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The Acute Stage: the hours and days following a brain injury
Recognize that you are already doing what you need to do by seeking reliable and relevant information. The next hours and days are critical and can affect your loved one’s recovery. There are issues that must be addressed immediately and health concerns that many people aren’t even aware of until being thrust into the world of traumatic brain injuries.
First, recognize the Center for Disease Control (CDC) reports an estimated 1.7 million people a year sustain a TBI. Of those, 1.365 million (nearly 80%) are treated and released from an emergency department and only 275,000 are hospitalized. Out of those numbers only 52,000 TBIs result in death. Half of those that do die do so within the first two hours. So, statistically speaking, if you’re loved one has made it through the early hours the odds are good. However, there are secondary conditions to be concerned about, but modern medicine can decrease or possibly prevent these complications from becoming life-threatening.
Provided there are no additional complications, the main goal of the emergency response team that arrived on the scene of the accident is to get the injured person to a Level I Trauma Center. A Level I Trauma Center is more than just an average emergency room. They meet criteria set forth by various governing agencies and typically house a trained trauma team, operating suite, imaging and laboratory facilities, trauma intensive care units, etc. 24 hours a day. They are able to handle the needs of both traumatically injured adult and pediatric patients.
Provided the situation called for an immediate medical response, emergency management of a traumatic brain injury starts at the scene of the accident. Initial acute treatment focuses on saving the victim's life. Rescue or emergency personnel stabilize the patient by unblocking airways, assisting breathing and maintaining blood circulation. Since little can be done to reverse the initial brain damage, attempts are made to prevent further brain damage during transport to a Level I trauma center.
There is no set standard for emergent treatment of a TBI, but a neurologist or neurosurgeon will order a series of tests. Some of these may include:
• CT Scans: A CT scan is a large imaging device that slowly moves the accident victim’s body in and out of a large rotating x-ray. The x-ray creates cross-sectioned images of the brain to show fractures, bleeding in the brain (hemorrhage), blood clots (hematomas), bruised tissue (contusions), and swelling.
• MRIs: An MRI is an imaging device that uses magnetic and radio waves to create an image of the brain. Because an MRI takes much longer than a CT scan, it may not be used in emergency situations.
• PET Scan: A PET is a nuclear imaging device often used in conjunction with a CT scan or MRI to give metabolic and anatomic information. It produces a 3D image of how the brain is functioning.
• Intracranial Pressure Monitor: An intracranial pressure monitor is a probe that can help evaluate and reduce the swelling of brain tissue. By inserting the probe through the skull, doctors can sometimes drain excess fluid to reduce swelling.
• EEG: An EEG, or electroencephalogram, measures the electrical activity in the brain to see if there is an abnormal pattern activity. An EEG can see what types of seizures may be occurring, assess an accident victim’s chances of recovery after losing consciousness, discover if a comatose person may be brain dead, or generally monitor brain activity.
A major concern after TBI is to ensure swelling of the brain is kept to a minimum. The neurosurgeon can do this in many ways depending on what he feels is the best for the victim. Sometimes all that is required is to give elevated levels of oxygen to the patient. Sometimes reducing swelling can be accomplished by giving medications that will increase blood flow into the brain, making sure that the brain is kept well oxygenated and sometimes by giving medicines that will drain fluid back from the skull into the body.
However, medication alone may not be enough and then surgery will have to be performed. Two common types of surgery to alleviate swelling involve installing a shunt to drain excess fluid from the brain or the removal of a portion of the skull to allow room for the brain to swell. Which method the neurosurgeon uses depends on individual cases and there is no single treatment that fits all brain damage victims.
The trauma physicians often only have a few moments to spend with a family initially in order to continue treating your loved one. Knowing what you need to ask after finding out the immediate condition of your family member will ensure that time is used effectively.
• What type of brain injury do you suspect has occurred?
• What was the initial GCS Score?
• Do you suspect that the brain injury is mild, moderate, or severe?
• What is being done to reduce intracranial pressure (swelling)?
• What area(s) of the brain are affected by this injury?
Recovery can be a tricky word. In the mind of a family asking this question for the first time recovery may mean your son or daughter, husband or wife, mom or dad receives treatment and leaves the hospital as they were before the injury. However, after only a little time spent in the world of brain injuries families quickly begin to understand a long road of very hard work to maximize recovery potential. Every injury is unique and therefore every recovery is, as well.
