Traumatic Treatment

ChEI treatments have been expanded also to include other dementias and CNS disorders, e.g. delirium, traumatic brain injuries and memory impairments, as well as myasthenia gravis, glaucoma and parasite infections. 

Traumatic brain injury is the most common cause of death in subjects under the age of 40, and an important risk factor for AD. Loss of hippocampal cells and depletion of ACh and of muscarinic receptors can be attenuated in injured experimental animals, improve blood perfusion in ischemic areas and increase cholinergic transmission in cortex and hippocampus the same mechanism invoked for treatment of VD. 

Indeed, 5-HT is also a substrate for the 5-HT transporter, itself an important player in the treatment of depression, and more recently for the whole range of anxiety disorders spectrum (GAD, OCD, social and other phobias, panic and post-traumatic stress disorders). It is the target for SSRIs (selective serotonin reuptake inhibitors) such as fluoxetine, paroxetine, fluvoxamine, and citalopram or the more recent dual reuptake inhibitors (for 5-HT and noradrenaline, also known as SNRIs) such as venlafaxine. Currently, there are efforts to develop triple uptake inhibitors (5-HT, NE, and DA). Further combinations are possible, e.g. SB-649915, a combined 5-HTia, 5-HT1b, 5-HT1d inhibitor/selective serotonin reuptake inhibitor (SSRI), is investigated for the treatment of major depressive disorder. 

Umbricht A, Hoover DR, Tucker MJ, et al Opioid detoxification with buprenorphine, clonidine, or methadone in hospitalized heroin-dependent patients with HIV infection. Drug Alcohol Depend 69 263-272, 2003 Villagomez RE, Meyer TJ, Lin MM, et al Post-traumatic stress disorder among inner city methadone maintenance patients. Subst Abuse Treat 12 253—257, 1995 Mining E, Kosten TR, Kleber H Clinical utility of rapid clonidine-naltrexone detoxification for opioid abusers. Br J Addict 83 567-575, 1988 Washton AM, Pottash AC, Gold MS Naltrexone in addicted business executives and physicians. J Clin Psychiatry 45 39 1, 1984 Wesson DR Revival of medical maintenance in the treatment of heroin dependence (editorial). JAMA 259 3314-3315, 1988... 

Post-traumatic stress disorder (PTSD) is a severe condition with a lifetime prevalence of about 12.5% in women and 6.2% in men (Pigott, 1999). About one in four individuals exposed to trauma develop the syndrome. Drug treatments are still being developed, mostly using antidepressants. Few systematic data are available on the pharmacoeconomics of the condition. 

The equivalent procedure for the main olfactory epithelial sheet (MOEx) is chemical ablation by treatment with (5%) zinc sulphate solution. The adoption of this approach was determined by practical anatomy, given the inevitably partial, let alone traumatic, results of cutting/scraping epithelia from the intricately folded sensory surfaces (Negus, 1958). 

Bandelow B, Zohar J, Hollander E, et al. Guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and post-traumatic stress disorders. World J Biol Psychiatry 2002 3 171-199. 

A prospective, randomized, placebo-controlled trial of paroxetine in adults with chronic post-traumatic stress disorder (PTSD) was recently conducted (Marshall etal., 2007). The subjects were New Yorkers, predominantly female (67%) and Hispanic (65.4%). Seventy subjects entered the study and after a one week placebo lead-in, 52 subjects were randomized to placebo or paroxetine for ten weeks. The subjects were treated with a flexible dosage design (mean dosage, 40.4 mg/day). Dropout rates were 32% for paroxetine and 51.9% for placebo. There were no differences in rates of adverse effects between treatment arms. Paroxetine was superior to placebo in ameliorating the primary symptoms of PTSD (56% vs. 22.2%). 

These data, taken together, demonstrate that topical application of rifaximin represents an effective and safe treatment of pyogenic skin infections. An additional application of this dermatological formulation would be infection prophylaxis in superficial skin wounds, particularly when used with a dressing that occludes the wound. Prophylactic topical antibiotic use makes particular sense for wounds in which the risk of infection is high, such as those that are likely to be contaminated (accidental wounds, lacerations, abrasions, and burns). Because all traumatic wounds should be considered contaminated, topical antibiotics are a logical measure to prevent wound... 

