Patho-pharmacological Foundations for Advanced Nursing Practice

Patho-pharmacological Foundations for Advanced Nursing Practice

Traumatic Brain Injury

It refers to the damage that occurs to the brain tissues out of external forces that are mechanical. It leads to post-traumatic amnesia or even loss of consciousness which is a manifestation of brain injury. The external force can be in the form of a violent blow or jolt to either the body or the head.

Patho-pharmacological Foundations for Advanced Nursing Practice
The condition contributes to a significant number of permanent disability case as well as death. In the United States, TBI leads to 30% of the total injury-related deaths. According to CDC, (2017), about 2.5 million people had TBI in the year 2010. National database, on the other hand, categorized the occurrence of TBI in terms of gender with men having a prevalence of 73.5% and women at 26.5%, ethnicity with whites leading at 67%, blacks at 18&, Asians at 3%, Hispanics at 10%, Native Americans at 0.5% and others at 1%. Concerning cause, 51% of TBI was associated with a vehicle crash, 12% for violence, 26% for falls and other related causes making up to 11%. The average age of individuals with traumatic brain injury was 41.59 years.


Traumatic brain injury occurs when there is abrupt trauma that damages the brain. Such an instance can happen when the head is violently struck by an object or even when the object pierces the skull and finds its way to the brain tissues thus causing a destruction of the cells and the entire structure. The event can either be an impact or non-impact. According to the National Institute of Neurological Disorders and Stroke, this depends on whether the head comes into contact with the object or experiences non-impact of force such as in the case of blast waves. The risk factors for TBI include vehicle crash, falls, and violence.  Traumatic brain injury can comorbid other conditions such as dementia and delirium.

Normal Anatomy

The brain is normally composed of three parts namely the cerebrum, cerebellum and the brain stem. Cerebellum composes of the right and the left hemispheres while the brainstem composes of the medulla, midbrain and the Pons. The cerebrum refers to the immediate portions below the skull and composes of frontal, temporal, parietal and occipital lobes depending on the skull bone unto which they lie. Depending on the part damaged during TBI, the brain can lose its function partially or fully.

In the event of a TBI, the neurological functions of the brains get altered. The neurotransmitters excesses within the first week of TBI leading to disturbances in monoaminergic systems. There is a change in cognition in the instances of frontal lobe damage. There also exists exaggerated display of emotional expression concerning the instability on the affective aspect of the brain (Sundman, Doraiswamy, & Morey, 2015). The damage also causes irritability, and the patient might manifest with a change of personality.

Types of TBI

Each case of TBI is unique depending on the mechanism and type of injury that causes it. The type of brain injury depends on the type of the force as well as the amount of force that impacts the brain. It is the type of injury that determines the extent of functional loss as it may affect one, various or all the areas of the brain. The kinds of TBI encompass the following:

  1. Coup-Contrecoup Brain Injury

It occurs when there is a substantial impact on the brain thus causing the skull or the brain tissue to slam in the side opposite to the area of impact (Whyte et al., 2016). The damage occurs on both the side of impact and the opposite region. This type of injury is common with instances of a blow to the head, violence, forceful falls, and car accidents.

  1. Concussion

It forms the most common type of traumatic brain injury leading to moderate brain damage. It is caused by an abrupt blow to the head making the brain to accelerate towards the direction of the impacting force (Gyoneva, S., & Ransohoff, 2015). The condition is common among football players and leads to moderate to severe brain damage.

  1. Brain Contusion

This type of traumatic brain injury is similar to contuitions and occurs together with them. It is a bruise that leads to bleeding under the skin. The extent of brain contuition depends on the location of the injury, size of the bleed, the effect of surgery as well as the length of time that it lasts.

  1. Diffuse Axonal Injury

This injury is similar to a concussion on the basis that in both cases, the brain is moving. However, in this case, the movement is relatively more severe. The head moves more violently than the brain stem thus making tears and shearing in the brain connections (Whyte et al., 2016). Depending on the level of the tears, the brain gets damaged in various degrees. The scale and manifestation of this damage are dependent on the areas of the brain that are affected.

