by Dr John Rees
The trauma of brain injury can be deeply affecting to all those involved. Dr Rees helps us understand this condition and after care
Head injury and by implication, traumatic brain injury is a common cause of admission to A&E centres around the country. Fortunately, only a small number are serious and require detailed medical attention.
Although the brain is surrounded and protected by a very strong bony cage, the skull can be fractured in a head injury. The fracture can be a simple ‘crack’ or complicated when bits of broken bone penetrate the brain and cause serious damage. Skull fracture can be associated with bleeding both inside the brain and on the surface of the brain which can be trivial or life threatening. What is less obvious is that the brain is a semi solid, so that when the skull hits or is hit by something hard, or is subject to rapid deceleration, the brain as it were ‘sloshes around’ inside the rigid skull. This may cause bleeding and may also be associated with rotational forces that can twist the upper part of the brain on its ‘stalk’ and cause tearing of many nerve fibres which are essential parts of the brain’s communication network.
There is an international system of assessing the degree of brain damage known as the Glasgow Coma Scale (GCS),which ranges from 0 to 15, 15 being normal. Ambulance personnel, A&E doctors and neurosurgeons around the world use this scale when a head injury has occurred to assess the patient. At a much later stage, the degree of memory loss after the event, called the ‘post traumatic amnesia’ period, is a helpful guide to the degree of brain injury sustained.
Once the patient has been stabilised, they are rapidly transferred to hospital (by helicopter if necessary), where a full assessment of the brain and any other injuries can be made. Detailed clinical examination including GCS, will help to indicate the degree and site of brain damage and this will be complimented with an urgent CT scan, looking for intracranial bleeding, the possibility of pressure on the brain, lacerations of the brain itself and blood clots within the brain. All of these possibilities will be assessed in conjunction with, as is often the case, major trauma to other parts of the body. Neurosurgery is an important part of any major trauma centre.
Brain injury may require immediate surgery and this may be lifesaving. Patients can be deeply unconscious and require help breathing in spite of a fairly normal looking CT scan because the injury has caused microscopic damage and swelling of the brain. Managing the increased pressure on the brain can be a major part of treatment. Sedation is often part of the intensive care that these patients need.
For a minority of patients, the degree of brain damage proves fatal. For others, when they recover consciousness, regular detailed assessment of neurological and intellectual function will be necessary, accompanied by physio and occupation therapists trained in head injury management. Many patients will need a formal assessment of IQ which may display significant problems which may affect work and social life even when they have made an excellent physical recovery. This aspect of post head injury management requires stressing so that all patients are properly assessed after the event and do not slip through the net.
Headway is a national charity that has been critical in brain injury management, the Brain and Spine Foundation can also help.