Managing Sleepiness After Traumatic Brain Injury

Sleepiness is common in patients who have sustained traumatic brain injuries (TBI). Pharmacologic intervention may be required to help address sleepiness, because problems with sleep regulation have been described in this population. But it is not always appropriate to address sleepiness by initiating such medications, because there are many reasons why a patient may exhibit sleepiness after TBI. In addition, medications commonly used to help with sleep may not necessarily be benign or have the desired outcome. There are no clear guidelines that help clinicians determine when it is appropriate to start medications to enhance sleep. This case scenario and the following point/counterpoint discussion addresses this common problem. A 48-year-old man has been on an inpatient TBI unit for 2 days. He was injured 7 days before his rehabilitation admission as a result of a head-on motor vehicle collision. He was an unrestrained driver and sustained right temporal and bifrontal contusions. The initial Glasgow Coma Scale score was 11. Neurosurgical intervention was not required. He received a 7-day course of phenytoin for seizure prophylaxis. In addition to his TBI, he sustained a left fibula fracture that was treated without surgery. On admission, he was moderately obese and in no acute distress. He was sleepy but arousable, was able to answer simple biographical questions, and was oriented to self only. Posttraumatic amnesia has persisted. He is impulsive and demonstrates little insight regarding his deficits. He also had poor balance, so he has required 1:1 supervision throughout the day and night since admission. His medical history is positive for hypertension. Current medications include subcutaneous heparin for deep vein thrombosis prophylaxis, metoclopramide, famotidine, and metoprolol, as well as acetaminophen for mild pain and oxycodone for moderate-to-severe pain as needed. Admission laboratory studies included complete blood cell count and electrolytes, both within normal limits. The rehabilitation team is reporting that he has difficulty staying awake during the day and that this is hampering his ability to benefit from therapy. He also states that he is having trouble sleeping. The team is asking that you start a medication to help with sleep. What is your decision? Guest Discussants