Medical Care After a Head Injury

Emergency medical personnel at the scene of a head injury try to stabilize the patient and focus on preventing further injury. Because many head-injured patients also have spinal cord injuries, paramedics are trained to take great care in moving the patient. The patient is placed on a backboard and in a neck restraint to prevent further injury to the head or spinal cord. Other concerns include insuring proper oxygen supply to the brain and the rest of the body, maintaining adequate blood flow, and controlling blood pressure. Emergency medical personnel may have to open the patient's airway or perform other procedures to make sure the patient is breathing. They may also perform CPR to help the heart pump blood to the body, and they may treat other injuries to control or stop bleeding.

How is the Seriousness of a TBI Diagnosed?

A standard assessment for a suspected head injury is the Glascow Coma Scale. This assessment is usually performed by emergency medical personnel. It tests 1) eye opening, 2) ability to respond verbally, and 3) ability to move the arms and legs. The scores of the three tests are added up to determine the patient's overall condition. A total score of 3 to 8 indicates a severe head injury, 9 to 12 indicates a moderate head injury, and 13 to 15 indicates a mild head injury.

Glasgow Coma Scale

Eye Opening

4 Eyes open spontaneously
3 Eye opening to verbal command
2 Eye opening to pain (being pinched)
1 No eye opening
   

Verbal Response

5 Oriented and speaks normally
4 Confused but speaks normally
3 Inappropriate words
2 Incomprehensible sounds
1 No verbal response
   

Motor Response (movement of arms and legs)

6 Obeys commands to move arms and legs
5 Withdraws from pain locally (where pinched)
4 Withdraws from pain generally
3 Flexes limb in response to pain
2 Straightens limb in response to pain
1 No movement in response to pain
   

What Tests Help Diagnose the Severity of a Head Injury?

A patient with a mild to moderate TBI Glascow Coma score may receive skull and neck X-rays to check for bone fractures and any evidence of injury to the spine. CT scans are typically performed on patients with moderate to severe injuries. The CT scan can show bone fractures, hematomas, contusions, and brain swelling, An MRI may also be performed and can show more detail in the brain than X-rays or CT. An MRI is usually not the first test performed because it takes longer than a CT, and not all hospitals have MRI equipment.

What Are the Levels of Consciousness that May Follow a TBI?

Stupor

Stupor is a state in which the patient is unresponsive but can be aroused briefly by a strong stimulus, such as sharp pain.

Coma

A patient in a coma is totally unconscious, unresponsive, unaware, and unarousable. Comatose patients do not respond to external stimuli, such as pain or light, and do not have sleep-wake cycles. Coma results from widespread trauma to the brain. Coma usually lasts a few days to a few weeks. After this time, some patients gradually come out of the coma, some progress to a vegetative state, and some die.

Vegetative State

Patients in a vegetative state are unconscious and unaware of their surroundings, but they continue to have a sleep-wake cycle and can have periods of alertness. Unlike coma, where a patient’s eyes are closed, patients in a vegetative state often open their eyes and may move, groan, or show reflex responses. A vegetative state can result from diffuse injury to the cerebral hemispheres of the brain without damage to the cerebellum and brainstem. (In the diagram, the cerebral hemisphere includes the frontal, parietal, occipital, and temporal lobes). Anoxia, or lack of oxygen to the brain, which is a common complication of the heart stopping, can also bring about a vegetative state.

diagram of brain lobes

Persistent Vegetative State

Many patients emerge from a vegetative state within a few weeks, but those who do not recover within 30 days are said to be in a persistent vegetative state (PVS). The chances of recovery depend on the extent of injury to the brain and the patient's age, with younger patients having a better chance of recovery than older patients. Adults have a 50 percent chance and children a 60 percent chance of recovering consciousness from a PVS within the first 6 months. After a year the chances that a PVS patient will regain consciousness are very low and most patients who do recover consciousness will be severely disabled. The longer a patient is in a PVS, the worse the resulting disabilities tend to be. Rehabilitation, however, can help the recovery.

Locked-in Syndrome

Locked-in syndrome is a condition in which a patient is aware and awake but cannot move or communicate due to complete paralysis of the body.

Unlike PVS, in which the upper portions of the brain are damaged and the lower portions are spared, locked-in syndrome is caused by damage to specific portions of the lower brain and brainstem with no damage to the upper brain. Most locked-in syndrome patients can communicate through movements and blinking of their eyes, which are not affected by the paralysis. Some patients may have the ability to move certain facial muscles as well. The majority of locked-in syndrome patients do not regain motor control, but several devices are available to help patients communicate.

Brain Death

With the development over the last half-century of medical equipment that can artificially maintain blood flow and breathing, the term “brain death” has come into use. Brain death is the absence of brain function. Before life support equipment was invented, the body would die as soon as the brain died because the brain is necessary to control vital bodily functions such as breathing and the beating of the heart. Brain function may stop after widespread damage to the brain leads to loss of the brain’s ability to coordinate activity among distinct areas of the brain. Brain death is irreversible. In 1981 the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research developed specific criteria to determine when brain death has occurred. Immediately after a brain dead patient is removed from life support equipment, the heart quits beating and breathing stops.

Do TBI Patients Need Surgery?

About half of severely head-injured patients will need surgery to remove hematomas, stop bleeding, or treat severe contusions. Patients may also need surgery to treat injuries in other parts of the body. These patients usually go to the intensive care unit after surgery.

Intracerebellar Hemorrhage – Head CT Scan

Intracerebellar Hemorrhage – Head CT Scan (the lighter area within the black oval is blood)

Sometimes when the brain is injured swelling occurs and fluid accumulates within the brain. While this is a normal occurrence in any part of the body after injury, the skull limits how much the brain can swell. As a result, swelling and fluid lead to increased pressure inside the skull. Pressure inside the skull is called intracranial pressure (ICP). Increased ICP can compress and kill brain cells.

When it is suspected that the ICP is high, an instrument is inserted through a hole drilled in the skull and connected to a monitor that measures ICP. There are medications that can be given in an attempt to lower ICP. However, if the pressure remains high it may be necessary for a neurosurgeon to perform a surgical procedure to bring the pressure down. This is accomplished by removing fluid that is normally in the brain with a procedure called a ventriculostomy.

Learn more about the complications, disabilities, and other long-term problems that can result from a TBI.

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