The key to recovery is to establish definitive, realistic goals. After a brain injury it is important to understand there may be irreparable damage to the brain making it impossible to accomplish certain tasks the same way they were accomplished before, if at all. Both the survivor and the family need to realize and accept this in an effort to avoid unnecessary frustration. A brain injury survivor is forever changed and expecting the survivor to go back to the way they were before is not what true recovery is about.
Families always have this question and honestly, there is no answer. It depends on the injury and each injury is unique. However, the medical field likes to say the first six months will show the most improvement. The second six months progress continues, but is maybe not as noticeable as the first six months. The second year it can still continue with hard work, but will potentially level off or plateau. This is not to say that improvement doesn’t happen after the one year or two year mark.
The typical length of stay in an acute hospital varies based on the presence and duration of a coma, the need for neurosurgery, and multiple traumas, but the average is 22 days. However, even during the acute phase early intervention with various therapies will aid the functional outcome. If no therapies are being offered, be sure to request what options are available and get started as soon as possible. Once the acute phase is over, a person with a moderate to severe brain injury will be admitted to an in-patient rehabilitation center for average stay of 32 days. Follow-up support with out-patient care will be needed, as well.
All severe brain injuries involve the patient being in an unconscious state. Sometimes, physicians choose to medically induce an unconscious state to allow the brain to rest and recover. Prepare yourself for this, but don’t let that stop you from talking to your loved one as you usually would. Whether they can respond or not does not mean they can’t hear you. It will seem difficult at first to talk to someone who appears asleep, but it will help both of you to try.
When going to see your loved one for the first time, be prepared for a lot of medical equipment. Don’t let this scare you, most of the equipment is in place to simply monitor the patient. The brain controls and coordinates all body functions, including breathing. Often a patient will need help to breathe and an ET (endotracheal) tube may be put through the nose or mouth into the lungs and hooked up to a ventilator, a machine that assists breathing. A patient on a ventilator may have wrist restraints to prevent him from pulling out the ET tube. It is hard, but try not to let this upset you, it is for their own good.
A small tube, called an intracranial pressure or "ICP" catheter may need to be surgically placed through the skull into the brain to monitor the pressure inside the skull and drain excess cerebral spinal fluid. The ICP catheter is connected to a transducer, a device that transmits signals to a monitor above the bed. This allows the doctors and nurses to tell what the pressure is inside the head. The transducer is often taped to a rolled up towel or washcloth and placed to the patient's head. The ICP catheter is also connected to a drainage bag. This bag is hung on an IV pole at the head of the bed.
Extra fluids and medications may be needed to regulate the amount of water, salt and potassium in the body. Blood pressure, if too high or too low, may also need to be regulated with medications. An IV inserted into the upper chest will be monitoring how effective the heart is beating and the amount of fluid in the body. Blood pressure is monitored by another arterial catheter or “A-line,” usually placed in the wrist or foot.
It is likely your loved one will be hooked up to a heart monitor, and will have EKG electrodes taped to the chest to monitor the heart rate rhythm. The patient may need medications to keep the heart beating normally.
The initial days are emotionally draining because a “good” day of progress may be followed by a really “bad” day. “Brain injury rehabilitation is a marathon, not a sprint,” is an analogy often used in the TBI world and remembering to pace yourself is important for the survivor and family members. Keeping a 24-hour vigil in the waiting room may not be the most effective use of time. Take time to educate yourself, research rehabilitation facilities, get things situated and rest. The time will come when your loved one will need you more and being rested and ready will reduce some of the stress of rehabilitating a TBI survivor.
Whatever the case may be, the injured person is still there underneath all of the medical equipment and they will need you now more than ever. They are at the beginning of a very long physically, emotionally and mentally draining journey to regain their life and independence. Your love and support throughout may be the defining factor that determines whether the end result is a positive one. Remember, taking care of yourself will also allow you to take better care of your injured loved one.
Get educated about everything relative to your loved one’s brain injury. Traumatic brain injuries affect every facet of life: physical, emotional, financial, legal, etc… Staying informed and learning all you can will do a number of things. It will keep you from being surprised and caught off guard by situations that are bound to arise. It will give you back some control in the midst of the crisis. It will also ensure that you make informed decisions regarding the care of your loved one that could have potentially life-long effects.