Brain Injury

Traumatic Brain Injuries: Initial Treatment

/ Jordyn Redwood / 1 Comment

Last post, I have a primer on traumatic brain injuries (TBI) that you can find here. Today, I thought I’d give an overview of the treatment guidelines.

Remember, the basis of treating TBI is manipulation of the three components within the skull: the brain, the blood, or the cerebrospinal fluid (CSF). Additionally, sometimes a portion of the skull is removed.

1. Manipulating Brain Tissue.

Removing brain tissue is an option and may be done to tissue that has died. Recovery of the patient is dramatically influenced by what part of the brain was removed.

Another management strategy is to put the brain at rest by placing the patient in a medically induced coma. Medication is used to heavily sedate the patient. Typically, the patient is on continuous EEG monitoring to ensure a minimal amount of brain activity is present. The purpose of the coma is to reduce the metabolic demands of the brain in hopes of keeping swelling down and allowing the brain time to heal.

Additionally a diuretic, either hypertonic saline or Mannitol, can be given to draw water out of swollen brain cells.

2. Manipulating Blood Flow.

This can entail a couple of areas. Remove blood that has collected in the brain. Sometimes when the brain is injured, blood vessels within the brain are ripped open. Two types of bleeding can occur between the brain and the skull: a subdural or epidural hematoma. A subdural hematoma occurs from veins. An epidural hematoma occurs from an artery. Depending on the size of the hematoma, a neurosurgeon may choose to operate and remove it. Sometimes bleeding occurs within brain tissue. This type of bleeding can be small and more diffuse. Although a risk for the patient it may not be an option to surgically remove it.

Another way to change blood flow is to manipulate the size of the blood vessels inside the patient’s head. This can be done by increasing the rate of the patient’s breathing on the ventilator thereby decreasing their blood level of carbon dioxide. When this level is lower, the blood vessels inside the patient’s brain shrink in diameter. This therapy is controversial and if done, only a mild drop in carbon dioxide levels is the goal.

Lastly, the blood pressure can be manipulated. A certain blood pressure or blood flow to the brain must be maintained in order to keep the brain alive. This is called the cerebral perfusion pressure (CPP) and is calculated by using the patient’s blood pressure and their intracranial pressure (ICP). Reducing the blood pressure is an option but you must maintain the cerebral perfusion pressure as well. This can be a challenging balancing act.

3. Manipulating Cerebrospinal Fluid (CSF)

A drain is placed to remove excess cerebrospinal fluid.

4. Removing a Portion of the Skull.

This is a viable option for management of brain swelling. A portion of the skull is removed (hemicraniectomy) to allow the brain room to swell. The portion of the skull that is removed is preserved by freezing so that is can be reattached at a later point once the swelling has eased.

Have you had a character in your novel with a traumatic brain injury? If so, what type and why did you choose it?

***Reposted from January 19, 2011.***

Traumatic Brain Injuries: A Primer

/ Jordyn Redwood / Leave a comment

The brain is our most complex organ and perhaps the most difficult to help heal. The biggest challenge is its protective covering: the skull. Management of acute traumatic brain injury, or TBI, typically involves manipulating the three components within the skull: the brain, the blood, and the cerebrospinal fluid (CSF).

What is the purpose of each of these components? The brain is the body’s supercomputer. The blood delivers oxygen and nutrients to feed the cells or neurons. The CSF nourishes the brain, helps remove waste products, and keeps the brain buoyant.

What happens when something is significantly injured? It swells. Think about a time you saw someone with a really bad sprained ankle. What happened? It blew up like a balloon. The same thing happens to the brain with a traumatic injury. It swells.

Unlike an ankle, brain swelling is inhibited by the skull but the pressure inside the head can continue to rise if swelling is unchecked. Too much pressure inside the skull (it can’t move) and blood flow diminishes, thereby starving cells of oxygen, which then swell more.

We can measure the pressure inside your skull, or intracranial pressure (ICP), by placing a sensor into a ventricle (a ventriculostomy).  A normal ICP is 7-15mmHg. Cerebral edema can be insidious as swelling peaks 48-72 hours post injury. A patient can initially present following commands. Then in 2-3 days, develop cerebral edema to the point of herniation (which means brain contents shifting) and die.

