SUB acute BRAIN injury

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"what is a sub acute Brain injury?"

The Sub Acute Stage: From four to 21 days post injury

“What immediate medical concerns should we have?”

With brain injuries health complications with other areas of the body can arise immediately following a TBI. These secondary conditions aren’t as prevalent with the preventative measures taken by medical staff, but it is important to be aware of them as they can become fatal quickly.

• SEIZURES

Seizures tend to happen at two periods after a TBI: Either within hours or days (average of 7-8 days) or as far into the future as nine months to one year following the accident. Seizures happen because of sudden, abnormal electrical activity in the brain. Because of the low percentage of post TBI seizures, medical professionals only use anticonvulsant medications to treat seizures, not prevent them.

• HYDROCEPHALUS

Hydrocephalus occurs when excess fluid builds up in the brain, most often because of an obstruction preventing proper fluid drainage. The excess fluid can compress surrounding, fragile brain tissue, causing brain damage. This condition can develop during the acute stage of TBI or may not appear until later. Typically, an Intracranial Pressure catheter is inserted after a TBI to monitor for pressure inside the skull and drain excess cerebral spinal fluid.

• CEREBROSPINAL FLUID LEAKS (CSF)

Any tear or hole in the membrane that surrounds the brain and spinal cord (dura) can allow the fluid that surrounds those organs to leak. This fluid is called the cerebrospinal fluid (CSF) and when it leaks the pressure around the brain and spinal cord drops. A CSF leak is usually associated with watery clear drainage out of the nose, ear canal or out of a surgical incision. These tears that let CSF out of the brain cavity can also allow air and bacteria into the cavity, possibly causing infections such as meningitis.

• INFECTION

Infections within the intracranial cavity are a dangerous complication of TBI and will typically occur within a few weeks of the initial trauma. They are most often the result of skull fractures or penetrating injuries, but as previously mentioned can also be caused by CSF leaks. Standard treatment involves antibiotics and sometimes surgery to remove the infected tissue. Meningitis may be especially dangerous, with the potential to spread to the rest of the brain and nervous system.

• BLOOD CLOTS (DEEP VEIN THROMBOSIS OR DVT)

Any damage to the head or brain usually results in some damage to the vascular system, which provides blood to the cells of the brain. The body's immune system can repair damage to small blood vessels, but damage to larger vessels can result in serious complications. Damage to one of the major arteries leading to the brain can cause the formation of a clot at the site of injury or other parts of the head. Prophylactic measures may be taken such as the use of intermittent pneumatic compression boots or compression stockings to try to prevent their formation. If a blood clot forms it is treated with anticoagulation medication.

• PRESSURE SORES (SKIN BREAKDOWN)

Lack of movement and positional changes can cause pressure sores, also known as skin decubitus. A pressure sore is any redness or break in the skin caused by too much pressure on the skin for too long a period of time. The pressure prevents blood from getting to the skin so the skin dies. Preventative techniques are very important as pressure sores take an extremely long time to heal. Techniques include frequent positional changes (every two hours, when medically possible), the use of pressure relief air mattresses and making sure skin is kept clean and dry.

• PNEUMONIA

Pneumonia occurs when an organism, most commonly a bacteria, causes an overwhelming infection in the lungs leading to inflammation and sputum production. This makes the absorption of oxygen difficult and increases the work of the respiratory system. TBI patients on ventilators are especially susceptible and must be monitored closely and will require suctioning to remove secretions from the lungs and airways.

• DROP FOOT

In patients who are in a coma or an unconscious state for extended periods of time drop foot is a complication where the toes point severely downward and the tendons shorten. It is difficult to reverse and makes walking difficult or in severe cases, impossible. Prevention of drop foot is simple when caught early with the use of splints.

“What are the potential long term consequences of sustaining a TBI?”

Brain damage is one of the most difficult injuries in which to adjust. All other kinds of injuries except the debilitating ones are either treatable, or can be managed. When it comes to brain injuries it is not so easy. There are a number of ways in which lives may be changed permanently:

• LOSS OF MEMORY

After spinal cord injury the nerve cells below the level of injury become disconnected from the brain. Following the period of spinal shock, changes occur in the nerve cells that control muscle activity. Spasticity is an exaggeration of the normal reflexes that occur when the body is stimulated in certain ways. After spinal cord injury, when nerves below the injury become disconnected from those above, these responses become exaggerated.

