“The brain can heal itself and actually grow new pathways to make up for damaged parts” Dr James Bender
What is Traumatic Brain Injury or TBI?
Traumatic brain injury (TBI), also known as intracranial injury, occurs when an external force traumatically injures the brain. TBI can be classified based on severity, mechanism (closed or penetrating head injury), or other features (e.g., occurring in a specific location or over a widespread area). Head injury usually refers to TBI, but is a broader category because it can involve damage to structures other than the brain, such as the scalp and skull.
TBI is a major cause of death and disability worldwide, especially in children and young adults. Males sustain traumatic brain injuries more frequently than do females. Causes include falls, vehicle accidents, and violence. Prevention measures include use of technology to protect those suffering from automobile accidents, such as seat belts and sports or motorcycle helmets, as well as efforts to reduce the number of automobile accidents, such as safety education programs and enforcement of traffic laws.
Brain trauma can be caused by a direct impact or by acceleration alone. In addition to the damage caused at the moment of injury, brain trauma causes secondary injury, a variety of events that take place in the minutes and days following the injury. These processes, which include alterations in cerebral blood flow and the pressure within the skull, contribute substantially to the damage from the initial injury.
Generally speaking, when brain injury is severe the person is described as being in a ‘coma’. Many terms are used and sometimes you may have read these in magazines – they are difficult to explain and may have been described incorrectly. Coma is a word used to describe a person who is unconscious – or a state where the person is unable to respond to the spoken word or to a stimulus (such as a pinch to the shoulder area or on the chest). There are varying levels of coma/unconsciousness. Sometimes the person may be able to move and open their eyes, but they are unable to obey commands (semi-conscious or semi-comatose).When the brain injury is so severe the person may be so deeply comatose that they can no longer cough or swallow properly and they could inhale their own saliva. To protect the airway and lungs the patient will need a Breathing Tube or Endotracheal Tube placed into throat and be attached to a breathing machine(Ventilators (Breathing Machines) to help breathe properly. As the hours go by after a severe brain injury, the brain may start to swell and the Patient’s condition may deteriorate.
- The Central Nervous System- What does it do?
- Traumatic brain injury(TBI)
- What happens in the Intensive Care Unit?
- Continuous EEG monitoring sometimes necessary for Traumatic Brain Injuries(TBI’s)
- How long will your loved one remain in Intensive Care?
The Central Nervous System (the Brain and Spinal Cord)
What does it do?
The central nervous system(CNS) is made up of the brain, the spinal cord and the nerves. It is one of the most complex systems in the body: controlling movement, feeling, emotions, breathing, blood pressure, temperature and even our personalities. The brain is housed within the skull.
The central nervous system (CNS) is the part of the nervous system that integrates the information that it receives from, and coordinates the activity of, all parts of the body. It contains the majority of the nervous system and consists of the brain and the spinal cord. Together with the peripheral nervous system, it has a fundamental role in the control of behavior. The CNS is contained within the dorsal cavity, with the brain in the intracranial space and the spinal cord in the spinal cavity.
In the brain can be divided into 8 different areas:
- The lobes of the brain
- The meninges
- The motor and sensory cortex
- The blood supply
- The cranial nerves
- The brain stem
- The pituitary gland
- The ventricles
These different areas work together to make the body move and feel, to breathe, maintain a normal temperature and blood pressure (basic functions of life) and it allows us to process information and respond appropriately. However, when trauma, such as an outside force such as a blow to the head causes injury to the brain, one or more of these control centres may stop working. In many cases the trauma causes swelling of the brain with less oxygen reaching the affected areas of the brain.
What happens in the Intensive Care Unit?
- If your loved one has been admitted to hospital with a severe brain injury, he or she will need specialised care in an Intensive Care Unit Specialist neurosurgical services. If your loved one was injured away from a major trauma centre, he or she will need to be transferred.