  1. Penetrating injury

This type of TBI occurs when the impacting object pierces through the skull to damage the brain tissues. In most cases, the injury is fatal as they lead to bleeding, blood clotting and cutting off the oxygen supply to the brain. Removal of the penetrating object may worsen the damage and lead to extensive bleeding. Bullets form the leading cause of this type of injury. The disability and prognosis following penetrating injury are dependent on the severity, location and absence or presence of a brain bleed.

Categories of severity

The severity of TBI depends on the extent unto which the brain is damaged. The categorization can be mild, moderate or severe. In each category, the patient experience range of symptoms that manifest the extent of damage to the neurological function and this can be evident through various examination practices. The prognosis for TBI also depends on the extent of the established damage. The age of the patient, location of the injury as well as the general health of the individual also has impact on the outcome of the condition.

Mild TBI occurs when the Glasgow Coma Scale scores are between 13 and 15. The patient may remain unconscious for about few seconds or minutes. The manifestations may also include lightheadedness, blurred vision, headache, confusion, bad taste in the mouth, behavioral or mood changes, ringing in the ears, lethargy, feeling exhausted, trouble on maintaining attention, thinking, concentrating and keeping the memory as well as experiencing a change in the sleep patterns. The patient may experience some disabilities such as problems with cognition, communication, sensory processing as well as mental health.

Moderate TBI, on the other hand, is a classification placed when the scores for the Glasgow Coma Scale scores are between 9 and 12. The patient may have symptom similar to the ones experienced in mild TBI in addition to a persistent headache, convulsions, repeated instances of nausea and vomiting, slurred speech, agitation, restlessness, increased confusion, loss of connection, weakness of the extremities and inability to wake up from sleep. On examination, one or both of the pupils are dilated. The patient may encounter instances of stupor and remain in the unresponsive state for some time. This can, however, be averted by strong stimulant such as pain to get the individual aroused.

Severe TBI occurs when the Glasgow Coma scale score ranges between 3 and 8. The patient exhibits symptoms similar to those displayed in the moderate state of TBI but occurs for an extended period. On examination, the patient may present with bilaterally fixed pupils, parietal cephalohematoma, cerebrospinal fluid leakage from the ears and negative corneal response.  According to Nelson et al., (2016) scan from the computed tomography can indicate subarachnoid hemorrhage, cerebral edema, and a fracture of the skull. According to the National Institute of Neurological Disorders and Stroke, about half of the patients with severe TBI may require surgery to extract clots, repair hematomas or contuitions. The patient can go into a state of coma where he or she may remain unresponsive, unarousable, unconscious and unaware of everything. Besides, a patient with severe TBI can also be in a vegetative state where the patient is unconsciousness and disoriented but continues to undergo the usual sleep-wake cycle and periods of alert or experience a persistent vegetative state that lasts for months.

Standards of Practice

The management of TBI is dependent on the various guidelines that are in line with the evidence-based practice to ensure a better outcome. Brain Trauma Foundation provides for the guidelines that are used to approach the treatment of TBI which are based on evidence exonerated from 189 publications.

In managing TBI, Carney et al. (2017) provide a range of pharmacological and non- pharmacological means to be used as per the Brain Trauma Foundation. Decompressive craniotomy can be used in the event of cerebral herniation secondary to cerebral edema originating from either primary or secondary form of TBI. The process entails the removal of a portion of the skull to reduce the raised intracranial pressure. Through various randomized control studies, the foundation determined Decompressive craniotomy to be a procedure required especially after the failure of other intracranial pressure targeted therapies.