Muscle spasms, or spasticity, can occur any time the body is stimulated below the injury. This is particularly noticeable when muscles are stretched or when there is something irritating the body below the injury. Pain, stretching or other sensations from the body are transmitted to the spinal cord. Because of the disconnection, these sensations will cause the muscles to contract or spasm.

Almost anything can trigger spasticity. Some things, however, can make spasticity more of a problem. A bladder infection or kidney infection will often cause spasticity to increase a great deal. A skin breakdown will also increase spasms. In a person who does not perform regular range of motion exercises, muscles and joints become less flexible and almost any minor stimulation can cause severe spasticity.

Some spasticity may always be present. The best way to manage or reduce excessive spasms is to perform a daily range of motion exercise program. Avoiding situations such as bladder infections, skin breakdowns, or injuries to the feet and legs will also reduce spasticity. There are three primary medications used to treat spasticity, Baclofen, Valium, and Dantrium. All have some side effects and do not completely eliminate spasticity.

There are some benefits to spasticity. It can serve as a warning mechanism to identify pain or problems in areas where there is no sensation. Many people know when a urinary tract infection is coming on by the increase in muscle spasms. Spasticity also helps to maintain muscle size and bone strength. It does not replace walking, but it does help, to some degree, in preventing osteoporosis.

Spasticity helps maintain circulation in the legs. It can be used to improve certain functional activities such as performing transfers or walking with braces. For these reasons, treatment is usually started only when spasticity interferes with sleep or limits an individual's functional capacity.

• MOBILITY IMPAIRMENT

When the brain injury results in partial loss of movement (for example, if the parietal lobe is injured it will result in difficulty in writing and in fine muscular movements.) job losses and family problems can occur. In cases where the injury is more severe and leads to partial or complete paralysis, the person may be completely dependent on family for support.

• DEMENTIA

Some athletes come down with cognitive impairment even when they are young. This will lead to chronic traumatic encephalopathy or CTE, which is a degenerative disease that will ultimately lead to dementia. CTE has been detected in people as young as 23 or 24, especially athletes who experience repeated blows to the head. A number of retired footballers and hockey players are being diagnosed with CTE in the prime of their lives because of brain damage suffered years earlier.

• BEHAVIORAL/PERSONALITY CHANGES

This is one of the aspects that people have come to be associated with and expect with brain injuries. Sometimes injuries to the frontal lobe can result in behavioral changes like irritability and aggressiveness in calm people and a lack of spontaneity that will give the impression of a lack of emotion. The degree of change depends on the severity of the injury and sometimes the patient will seem like an entirely new person because of this. These changes are the most difficult to handle by others and can lead to a lot of misunderstanding and helplessness in the home.

• VISUAL IMPAIRMENT

We are dependent on sight and any damage that results in even the smallest degree of impairment in sight will render him almost useless for most jobs. It will also mean that they will be dependent on their family for even the smallest of functions. Many visually impaired people have care dogs that are trained to help them with most normal day-to-day functions. These dogs help the person suffering from visual problems to be independent and happy as they will no longer need someone else to help them with small activities and the dogs act as good companions as well.

• SPEECH IMPEDIMENTS

In some cases known as Aphasia, the ability to understand and write a language is lost when that particular part of the brain is damaged. Another common effect of brain damage is slurring in speech, which is known as Dysarthria. These effects do cause a lot of damage as in the case of Aphasia, the person is totally lost as they have forgotten the basic language of communication. On the other hand, slurring of speech, although it may be inconvenient and frustrating, can be managed to a large degree enabling the person affected to lead a normal, healthy and happy life.

Though all the long-term effects of brain damage will change the personality and the physical ability of the person, not all is lost. Most people who suffer from these effects of brain damage can lead a healthy life. Although in extreme cases where they are physically unable to do their job, it is important that family and well-wishers pitch in to do what they can to make things simpler for them. This is where support groups are important as people who have experienced the same trauma either themselves or in one of their loved ones will be able to help the patient see things in a more positive light. This will in turn help them lead as normal a life as possible.