- Initially if the injury can be repaired with an operation, this will happen as soon as possible. Other treatment may include:
- Your loved one is continuously monitored with a Bedside Monitors- Your loved ones vital signs such as Blood pressure is usually displayed continuously on the bedside monitor via an Arterial Catheter. Your loved ones Heart, Heart rhythm(ECG), temperature and breathing rate is continuously monitored and displayed on the monitor. Oxygen levels are continuously monitored by an oxygen saturation probe attached to the finger or to the ear. Furthermore oxygen levels are intermittently checked with ABG’s(Arterial Blood Gases), where blood is drawn out of the Arterial Catheter and tested immediately via a Blood Gas Analyser.
- Your loved ones breathing will be supported by additional oxygen via an oxygen mask, or Non- Invasive Ventilation(NIV) or BIPAP ventilation, however your loved one may be on a Ventilator (Breathing Machine) and have a Breathing Tube (Endotracheal tube) inserted into their airway. Most Multi- Traumas are in an induced Coma and therefore require mechanical ventilation with a Ventilator (Breathing Machine). Multi Trauma can also lead to Tracheostomy insertion Tracheostomy ventilation. If Your loved one is ventilated, he or she will require suctioning to remove secretions from the lungs and airways
- Your loved one may require monitoring of the pressure in the brain Intracranial Pressure Monitoring(ICP monitoring), and an external ventricular drain (EVD) to help reduce the pressure inside the brain
- Cooling blankets may be needed to keep the temperature normal.
- An air mattress may be used to prevent pressure areas developing
Continuous EEG monitoring sometimes necessary for Traumatic Brain Injuries(TBI’s)
If your loved one has been admitted to Intensive Care with a TBI (Traumatic Brain Injury), raised ICP’s(Intracranial Pressures) or intracranial hypertension may occur quite frequently. TBI, raised ICP’s and intracranial hypertension are often associated with death and disability and therefore need to be managed quite aggressively.
Barbiturates(usually Phenobarbital or Thiopental) usually act as central nervous system depressants and therefore, used in high doses in Intensive Care to manage raised ICP’s and intracranial hypertension aggressively. They are also used as anticonvulsants, preventing seizures.
If your loved one is sedated with Barbiturates, he or she usually requires continuous EEG monitoring, due to the strength of Barbiturates, compared to other less stronger sedatives, such as Propofol or Midazolam.
Please also bare in mind that Barbiturates and Thiopentone in particular, has a very long half life, meaning when the infusion is stopped, the drug redistributes from the tissue to the blood, prolonging the sedative effect.
How long will the your loved one remain in Intensive Care?
The length of time your loved one remains in Intensive Care depends on how badly injured the brain is and how quickly the person begins to recover. The recovery after TBI can be extremely slow and sometimes there is no recovery at all. One of the most frustrating things for families is that it is very difficult to predict how the person will be after a brain injury. It is often a struggle in the first few days to keep the person alive and it is only after this that the extent of the damage may be known. Having your loved one in Intensive Care after a traumatic brain injury can be an emotional roller coaster. If your loved one wakes up (regains consciousness) they may behave differently to how they would have before their injury. This may be very frustrating, uncomfortable and confronting for your loved one and for you and your Family and friends. Regaining control of the body and being able to live in society are challenges for the person who survives a major brain injury. Often life is never be the same, however sometimes after a brain injury time is a healer, but time sometimes also means many months. Be Patient. There are many organisations available to help both your loved one and their Families.
References & Internet Links
Brain Injury NSW – advocacy group for people with acquired brain injury, their family and carers and service providers. Website includes multicultural communication
Brain Foundation Australia
Brain Injury USA
https://www.headway.org.uk/home.aspx The brain injury association UK
Of course, if you have any questions or concerns, please discuss them with the ICU nurses and doctors.
All Intensive Care interventions and procedures carry a degree of potential risk even when performed by skilled and experienced staff. Please discuss these issues with the medical and nursing staff who are caring for your loved one.
The information contained on this page is general in nature and therefore cannot reflect individual patient variation. It is meant as a back up to specific information which will be discussed with you by the Doctors and Nurses caring for your loved one. INTENSIVE CARE HOTLINE attests to the accuracy of the information contained here BUT takes no responsibility for how it may apply to an individual Patient. Please refer to the full disclaimer.
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