Another mode of treatment involves the provision of prophylactic hypothermia. This treatment aspect is based on the basis that hypothermia is standard of care of neuro-protection as it reduces the intracranial pressure. After studies comparing normothermia and hypothermia in the preservation of brain cells, the GCS for patient subjected to hypothermia was better thus prompting the recommendation of the treatment. If TBI leads to increased ICP, this method can be used. The Brain Trauma Foundation, however, cautions the use of this method after the failure of two recent high-quality pediatric trials to show its benefits in managing TBI.

Besides, cerebrospinal fluid drainage can also be used in the event of severe brain damage through the external ventricular drainage systems. The decision to use this mode of treatment, however, is dependent on the patient’s age, physician’s preference as well as the hospital resources available to support the procedure. Carney et al., (2017) eludes that in pediatrics, continuous drainage of the cerebrospinal fluid enhances improvement in the management of increased intracranial pressure as well as the injury biomarkers. The continuous drainage of cerebrospinal fluid can be done with intermittent measurement of intracranial pressure.

Ventilation therapies are used based on the fact that patient with severe TBI need ultimate airway protection as they are at risk of pulmonary aspiration or depressed respiratory function due to damaged respiratory centers. In cases of cerebral herniation, the patient requires transient hyperventilation. By maintenance of partial pressure of carbon dioxide, (PaCO2), the average flow of cerebrospinal fluid is maintained. Low levels of PaCO2, therefore, will lead to an impaired flow of cerebrospinal fluid thus can lead to cerebral ischemia. Through supporting ventilation, the usual flow of CSF is ascertained, and brain function is preserved.

According to Penn, Chi, & Proctor, (2017), the use of intracranial pressure monitoring for both adults and pediatrics in managing severe TBI has limited evidence. In a randomized study, non-superiority of ICP monitoring emerged when compared to other radiographic and clinical monitoring. From the Pediatric Health Information System database and National Trauma Data Bank, 3084 patient who had severe TBI from 30 hospitals were engaged in a study. 32.5% underwent the placement of an ICP monitor for 24hours and with the 67.5% having no ICP monitor. The outcome indicated increased instances of tracheostomy, gastrostomy placement, and mortality. Many observational studies also do not support this approach of treatment due to its impact on the patient. The current guideline used for pediatrics states that despite the fact that raised ICP makes the condition to have a poor prognosis, it makes the ICP monitoring a level III recommendation to be used in children with severe TBI.

Pharmacological Management

In the event of intracranial hypertension and herniation syndromes, Carney et al., (2017) suggest the use of hyperosmolar therapy in line with various studies that showed a reduction in the volume of the brain after their administration. Some of the routinely used components include mannitol and hypertonic saline which through various studies emerged to reduce the intracranial pressure as they facilitate dieresis and loss of water from the system. Caution is however taken in hypertensive and hyponatremic patients.

Other pharmacological therapies used in TBI include the use of anesthetics, analgesics, and sedatives. These methods are mostly used in the management of acute TBI in the control of seizures as well as intracranial hypertension. Barbiturates control the ICP via preventing unnecessary movements as well as suppressing metabolism. There use has been supported by one randomized control trial that was used to measure its quality. This treatment is however hindered by the side effects of the drugs since 54% of the participants in the study developed side effects when compared to 7% in the control group.

Other drugs for management of TBI are the steroids which are critical in the control of cerebral edema. Through experimental studies, the drugs control the edema via reducing the production of cerebrospinal fluid, restoration of the impaired vascular permeability as well as attenuating the production of free radicals.

Patho-pharmacological Foundations for Advanced Nursing Practice

In California, the first line of treatment entails the use of steroids to reduce edema. The second line of treatment encompasses the use employment of antiseizure prophylaxis for example phenytoin, infection prophylaxis, the use of analgesics and sedatives, decompression craniectomy and prophylactic hypothermia (Diaz-Arrastia et al., 2014). In the event of less or no progress, the third line treatment can be used. This includes deep vein thrombosis prophylaxis by the use of unfractionated heparin.