For aerosol products, the eye should be held open and the substance administered in a single, 1-s burst at a distance of about 4 inches directly in front of the eye. The velocity of the ejected material should not traumatize the eye. The dose should be approximated by weighing the aerosol can before and after each treatment. For other liquids propelled under pressure, such as substances delivered by pump sprays, an aliquot of 0.01 ml should be collected and instilled in the eye as for liquids. 

Although traumatic brain injury (TBI) is not, in and of itself, a psychiatric illness, it nonetheless warrants attention in our discussion of psychiatric medicines for two important reasons. First, it is not unusual for TBI to produce psychiatric symptoms severe enough to require pharmacological treatment. Second, treatment with psychiatric medicines after TBI often raises clinical concerns that are unique to these patients. More specifically, an injured brain is often especially vulnerable to medication side effects. Thus, the medical axiom first, do no harm is particularly important when treating TBI patients and must be considered when deciding whether to use psychiatric medicines, and if so, what medicines to use, and at what doses. 

The full complement of anxiety syndromes including panic, generalized anxiety, obsessive-compulsiveness, and post-traumatic stress disorder can arise in the after-math of TBI. In fact, anxiety may be the most common neuropsychiatric complication of TBI. Anxiety appears to be most likely to arise when the injury occurs to the right side of the brain. The treatment alternatives for post-TBl anxiety parallel those used when treating anxiety disorders and include serotonin-boosting antidepressants, buspirone (Buspar), and the benzodiazepines (see Table 12.1). 

Glenn MB. A differential diagnostic approach to the pharmacological treatment of cognitive, behavioral, and affective disorders after traumatic brain injury. J Head Trauma Rehabil 2002 17(4) 273-283. 

In addition to their proven efficacy in the treatment of all types of depression, the SSRIs have been shown to be the drugs of choice in the treatment of panic disorder, obsessive-compulsive disorder, bulimia nervosa, and as an adjunct to the treatment of alcohol withdrawal and relapse prevention, premenstrual dysphoric disorder and post-traumatic stress disorder. The usefulness of these drugs in treating such a diverse group of disorders reflects the primary role of serotonin in the regulation of sleep, mood, impulsivity and food intake. 

The mechanisms of flashbacks are probably mixed. Some cases may be similar to post-traumatic stress disorder induced by a bad trip (Paton et al., 1973). Abraham (1983) suggested that some of the visual phenomena, such as trailing and after-images, were due to failure of inhibition in visual pathways, possibly mediated in the lateral geniculate nucleus which (in the macaque monkey) contains on-off colour neurons with receptor fields similar to those described in flashbacks. The neurochemical causes of such flashbacks, which can be very disturbing, remains elusive and attempts at treatment are usually ineffective. 

In recent years many of these primary care cases that would formerly have been seen as anxiety disorders have been portrayed as anxious-depressives and have led to treatment with antidepressants, in particular the more recent serotonin reuptake inhibitors. As part of this rebranding a variety of states such as panic disorder, post-traumatic stress disorder, social phobia and generalized anxiety disorder have appeared, along with more traditional disorders such as obsessive compulsive disorder (OCD). Many of these diagnoses are likely to lead to prescriptions of an SSRI although the evidence for benefit from SSRIs is poor except for OCD. 

Data of animal experiments discussed in this chapter suggest a variety of potential pharmacological targets for the treatment of pathological anxiety (Fig. 1). As the occurrence of traumatic events is usually unpredictable, it seems more promising to interfere with consolidation than with acquisition processes. In this context, the sympatho-adrenergic and the hypothalamic-pituitary-adrenal system are of particular interest. Both noradrenaline and corticosterone/cortisol are known to facilitate memory consolidation, in par-... 

The effects of P-adrenergic blockade on the consolidation of traumatic memories has been an area of special interest for the treatment of posttraumatic stress disorder (PTSD), and recently the first randomized controlled study on the effects of propranolol in the prevention of PTSD was published. Pittmann and coworkers (2002) could demonstrate that propranolol may reduce PTSD... 

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