Brain Injury

History and Background       


A brain injury is caused by the disruption or death of nerve cells in the brain. This can occur from blunt force trauma (ie: those that occur in motor vehicle accidents, falls, and contact sports), a penetrating injury (ie: stabbing, and gunshot wounds), space occupying lesion (brain tumor), or from deprivation of oxygen to the brain leading to cell death (infection in the brain, heart attack). A brain injury can range in severity from mild to severe.  This can result in problems with vision, thinking and reasoning skills, memory, emotions, and motor function.

What Causes A Brain Injury?

Traumatic Brain Injury – Insult to the brain that occurs after birth from a mechanical external force causing damage to brain tissue.

Cerebral hypoxia – Brain tissue can also be damaged with their is a loss of blood flow, depriving the brain of oxygen. There are is focal hypoxia (which occurs following an ischemic stroke and diffuse cerebral hypoxia.

What is a brain injury classification?

Classifying the severity of a brain injury helps healthcare professionals establish an appropriate plan of care as well as help the health care community to communicate with each other using a common language. Here are the most common tools used to rate the severity of a brain injury.

The Glasgow Coma Scale (GCS) is a 15 point scale that looks at spontaneous eye opening, motor response and verbal response and is used in the first 48 hours following the brain insult. The score classifies the brain injury as mild (score 3-8), moderate (9-12) or severe (13-15).

The Rancho Los Amigos Scale of cognitive functioning is used during the recovery phase to define where the patient is in the recovery process.  There are 8 levels.

Level I: No response

Level II: Generalizes Response

Level III: Localized Response

Level IV: Confused-Agitated

Level V: Confused-Inappropriate

Level VI: Confused-Appropriate

Level VII: Automatic-Appropriate

Level VIII: Purposeful-Appropriate

 

The Simplified Motor Score (SMS) is a 3 point scale that was developed for a more simplified scoring system.

Obeys Commands = 2

Localized Pain = 1

Withdraws to pain or worse = 0

Source: Medscape, WebMD

Mechanism of Injury

In some cases brain tissue  is stretched or deformed beyond it’s tensile or elastic capabilities. For example, if the head collides with a stationary object, or the head is forced into high speed movement. If this happens, brain tissue can be damaged. This type of damage is called a contusion. There are two types of contusions.

 

Coupe Contusion

When the head is struck by a small object, the force is over a smaller surface area and causes a contusion at the site of impact. This type of contusion is a coupe contusion.

 

Contrecoupe Contusion

When the head is struck by a larger object the brain is able to dissepate the force at the site of impact however the brain is forced into a rapid movment causing a collision with the opposite side of the skull. When the contusion occurs on the opposite side of the brain from the initial impact, this is call a contrecoupe contusion.

Secondary Brain Injury


Injury to brain cells (not related to the initial insult) may occur days or weeks following the initial injury. This is referred to as secondary brain injury. Here are four situations where secondary brain injury can occur.

Increased Intracranial Pressure (ICP)

An increase in pressure >40 mmhg following the injury can lead to further cell death

 

Cerebral Edema (brain swelling)

This can occur due to an increase in the ICP. Furthermore, several neurochemical processes are impaired resulting in disruption in the autoregulation of blood vessels to expand and contract appropriately.

Hydrocephalus

The insult can also disrupt the flow of cerebral spinal fluid (fluid that surrounds the brain to act as a cushion)

Brain Herniation

This can occur due to increase ICP or uncontrolled cerebral edema where the brain has expanded beyond the available space in the skull and brain tissue is forced our of a foremen (opening) in the skull.

Brain Injury Recovery


Depending on the severity of the brain damage, patients will stay in an intensive care unit where they for close monitoring.

 Lines, tubes, and “noises”

In this stage the medical team monitors heart rate, ICP, blood oxygen saturation, breathing rate, and heart rhythm.  Alarms are set up to quickly notify the nurses should any of these numbers make the slightest change.

 Intravenous (IV) lines

Often times patients will have an IV line to quickly and easily administer medications, electrolytes, and fluids. The IV is extremely important. Therefore it is also common to see mits, boards, and soft splints to protect the IV from becoming dislodged

 Nasal Gastric (NG) tube

Often times a tube will be inserted through the nose that lead to the stomach to maintain proper nutrition

Breathing Tubes

Patients may have a breathing tube.  If an airway cannot be maintained through the mouth, this tube may be inserted through the neck (tracheostomy).

Medically Induced Coma

For a patient to recieve the propr medical care, a doctor may decide to keep the patient in a medically induced coma.

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Visitation

Patient’s can often times hear.  Having familiar voices in the room may bring a patient in this stage comfort.

CHILDREN

It is important to thoughtfully consider a childs age and maturity level before bringing them to this setting.

Progressive Care Unit (step down unit)

Once the doctor is confident that all critical (life threatening) issues have been resolved, the patient is usually transferred to a step down unit. Many of the life sustaining lines and tubes that were present in the ICU will be taken off.  Patients vitals are still monitored.

Brain Injury Rehabilitation


 

Inpatient Rehabilitation (weeks - months following the initial injury)

Often times patient’s will need to go to a rehabilitation facility where they will work on gaining more independence prior to going home.  At this stage, patients are medically stable and often times continous monitoring of vitals is changed to intermittent monitoring. The goals for rehab is for pateints to gain independence for a successful transition back to home.  Patients are encouraged to wear “street clothes”.  Here the medical team will challenge the patient to perform bathing, dressing, grooming, and eat meals with as little help as possible.

 

Outpateint Rehabilitation (months - years following injury)

Once the patient is in the home environment, outpatient therapy will focus on higher level physical and cognitive training. This can last up to 2 years after the injury depending on the patients goals.  At this stage the additional resources page may provide helpful links and information.