Clinical Guidelines

National Institute of Neurological Disorders and Stroke provides the guidelines that ought to be followed when handling a patient with TBI to ensure a positive outcome. According to the institute, any patient with signs and symptoms of either moderate or severe TBI need immediate attention. The aim of management at such point is on prevention of further brain damage as well as stabilizing the patient in the state since less can be done to reverse the already experienced damage.

The initial and primary management entails oxygen therapy to nourish the brain and other body parts, controlling the blood pressure and ensuring sufficient blood flow. In diagnosing the patient and determining the prognosis of the condition, imaging tests are used. In patients with mild to moderate traumatic brain damage, X-rays for the skull and the neck may be done for the determination of spinal instability or bone fractures. In the cases of moderate to severe TBI, computed tomography or magnetic resonance imaging may be done to provide detailed information concerning the injury.

In the management of patients, the moderately to severely injured individuals undergo rehabilitation. This program entails patient-centered treatment programs that cover various needs of the patient. The therapies included in the program encompass social support, psychological support, occupational therapy, speech therapy in case of impaired communication, physical exercises and medications prescribed.

Clinical guidelines

The clinical guidelines determine, summarizes and evaluates the evidence-based practice that is current concerning prevention, diagnosis, and treatment of the condition. These guidelines work for various patients within certain states despite the fact that the care provider bases the individuals’ regiment to meet the personal needs of the patient. The recommendation on the assessment, diagnosis, prognosis and health education to the patient is as illustrated below.


According to Scholten, Vasterling & Grimes, (2017), consistent and sound assessment for TBI patient is critical in managing the condition. The assessment of the patient revolves around the determination of a headache, functional impairment from dizziness, spatial disorientation as well as disequilibrium. There also exist the determination of sleep disturbances and memory loss due to the impact of the brain.


In diagnosis TBI patient, there is the use of one or more tests depending on the presentation of the patient to determine the physical, nerve and brain functioning as well as the level of consciousness. The patient can be subjected to brain imaging including the computed tomography and magnetic resonance imaging (Levin & Diaz-Arrastia, 2015). Cognitive evaluation is also done in determining the neuropsychological functioning. Other evaluation s revolves around the physical, occupational and speech abilities.


The outcomes in patients with TBI is dependant mainly on the severity of the injury, the location of the injury, the age of the individual as well as the overall well-being of the person. These factors affect the influence of the condition on the patient. According to the National Institute of Neurological Disorders and Stroke, the above factors will also impact the severity of the condition regarding the loss of functions and development of the disability. With the revelation, the patient will require various modes of treatment depending on the impact on the individuals normal functioning.

Health Education

In most instances, the occurrence of traumatic brain injury leads to physical, social and cognitive disabilities as well as crippling. These happenings usually leave the patient in total or partial assistance from the family members or the rehabilitation staffs. This situation calls for health messages that will ensure proper management and rehabilitation of the patient holistically.

The immediate communication to the family members will entail reassurance and allaying of the anxiety which may have built up within them due to the patient’s situation (Marshall et al., 2015). The message will involve the explanation of the condition of the patient and what the treatment of the patient will entail. This communication is done with consideration of patient’s privacy as well as confidential of patient’s details.
Patho-pharmacological Foundations for Advanced Nursing Practice

The teaching will extend to encouraging the family members to participate in the care of the patient. This move will be undertaken during the recovery period when the patient gains alertness. In the process, the patient gets to be familiar with the area of care thus promoting recovery.

For patient education upon substantial recovery and during discharge, the teachings will involve resting or engaging in quiet activities.  The patient ought to limit the period of watching television or participating in computers usage as well as other activities that may need a lot of thinking. The patient would also be advised to avoid sporting activities that may lead to another hit in the head. The patient is also informed on precautionary measures that need to be observed to prevent another head injury. These measures may include wearing helmets that fit appropriately, use of safety belts in cars

For the family members, it would be advisable that they provide supportive care by having an individual staying with the patient for 24 hours. This aspect will allow continuous monitoring for any complications or assistance that the patient may need upon discharge. As the significant others to the patient providing support to him or her, the family members together with the patient are instructed to adhere to all medications provided to them as well as maintaining clinical appointments as directed to facilitate healing. The family is also taught on screening for complications such as depression that need to be reported to the healthcare facilities.

