Synapse - reconnecting lives

Initial treatment of a brain injury is often in the emergency department with a priority on an initial diagnosis, stabilizing the patient's condition, and appropriate treatment.

Stabilizing a patient can include breathing assistance (e.g. the use of ventilators) and maintaining blood circulation. Secondary problems such as blood clotting, bleeding and brain swelling, and oxygen supply to the brain will also be treated. 

Tests & diagnosis

Once stabilized, various tests will usually be conducted to determine the cause and extent of the brain injury, which can be established with X-rays, Computerized Axial Tomography (CT), Magnetic Resonance Imaging (MRI), and other tests.

The CT brain scan provides a series of X-rays at different levels of the brain and can be used to determine whether surgery is needed. Depending on the results of the scan the patient may be transferred to an operating room for surgery, intensive care unit (ICU) or a general surgical/medical ward. An MRI provides a detailed picture of the brain without using X-rays.

Surgery

Approximately half of severe brain injuries will need surgery to remove or repair hematomas or contusions. These are often emergency procedures. In other cases such as some brain tumours more time is available to prepare the patient for surgery.

Prior to surgery a doctor will, when possible, seek informed consent from the patient. Informed consent means understanding the costs, benefits and possible adverse outcomes of surgery. 

There are many tests done prior to surgery - not all of them relate to the brain as the doctor will ensure your other organs are capable of surviving surgery. Patients can be anxious the night prior to surgery and have trouble sleeping - medication can be prescribed to ensure a good night's sleep. 

Intensive care unit (ICU)

Patients may be placed in the ICU if special drugs or assistance with breathing are needed. The patient is attached to a range of tubes and machines which can be disturbing for visitors to view.

The patient is often heavily sedated and may be unconscious. Pads may cover the eyes to keep them closed and to prevent them from drying out. If an operation was required, the patient's hair may have been partly shaved.

If the patient is unconscious, it is generally accepted that visitors should behave as if the person is conscious and talk to them. Typically patients do not remember anything of their stay in the intensive care unit. 

Brain swelling

Sometimes when the brain is injured swelling occurs and fluids accumulate within the brain space. Because the skull restricts the brain, this swelling can create a dangerous degree of intracranial pressure (ICP) which can be relieved through medication, catheters or surgery. 

Spinal injuries

In cases where spinal injury is even suspected the patient may be placed in a hard collar and receive special nursing care. It is important to remember that hard collars are used as a precaution if there is any possibility of spinal injury - it does not mean that the patient definitely has a spinal injury.

Coma 

Coma is a loss of consciousness in which patients typically do not open their eyes, do not speak and cannot follow instructions. In the case of a mild brain injury, the loss of consciousness, or coma, may last for one or two minutes, while coma after a severe injury can continue for days and, in some cases, even longer. Patients may also be put in an induced coma if it will help with the recovery process. 

A measure called the Glasgow Coma Scale (GCS) is used to monitor the level of coma and the patient's emergence from coma. It rates the patient according to response to stimulation, eye opening and ability to speak. A fully conscious person has a score of 15, a person in profound coma has a score of 3. Usually a shorter duration of coma and lower depth of coma (i.e. higher GCS score) is associated with a greater degree of recovery from the injury. 

Post-traumatic amnesia (PTA)

An individual coming out of a coma doesn't just wake up, but will go through a gradual process of regaining consciousness. This may last for hours, days or weeks. The patient will not be able to remember recent events, often even things that happened minutes ago.

Individuals in PTA can be fully awake but are confused about the time, day of the week, where they are, what is happening, and sometimes who they are. They may be afraid, aggressive, disinhibited, agitated and restless. If physically able, they may wander. Too much stimulation during this time can compound the person's confusion and distress.

In conjunction with the Glasgow Coma Scale, length of PTA is frequently used as a guide to the severity of brain injury.