Physician's Field Guide to Neuropsychology

Abstract

Collaboration between the neuropsychologist and a variety of physicians involved in the care of a child with traumatic brain injury (TBI) is complex and critical to optimal patient outcomes. Management of TBI is best viewed as a dynamic process, beginning in the field with first responders, continuing through the emergency department (ED) and pediatric intensive care unit (PICU), and ultimately to the general medical floor and post-hospitalization. Primary neuropsychological and medical concerns change as the child progresses through these stages, with initial focus on life sustaining measures and prevention or reversal of secondary brain injury. Primary brain injury from physical trauma to tissue is often irreversible, with recovery being related to neuroplasticity or compensatory mechanisms. However, secondary brain injury from the pathophysiological effects of the primary injury (edema, bleeding, hydrocephalus, increased intracranial pressure, vascular compromise, metabolic dysregulation, seizures, etc.) is often amenable to prevention or even reversal [1–3]. Initial management in the ED and PICU focuses primarily on minimizing the effects of secondary brain injury, in lieu of patient functioning. Once medically stable, focus moves to recovery of functioning, and maximizing independence via pharmacological and therapeutic interventions, and ultimately long-term treatments designed to optimize the child’s future development, school success, and eventually transition to adulthood. Although there is considerable overlap between the initial treatment of concussions and TBI in children, the differing pathophysiologies for these two conditions result in disparate post-injury treatment planning and collaboration between the neuropsychologist and physician attending to the child. Similar to TBI, management of concussion is dynamic, although generally involves less intensive services, usually terminating after ED intervention and ongoing care from the family, with outpatient follow-up as needed.