Patho-pharmacological Foundations for Advanced Nursing Practice Standard of Practice Disease Management

The National Institute of Neurological Disorders and Stroke provide for the guidelines of managing TBI. It entails early determination, categorizing of the injury as mild, moderate and severe and management through pharmacological and non- pharmacological means. These are followed by follow-up care of the patient while ensuring rehabilitation of the patient to provide occupational competency.

In spite of the fact that California state following a prescribed guideline towards the management of TBI, the rate of hospitalization and cases of mortality rate still high. According to the United States centers for Disease Control and Prevention, approximately 30,000 indivduals in the state suffer severe TBI every year and requires hospitalization. The number accounts for about 10% of the total population requiring hospitalization. In terms of national statistics, TBI leads more than 50,000 cases per year. This number is usually hiked by car accidents which accounts for 30% of the cases. Two thirds of all the cases are usually men.

In the United States, TBI contributes to about 30% of the total deaths from injuries. In 2013, approximately 2.8 million related visits, hospitalization, and deaths were reported in the United States. In general, the rates of the condition increased by 47%, hospitalization increases by 2.5% and death rate decreasing by % between 2007 and 2013 (CDC, 2017).

Patho-pharmacological Foundations for Advanced Nursing Practice Characteristics and resources for well-managed patients

Indeed, a well managed TBI patient regains the cognitive functions that are interfered with during the disease process. Besides, the management can prevent various mortalities and improve the life expectancy which is usually reduced by about eight years after TBI. At the same time, the well-managed individuals can access various assistive devices that will allow proper and quick rehabilitative process compared to the poorly managed who may not be able to access such devices thus increased morbidity.

The access to care abd the treatment options determines the amanegemtn of TBI as the patient sia able to receive the immediate diagnosis and management of the condition which is in line with the guidelines for the management of TBI. The presence of these resources facilitates the process of care to the patient thus functionality of the patient can be obtained via prevention of complications and disabilities that may ensure.

According to the National Data and Statistical Center, there exist the inpatient rehabilitative services that also assist the patient to get along with the recovery process form the TBI. Through the Traumatic Brain Injury Models and Systems (TBIMS) program, researchers are able to access data that enables the advancement of medical rehabilitation thus improving the management of patient. The existence of TBIMS centers and homes have made the rehabilitation process easier to the well managed individuals with TBI. With the existence of technical assistance, training as well as methodological consultations to about 16 TBIMS centers provides the communities understudy an opportunity to access the rehabilitative services that will enhance the management of TBI patients.

Disparities in the management nationally and internationally

The UK, Netherlands and the United States use multimodal management regiment to attain better patient outcomes in the cases of TBI. According to international brain injury association, the globe is subjected to the WHO standards for surveillance in the determination of the central nervous system injury. Tosetti et al., (2013) states that through the European Commission and National Institutes of Health workshop, there existed a resolution between Europe and united states to have an international initiative towards the management of TBI.

There exist disparities in the utilization and cost of health services related to TBI in the USA and worldwide at large. According to Dismuke, Walker & Egede, (2015), the costs of TBI depends on the population under study, the severity of the condition and the period. The variations were also dependent on the geographical region, the type of service as well as the comorbidity. Highest costs of TBI treatment were evident in the states of California and Washington. Regarding age, the inpatient services for the elders within the United States was relatively lower as well as the outpatient and nursing home costs for the younger population.