What happens when a patient develops significant cerebral edema and ICP pressures skyrocket?

First bad thing: Blood flow is reduced. The brain is very sensitive to blood flow and greedy for oxygen. If there is diminished blood flow, neurons (brain cells) begin to die. If there is no blood flow, the brain will die. You may have heard the term brain death. This is determined by several factors but the definitive one is by taking the patient to radiology and doing a brain flow study. Roughly, a dye is injected into the blood and x-rays are taken. If there is no blood flow, the patient is declared brain dead.

Second bad thing: Brain contents shift into areas where they’re not supposed to be. This is called herniation. When neurons are compressed, they don’t function properly and will begin to die as well. When brain cells die, machines and medications have to take over their function to keep the patient alive.

Unfortunately, if brain death has occurred, the medical team will start discussing withdrawal of care with the family.

***Content reposted from January, 12, 2011.***

Treatment for Amnesia

/ Jordyn Redwood / Leave a comment

Marissa Asks:

How do doctors proceed if they suspect amnesia? In my novel, the patient was brought to emergency after being found on the side of the road (in the snow.) The patient shows signs of physical torture: multiple rapes, bruises, lacerations, glass embedded mainly in his hands, hypothermia, and a cold (because obviously my character needs to be ill on top of everything).

burnout-384086_1920The patient has just woken up and had a panic attack. Been settled down. You asked for his name and he seemed uncertain as he gave his first name. You asked for his last name and the patient shook his head. What next? I mean obviously the glass would have been removed from his hands and a drip put in for painkillers but what next? Who does the nurse call? Or what does she ask now? And if memory loss is confirmed, how do they find out it’s amnesia like which SPECIFIC tests do they do? Who is contacted and brought in to liase?

I just sort of need a timeline rundown because my character is going to be going through that.

Jordyn Says:

Thanks so much for sending me your question. First of all, it sounds like this patient has a period of time where he is unconscious in the ER. You make it sound like he wakes up on his own and not in response to an exam by a doctor.

So an unconscious patient found with these injuries would have a CT scan of his head. Hypothermia could be determined simply by taking the patient’s temperature and warming him up with something as simple as warm blankets to more complex as heated IV fluids. Regarding the IV drip for pain— this is actually unlikely in the ER. This is referred to as a PCA pump (patient controlled analgesia) and I’ve never seen them used in any ER setting. Would we treat the patient’s pain? Yes. But, you might be surprised that we may choose not to use a narcotic (for many reasons) and instead try something like Toradol which is an IV form of an NSAID (which is in the same drug class as Ibuprofen.)

The glass embedded in his hands would be removed. The wounds irrigated and stitched closed if necessary. The lacerations would be treated the same way. Keep in mind, not all lacerations can be stitched closed if they’ve been open too long due to the risk of infection.This patient would also receive a tetanus booster if he hasn’t had one in the last five years (even if he can’t remember the last time he had a shot.) If anything looks infected, he would receive IV antibiotics.

If the patient wakes up and doesn’t know who he is (and doesn’t have any form of identification on him) then we would involve the police. Likely, they are probably already involved considering the circumstances— that he was found unconscious and beaten. Plus, you mention that the character has been raped several times so a sexual assault kit should be collected, but the patient’s consent is required, so we’d ask him if he wants this when he’s awake. Yet another reason the police would be involved.

If the doctors think the amnesia is related to a brain injury from the beating, they may just see if it improves with time.

I think it’s reasonable to admit this patient to the hospital and I speak a lot here about how it is actually rare to admit a patient with concussion, but considering the amnesia (it sounds like you want it to persist), the beating, the rapes, the wounds to his hands (as well as additional lacerations), and the hypothermia then some watchful observation is warranted. The doctors could consider a neurological and/or some type of psychological evaluation considering the circumstances of the case to see if his memory loss has a non-medical cause. Neuro might request an MRI of his brain to look for additional injuries not as easily discerned via CT scan.

In the end, if he never remembers, there’s little treatment to “correct” amnesia. This is good for the writer because you have a lot of leeway in what you want to happen to the character. Your time frame can be what you wish.