“On top of the brain injury my loved one sustained a spinal cord injury. What does this mean?”

A spinal cord injury, in the most basic terms, causes a disruption or termination of signals to and from the brain resulting in paralysis. For more information, visit our section on Spinal Cord Injury.

“When will he/she wake up?”

This is often the question families want answered the most and unfortunately, there is no way of predicting. Each injury is different and the amount of time before someone “wakes up” is dependent on the severity of the injury. It is rare for a coma to last more than several weeks and most TBI survivors will eventually awaken from a coma. Remember, coming out of a coma is a gradual process in which the brain injured survivor may go through several stages including: disorientation, post-traumatic or anterograde amnesia (survivor has no memory of recent events), agitation, etc...

“We don’t have medical insurance, how do we get the care needed?”

The first step is to contact a caseworker at the hospital to begin the process of gathering the necessary paperwork to apply for government programs, such as Medicare/Medicaid, Social Security and the Department of Rehabilitation.

Also, there are state health insurance programs in place for patients under the age of 18. It varies state by state, but pediatric patients may also qualify for Supplemental Security Income.

There are also private foundations dedicated to providing assistance to qualified applicants for home modifications, medical equipment, transportation, etc. Spend some time conducting an online search for relevant foundations.

This may also be the time to seek Legal counsel.

“What does this mean for our family financially?”

According to the most recent report by the Center for Disease Control (CDC), the costs of a TBI can be considerable, and vary greatly due to the severity of injury.

“Do we need to seek legal advice?”

To answer this crucial question, please visit our Legal FAQ's page for more information.

“How do we pick a qualified rehabilitation facility?”

Choosing a rehabilitation facility is one of the most important decisions to be made in this entire process. Each rehabilitation facility has varying admission policies and depending on where in the country it is located transportation will need to be secured. These decisions need to be made during the Sub Acute Stage so as soon as the TBI survivor is medically stabilized they can begin therapy. There are many factors to consider when choosing a rehabilitation facility, but at the very least the facility should meet the following criteria to handle the needs of a brain injury patient:

• Have accreditation from the Rehabilitation Accreditation Commission (CARF) for brain injury treatment
• A physician in charge who specializes in physical medicine and rehabilitation
• Physician coverage seven days a week, 24 hours a day
• A support staff that is specifically trained in traumatic brain injuries
• The availability of rehabilitation nursing and respiratory care on a 24 hour basis
• The projected length of stay and amount of therapy sessions per day (typically a minimum of three hours per day is suggested)
• Specialties offered such as driver education, therapeutic recreation, XXXX
• A full roster of weekend and evening activities for residents
• Programs that include family and loved ones in the care and rehabilitation of the survivor It is common for families of survivors to contact, or if possible visit, at least three rehabilitation facilities before choosing a program. Other factors to consider are:
• The availability of continuum of care programs to offer support post-rehab
• Education, research and clinical trials being conducted
• High patient satisfaction and quality outcome data
• The availability of affordable housing nearby for family member/caregiver
• The availability of patient transfer/transportation

The Injury Co-op has developed a printable PDF Choosing a Qualified TBI Rehab Facility Guide for your convenience.

“What is a ‘support network’ and why is it important?”

A support network can be family and friends who commit to playing a role in the life of the TBI survivor and even in the lives of caregivers and immediate family. It also extends to support groups that are often available while in the rehabilitation phase and after discharge.

Support groups perform an important function, and that is to give brain-damaged people a place to go to where they will meet others like them. This is important for a number of reasons. First, simply finding that there are others like you, or even worse than you, who have weathered the storms of time successfully will be a tremendous motivating factor. Second, it will help both you, as well as your family, get to grips with what can be expected after a brain injury. Hearing the problems that you may have to face from a doctor who has never experienced anything similar is totally different from hearing it from someone who has gone through it all.

Family members will be able to get help and support from others in their group during difficult times. Just the fact that they will learn more about the problems that they or their loved one will be likely to face is a big help. In fact, a support group is one of the best ways for you to explore all your options and if you feel that you need legal advice, a support group is the best place to sound out your idea.