Internationally, the costs of treatment of TBI associated with accidents is higher than those related to blows in China (Dismuke, Walker & Egede, 2015). For both England and Wales, the costs were dependent on the length of stay in the care units. Within the United States, the utilization of health care among patient with TBI ranged from 81% utilizing medical services, 66% transport services and 40% using the vocational rehabilitation. Concerning international utilization of healthcare, Italy has 40.4% of its patient accessing the rehabilitative services. At the same time, Spain used computed tomography in lower rate of 6% compared to Sweden and Germany as a method in diagnosis the condition.

Within the United States, the costs and utilization of healthcare also had other disparities related to race as many non-whites lack insurance coverage. This deters them from access and utilization of various services. In other nations such as Australia, the rural TBI patients are likely to be attended to in non-inpatient setting compared to the urban patients. In Israel, the terror victims are likely to undergo brain surgery compared to non-terror patients.

Managed disease factors

One of the factors that provide for the management for the condition include the financial resources. The funds are essential in the catering for various procedures that may be required during the care of the patient. This also extends to the affordability of the rehabilitative services as well as the follow-up care that are all key to managing TBI.

Another factor is the accessibility to the care centers offering both inpatient and outpatient care for the services. With the management guideline of     TBI requiring early determination and prompt intervention, the access to care is essential in achieving these objectives. In so doing, the access to healthcare assists in the prevention of complications that may occur with delayed treatment.

Health literacy concerning the brain trauma is also an aspect that determines the management of TBI. With informed individuals, immediate seeking of medical attention can be given priority as well as the utilization of the inpatient services which are all key to enhancing the outcome of the patient. The literate individuals are also likely to attend the rehabilitative programs that enhance the functionality and recovery of such individuals.

Unmanaged disease factors

Financial resources- with the management of TBI requiring numerous resources regarding the care of patient, diagnosis, and treatment of the condition, the affordability issue is vital in going about the condition. In the instances where the individual is unable to afford the various required procedures and diagnostic services, the condition may not be managed efficiently. The unmanagement would then be as a result of the nonadherence to the required treatment programs and procedures.

Access to Care- the need for prompt diagnosis and management calls for quick access to healthcare services. If the patient is not able to access the care services, the disease may progress to complication. This may lead to the negative patient outcome as well as the development of disabilities that may be irreversible.

Health Literacy- the management of TBI is dependent on literate patients and the public at large based on the fact that this will determine the use of healthcare services. In the event of illiteracy, the medical attention may not be sort immediately, and this may lead to the development of complications. At the same time, illiteracy will impair the use of rehabilitative services and adherence to the management guidelines thus leading to mismanagement of the condition.

Unmanaged disease characteristics

Patient with unmanaged TBI presents with increased brain swelling, permanent drainage as well as death. These are common among the adolescents and the children. According to CDC (2016), the patient can also present with poor concentration and memory, headache as well as poor balance and stability.

Patients, families, and populations

A patient who has managed to be treated of TBI are considered to be successful and can engage in various activities within the community. This improved functionality can also leady to employment in various areas as they are sound mentally after the treatment. In the instances of an unmanaged condition, the patient may develop a disability as well as a mental illness that can reduce the individuals functioning in the society.

In the entire management of the condition, the family members are pegged with the responsibility of assisting the patient to achieve the daily needs till recovery. They provide the social support that the patient is dependent on to promote the recovery. In the case of neglect, the family member can impact the life of an individual negatively thus leading to both emotional and physical problems to both parties. The family members may also be constrained financially with the entire procedure of treating TBI as it entails funding various procedures ranging from diagnostic, curative and rehabilitative services.

For the residents of California where I live, the increased incidence rate of TBI has led to an increased allocation of funds to the care centers to enhance the management of the condition. Further development of the rehabilitative canters is also vital to the community as it improves the access of care to the community members.

