Treatment of Car Accident Victim with a Brain Injury

Leslie Asks:

My character has been in a car accident and sustained head damage (swelling to the brain)— is there a medical term for that? Also, the swelling becomes so bad the doctors have to remove part of her skull— is there a name for that? How long does that swelling usually take before it goes down so they can replace the skull? Does the character regain consciousness? I have her in an induced coma which I want her in for a while.

Jordyn Says:

Upon further clarification of this question from the author, she says there is not a significant description of the motor vehicle collision in the manuscript and the scene is being told from the POV of a nurse.

The brain swelling is called cerebral edema. Usually, if it’s a significant car accident then there is usually bleeding as well. This is why I ask about the car accident. It should be pretty serious.

A nurse will use language that a family can understand. So, I might actually avoid a lot of medical terminology when speaking to the family unless I also clarify what the words mean.

I might say something like, “Your mother (or whatever relation) has a lot of swelling in her brain as a result of the car accident. We call this cerebral edema.”

A craniectomy is where they remove a portion of the skull.

Peak brain swelling is generally 48-72 from the time of injury and diminishes from there. Induced coma is a reasonable medical scenario here.

Whether or not this patient regains consciousness is up to you as the writer. Statically, the odds are pretty low for her to be the same person she was before. If she does wake up, she’ll have extensive rehab needs for sure– but you could write it either way.

Best of luck with your story!

Traumatic Brain Injuries: Initial Treatment

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.***

Author Question: Car versus Pedestrian

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.