Comprehensive brain injury agitation management in the critical care setting: Preliminary results on a multidisciplinary neurobehavioral approach

Management of agitation following traumatic brain injury (TBI) in the critical care setting is complex, often with the primary goal of stopping behavior, with lesser concern for long-term iatrogenic pharmacological consequences. Complicating matters, agitation following TBI is oftentimes not clearly defined or the cause specific. These preliminary results present a novel approach to TBI agitation management in our critical care setting, and present the Agitated Behavior Scale (ABS) ¹ as a critical care tool.

Table 1.

Sample demographics: means and standard deviations.

	Agitated	Non-agitated	Total
Age	51.9 (17.4)	49.9 (17.2)	51 (24.5)
Gender
Male	12 (100%)	12 (67%)	88 (71%)
Female	0 (0%)	6 (33%)	36 (29%)
Education	HS 11/C1	HS 6/UNK 12	HS 16/C2/106 UNK
Race
White	12	14	111
Black	0	2	16
Hispanic	0	0	3
Other	0	2	1
Previous psychiatric history	1	0	3
Glasgow Coma Scale score total	9.3 (4.98)	8 (4.31)	12.6 (4.03)
Length of stay	20.58 (6.08)	15.39 (16.75)	7.87 (11.30)

In our unit, the neuropsychologist completes daily neurobehavioral examinations, which is a component of daily bed rounds with trauma surgeons, critical care nurses and nurse practitioners to identify causes for agitation, determine pharmacological intervention and identify environmental overstimulation and to assist with family education. Neurobehavioral examinations consist of assessment of consciousness (generalization, localization, tracking and following), orientation, attention, memory, basic problem solving, behavior and emotional state. Critical care nurses rate patients twice daily using the ABS which populates the clinician’s daily patient notes. Agitation was considered present if the total score was >21 for two 12-h shifts. To limit overstimulation, the organization employs a “MIN/LOW Stimulation” procedure that limits visitors and facilitates a normalization of sleep/wake cycles.

In general, there is limited evidence to accurately guide clinicians in the pharmacological management of TBI agitation.^2,3 Our efforts focused on utilizing valproic acid, quetiapine and propranolol, either singly or in combination, and titrating accordingly, with the duration of agitation lasting on average 11.58 days (s.d. = 6.9), as measured by the ABS total score of less than 21 for two consecutive shifts. Our goal simultaneously sought to limit benzodiazepines except in cases of alcohol withdrawal or seizure, and limit haloperidol to breakthrough TBI agitation.

The total number of TBI patients admitted during our six-month sample time was 124, and the overall LOS for the entire sample 7.87 days (s.d. = 11.3). We focused on patients with Glasgow Coma Scale (GCS) score below 13, or LOS greater than three days, which refined our sample to 30. For the agitated group, neurobehavioral issues presented an average of 9.5 days post injury (s.d. = 6.3) as identified by the ABS. Treatment was considered effective with the ABS total score of less than 21 for two consecutive shifts. These patients reached the non-agitated level of their recovery at an average of 20.6 days (s.d. = 6.1), at which time pharmacological intervention was gradually removed. The average length of stay (LOS) for these agitated versus non-agitated patient groups was not statistically significant (p < 0.31) (Table 1).

These preliminary results endeavor to demonstrate the efficacy of a multidisciplinary approach to the reduction of LOS in TBI patients by focusing on the agitated patient. However, our sample size is small and our lack of significant LOS results may be due to small sample size. Our investigation is also limited to our institution, and we did not address long-term outcome, nor did we have the opportunity to examine LOS prior to this protocol’s implementation, but future research efforts are underway. The use of the ABS in the critical care setting is unique, as it allows for objective reporting of neurobehavioral issues given that subjective impressions are frequently contradictory and misleading, ¹ and the ABS helps to establish a consensus definition ⁴ for critical care professionals.