Costs for patients, families, and populations

According to Humphreys et al., (2013), there exists little information concerning the burden of TBI which can be related to fewer research studies on the subject. With the condition leading to long-term care, leading to disabilities and poor prognosis, the costs have been heavy to the patients’ families and the entire USA population. The costs for the rehabilitation programs that affect the financial status of both the patient and the family encompasses of about $33,284 to $35,954 for mild TBI and $25,174 to $81,153 for moderate TBI. For the patients, the total costs for TBI treatment revolved around annual life care cost of $222,600, projected post-acute rehabilitation at $450,000, annual supervised home care at $49,688 and $84,082 for annual life care estimates concerning the behavioral group home placement. The costs of the condition to the entire population ranges from $81 million for direct health care services and $2,3 billion for indirect health care services (Humphreys et al., 2013). For California, both indirect and direct costs amount to $320 million every year.

Promotion of Best services

Despite California not being ranked among the states with the high prevalence of TBI, the cases within the state are significant enough that needs mitigation. This move can only be attained via application of various practices that would curb their occurrences as well as proper management in the instances they occur as this will reduce the morbidity and mortality rates. Some of the best practices to employ are the observation of safety precaution concerning traveling and games, e.g., putting safety belts while using cars, using protective gears during games as well as during the construction points. Training of both healthcare providers and the public on handling patient suspected to have a head injury can also allow for prevention of the morbidities and mortalities.

Other best practices concerning TBI include early identification of the condition and classifying it as mild-moderate and severe to facilitate management. There also exists proper management by the use of both pharmacological and non-pharmacological methods to manage the condition. Effective follow-up to enhance proper rehabilitation of the patients.

Strategies to implement the best practices

  1. a) Health education on the process of handling patients with suspected TBI for the healthcare providers. The training sessions for the healthcare providers can equip them with better skills that will allow prompt and efficient management of the patient. This will enable prompt determination of the condition and its management.
  2. b) Use of developed guidelines for the treatment purposes includes regimens and other non-pharmacological methods (Bosch et al., 2016). All the cases of TBI have to be recorded with the guidelines applied during the various process of its management. This will be able to quantify the impact of the use of guidelines in its management.
  3. c) Establishing support groups of patients recovering from TBI as well as determining the data concerning many patients under follow-up against the number of patients with TBI. With the establishment of the support groups, the patients can get social support as well as learn various strategies to reduce further injury (Ponsford et al., 2014). By analyzing the data on follow up patients against the total number of patient who had TBI can give information of the progress of management of the condition.

Evaluation of the implementation strategies

  1. a) To determine the knowledge level of the healthcare professionals concerning TBI, a voluntary survey will be conducted for the healthcare providers in the emergency department and the intensive care unit after the training sessions. This determination will identify the impact of the training on readiness to hand TBI cases. The number of promptly determined cases ought to increase due to the advanced knowledge and skills in handling the situations.
  2. b) Statistics will be recorded for the outcomes of every TBI case handled against the use of various guidelines regarding therapeutic methods used (Bosch et al., 2016). The deviation will indicate either a positive or a negative impact of guideline use in the management of TBI.
  3. c) The number of social groups for the patients will be determined. At the same time, the number of patients in these groups against patients who are recovering from the condition will be determined (Ponsford et al., 2014). An increase in membership of the social groups can communicate its positive impact on the recovery condition with a negative deviation indicating various factors hindering the use of such therapeutic methods.


The occurrence, determination, management and follow up of a case of TBI ought to be under the watch of the guidelines in any state. With the above statistics, the state seems to be slightly less compliant with various guidelines based on the fact the deaths from traumatic brain injury being high. This determination points out the need for interventions geared towards prevention of the incidences by investing in adhering to safety measures. In the case of occurrence, there is a need for California to comply mainly with the management guidelines via the use of the various recommended therapies to prevent mortalities and enhance recovery as well as rehabilitation among patients. It is critical to employ strategies on the control of the origin of injuries as done in South Carolina, New York state, Arizona, Minnesota, Colorado, Oklahoma and Missouri where the TBI related deaths and hospitalization are relatively lower by 20% compared to other regions.




