administration of the medication. The pupillary reflex, pupillary symmetry, ambulatory status, and mental status of the patient should be assessed. The use of the modified Glasgow scale can provide a quantitative assessment that allows an objective reassessment over time.
In addition to asking about comorbidities and medications he may be receiving, the history should include specific questions to assess when the trauma occurred and to assess for any post-trauma loss of consciousness, mental activity, and seizures.
Diagnosis
When managing patients with TBI, it is essential to minimize stress and prevent the patient from suffering; however, sedation and general anesthesia are contraindicated in most of these cases. Administration of a pure mu-opioid may help treat pain and ease management while the patient is being evaluated.
A complete blood count, serum biochemical profile, and urinalysis should be performed in these patients. Jugular venipuncture should be avoided when collecting samples, as compression of this vein can increase intracranial pressure. Blood pressure should also be measured noninvasively, preferably with a Doppler, blood gas analysis performed, and imaging tests necessary to evaluate other injuries (such as chest X-rays and ultrasound).
MRI is the imaging test of choice for brain imaging. If it is considered necessary to perform it, the patient must be cardiovascularly stabilized before anesthesia. Computed tomography is the imaging test of choice for evaluating skull fractures, as radiographs are difficult to interpret and may be inconclusive.
Treatment
Treatment goals for patients with TBI will vary depending on their condition at presentation and existing comorbidities. Basic stabilization measures, including placement of a large-bore intravenous catheter, administration of intravenous fluids, and administration of supplemental oxygen, can significantly improve mental status in some patients. Pain control is also essential and pure mu-opioids are recommended as they can be easily reversed in case of deterioration of neurological or cardiovascular status.
More specific treatment goals include control of seizures, control of increased intracranial pressure, maintenance of carbon dioxide levels, and maintenance of cerebral perfusion pressure. Powers reminded veterinarians that "by preventing hypovolemia and hypoxemia secondary to shock, brain function will often improve without necessarily directly treating brain trauma."
Corticosteroids are no longer recommended as first-line therapy, as there is limited clinical evidence in human medicine to support their use.
In most cases, giving the patient time to recover is essential for treatment. During recovery, hospital care by staff is essential to prevent secondary problems such as pressure ulcers, aspiration pneumonia, urinary retention, and corneal ulceration. Oral medications, food, and water should be withheld until the patient is able to swallow on their own.
Prognosis and recovery
The prognosis of patients with TBI varies depending on the severity of the injury and comorbidities. Both primary and secondary brain injuries occur as a result of a TBI, leading to immediate and delayed effects. The Glasgow scale score can help predict prognosis. In Human Medicine, Powers stated that prognosis is "significantly correlated with oxygenation level and systolic blood pressure before and during medical intervention."
Powers noted that while recovery can be variable, for pets, "the degree of recovery may be less important if they can perform the required tasks as a companion animal, as opposed to a working animal or person." Quality of life, comfort, and the ability to perform basic tasks such as eating, drinking, and walking are the most important considerations for companion animals recovering from TBI. Pet owners who have sustained a TBI should be advised that seizure episodes can occur up to four years after brain injury, but the longer a patient goes without seizures, the less likely they are to develop.
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