I think if he were stable in the hospital for a few days and the neurological/psychological evaluation didn’t warrant anything that required further inpatient treatment, he could be discharged home even if the amnesia persists with outpatient neurological follow-up and perhaps outpatient therapy if he consents.

Obviously the police would be very involved with this case.

Treatment for Multiple Concussions

/ Jordyn Redwood / Leave a comment

This question came to me via my blog comments section.

Melody asks:

ice-hockey-1084197_1280I’m working on a hockey injury scenario where it’s the second hit to the head in a matter of a week, with a dull headache that hadn’t really went away to begin with (but he kept it to himself).

The second hit knocks him out for a few minutes, and he has confusion (and afterwards his demeanor is now very mean vs his nice personality before the hit). Would a second hit to the head with confusion, headache (and I’ll add nausea) require the CT scan? Would they be worried about brain swelling? Would they keep him or send him home with a headache that is extremely sensitive to every little sound (like a baby crying would send him through the roof)?

Jordyn Says:

Hi Melody. Thanks for submitting your question.

Yes, shame on this character for not being honest about his symptoms because if he had persistent headache then he shouldn’t be playing hockey until that resolves— like at all.

To be honest, if this is an adult patient, he’s going to get a CT scan of his head. In reality, CT scanning is much more prevalent in an adult ED (or community ED) than in a pediatric ER run by specially trained pediatric ER physicians. There are many reasons for this that I won’t go into here.

The CT scan will show if there is brain swelling. Depending on the extent of the brain swelling then medical decisions would be made. If mild, then admission to the hospital and observation. If significant, this could require specialized medications, going on a breathing machine, and ICU admission. Though if the swelling were severe the patient would likely be unconscious.

Sometimes headaches associated with concussion are treated like migraine headaches to see if that will improve the pain. But no, a patient wouldn’t be sent home until his headache pain is significantly improved, but it doesn’t have to be entirely gone. We just want to make sure it improves with medications. In some more serious medical conditions like brain tumors and brain bleeds, medications have little effect on the pain.

Then again, in this patient, CT scan would have shown whether or not these other things are present.

Author Question: Car versus Pedestrian

/ Jordyn Redwood / Leave a comment

Alex Asks:

My character suffers the following injuries. I want the injuries to be severe enough that they require immediate surgery, but also that he recovers after about a month in the hospital and a stay in rehab.

carpedistrian1. Character is standing in the road, tries to run but is hit by the car front on.  Body smashes into the windscreen, sending him up into the air.

2. Hits his head on the pavement on landing and suffers broken bones as a result.

3. He blacks out from the impact and wakes up several hours later. In this instance, would he be able to survive for several hours with the kinds of injuries he could have?

4. Possible injuries I thought he could have included: bleeding on the brain, broken leg/s and/or arms, fractured ribs which could cause a puncture to one of his lungs.

5. As a result he suffers from retrograde amnesia when he wakes up at the scene because of the injuries to his brain. Cannot remember his name/where he is or other events in his memory. Again here I am not sure what kind of specific head trauma could cause this.

6. After surgery to the brain, he is put into an induced coma to monitor the swelling. He will eventually wake up from this about a month later.

Jordyn Says:

The accident you describe would include some very serious injuries— perhaps not even survivable. It’s not just the injuries the character suffers getting thrown from the impact onto the pavement, but also the injuries he suffers from getting hit by the car. An impact that is so violent that it throws someone into the air would also likely shatter the windshield indicating to EMS responders that there was a lot of violent energy associated with this collision— which means bad things for the patient.

My first opinion is if you want this character to wake up in a few hours would be that he doesn’t fall directly on his head after he’s thrown into the air from the first impact. Overall, for your scenario, you might want to lessen the violence of this crash if you want him up in a few hours. It wouldn’t be surprising for this patient to require surgery to fix broken bones and/or internal bleeding.

A pedestrian surviving this crash is not impossible but it is more on the improbable side. This patient will have a lengthy hospital stay. May not wake up for days or months— not just hours. What you outline is a high speed impact to a pedestrian.