Carney, N., Totten, A. M., O’reilly, C., Ullman, J. S., Hawryluk, G. W., Bell, M. J., … &

Rubiano, A. M. (2017). Guidelines for the management of severe traumatic brain

injury. Neurosurgery80(1), 6-15.

Diaz-Arrastia, R., Kochanek, P. M., Bergold, P., Kenney, K., Marx, C. E., Grimes, C. J. B., … &

Salzer, C. W. (2014). Pharmacotherapy of traumatic brain injury: state of the science and

the road forward: report of the Department of Defense Neurotrauma Pharmacology

Workgroup. Journal of neurotrauma31(2), 135-158.

Dismuke, C. E., Walker, R. J., & Egede, L. E. (2015). Utilization and cost of health services in

individuals with traumatic brain injury. Global journal of health science7(6), 156.

Gyoneva, S., & Ransohoff, R. M. (2015). Inflammatory reaction after traumatic brain injury:

therapeutic potential of targeting cell–cell communication by chemokines. Trends in

            pharmacological sciences36(7), 471-480.

Humphreys, I., Wood, R. L., Phillips, C. J., & Macey, S. (2013). The costs of traumatic brain

injury: a literature review. ClinicoEconomics and outcomes research: CEOR5, 281.

Levin, H. S., & Diaz-Arrastia, R. R. (2015). Diagnosis, prognosis, and clinical management of

mild traumatic brain injury. The Lancet Neurology14(5), 506-517.

Marshall, S., Bayley, M., McCullagh, S., Velikonja, D., Berrigan, L., Ouchterlony, D., &

Weegar, K. (2015). Updated clinical practice guidelines for concussion/mild traumatic

brain injury and persistent symptoms. Brain injury29(6), 688-700.

Nelson, C. G., Elta, T., Bannister, J., Dzandu, J., Mangram, A., & Zach, V. (2016). Severe

traumatic brain injury: A case report. The American journal of case reports17, 186.

Penn, D. L., Chi, J. H., & Proctor, M. R. (2017). Severe traumatic brain

injury. Neurosurgery82(1), N9-N10.

Ponsford, J. L., Downing, M. G., Olver, J., Ponsford, M., Acher, R., Carty, M., & Spitz, G.

(2014). Longitudinal follow-up of patients with traumatic brain injury: outcome at two,

five, and ten years post-injury. Journal of Neurotrauma31(1), 64-77.

Scholten, J., Vasterling, J. J., & Grimes, J. B. (2017). Traumatic brain injury clinical practice

guidelines and best practices from the VA state of the art conference. Brain injury31(9),


Report to Congress: Traumatic Brain Injury in the United States | Concussion | Traumatic Brain

Injury | CDC Injury Center. (2017). Retrieved 2 March 2018, from

Severe TBI | Concussion | Traumatic Brain Injury | CDC Injury Center. (2017).

Retrieved 3 March 2018, from

Sundman, M., Doraiswamy, P. M., & Morey, R. (2015). Neuroimaging assessment of early and

late neurobiological sequelae of traumatic brain injury: implications for CTE. Frontiers

            in neuroscience9, 334.

Traumatic Brain Injury Information Page | National Institute of Neurological Disorders and

Stroke. (2018). Retrieved 2 March 2018, from


Tosetti, P., Hicks, R. R., Theriault, E., Phillips, A., Koroshetz, W., & Draghia-Akli, and the

Workshop Participants, R. (2013). Toward an international initiative for traumatic brain

injury research. Journal of neurotrauma30(14), 1211-1222.

Whyte, T., Gibson, T., Anderson, R., Eager, D., & Milthorpe, B. (2016). Mechanisms of head

and neck injuries sustained by helmeted motorcyclists in fatal real-world crashes:

analysis of 47 In-depth cases. Journal of neurotrauma33(19), 1802-1807.