To answer some of your medical questions— surgery may be required for the bleeding on the brain depending on its location. All patients who have a brain bleed do not necessarily go to surgery. A punctured lung will require a chest tube to be placed which further complicates your patient’s medical picture. This patient would be placed on a breathing machine for sure to stabilize him until all these injuries could be sorted out.

Could a patient with a significant brain bleed be conscious at the scene after the accident? Yes. There is a specific type of brain bleed that fits this scenario called an epidural bleed. It does have a characteristic lucid period before the patient becomes unconscious again. It does require surgery to correct. If no surgical intervention is done then the patient will likely die. Honestly, as a writer, you have a lot of leeway in regards to what to do with amnesia. Any type of traumatic brain injury (and this certainly qualifies) could cause amnesia.

Medically induced comas are used frequently in medicine as a way to help control brain swelling. However, the medicines are not used forever. Peak brain swelling usually occurs 48-72 hours after the injury. After this time has passed, the medical team will evaluate when to decrease the medications keeping the patient in the coma. Keep in mind, even after these medications are discontinued, the patient may never wake up. Further studies would need to be done to determine the extent of the damage to his brain. These changes will evolve over time becoming more stable the more time that goes on.

My recommendation would be to lessen the severity of the crash. The car hits him, he hit the windshield, breaks it and then falls to the ground. This alone could cause a femur fracture and brain injury for which he could suffer amnesia and require surgery. If it’s an epidural bleed then he gets surgery, perhaps with some swelling and therefore the medically induced coma, but wakes up in a month. The leg is set in surgery with pinning or a rod. I think just having these two things is enough for your scenario.

All the rest might prove too complicating.

Author Question: What Kind of Trauma Causes Blindness?

/ Jordyn Redwood / 2 Comments

Belle Asks:

One of my characters is in a minor plane accident. When you see him next, he is blind. What could cause him to be blind as a result of this accident?

eye-211610_1920Jordyn Says:

A character can lose vision as a result of this accident in one of two ways. Either direct injury to the eyes themselves or injury to brain centers that are involved in the processing of visual information.

Direct injury to the eye could include the eye itself or bones around the eye could become fractured and impinge on certain nerves that could ultimately lead to blindness. You could also have traumatic retinal detachments that if not repaired could lead to blindness.

Many areas of the brain are involved in processing the information our eyes takes in. Any injury to any one of these centers could lead to blindness even though the eye itself looks perfectly normal. This article gives a basic outline and would probably be a good jumping off point for further research. As mentioned in the piece, some of these conditions would be called “cortical visual impairment, cerebral visual impairment, neurological vision loss, brain-damage-related visual impairment, and vision loss related to traumatic brain injury”.

Best of luck with your story!

Author Question: Suicide Attempts That Could Lead to Brain Death

/ Jordyn Redwood / Leave a comment

Jennifer asks:

I am trying to find a scenario where a suicide attempt would lead to traumatic brain injury with long-term repercussions (reduced mental and physical functioning afterward) but not death.

Jordyn says:

There are actually several ways a person could attempt suicide and end up with a brain injury. It doesn’t have to be a traumatic brain injury but anything that would lead the person to have a hypoxic event (where they weren’t breathing for a period of time) could lead to brain damage and difficulty down the road.

If you want direct brain injury then a gunshot wound to the head would be the best bet. Maybe it was misdirected somehow and the person just got a glancing blow.

If you want to go with the lack of oxygen aspect then:

1. Attempted hanging.

2. Drug Ingestion.
3. Ingestion of poison.
4. Cutting the wrists– if you lose enough blood you will code which could lead to an hypoxic event as well.

Really, any suicide attempt that leads to a code event can cause brain injury.

Follow-up question . . .

Jennifer asks: Would it be covered by insurance since it was a self-inflicted injury?

Jordyn says: Medical insurance will cover if it is a self-inflicted injury. You might be thinking of life insurance that usually does have a clause where if a person dies as a result of suicide the life insurance policy won’t pay out. However, from my personal experience with purchasing life insurance policies, this is usually limited to the first 6 months to two years of the policy depending on the insurer.

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Jennifer Slatterywrites missional romance novels for New Hope Publishers and Christian living articles for Crosswalk.com. You can visit her online at http://jenniferslatterylivesoutloud.com/