What Happens if You Hit Your Head Again After a Severe Tbi

Traumatic brain injury

Overview

Traumatic brain injury (TBI) is sudden damage to the brain caused by a blow or jolt to the head. Mutual causes include car or motorcycle crashes, falls, sports injuries, and assaults. Injuries can range from mild concussions to severe permanent encephalon damage. While treatment for mild TBI may include residue and medication, severe TBI may require intensive care and life-saving surgery. Those who survive a brain injury tin face lasting effects in their physical and mental abilities also as emotions and personality. About people who suffer moderate to severe TBI volition need rehabilitation to recover and relearn skills.

What is a traumatic brain injury?

TBI is an injury to the brain caused by a blow or jolt to the head from blunt or penetrating trauma. The injury that occurs at the moment of impact is known as the primary injury. Primary injuries can involve a specific lobe of the encephalon or can involve the unabridged brain. Sometimes the skull may be fractured, just not always. During the bear on of an blow, the brain crashes back and forth within the skull causing bruising, bleeding, and tearing of nerve fibers (Fig. 1). Immediately after the accident the person may be confused, not think what happened, have blurry vision and dizziness, or lose consciousness. At get-go the person may announced fine, merely their condition can decline rapidly. After the initial impact occurs, the encephalon undergoes a delayed trauma – it swells – pushing itself against the skull and reducing the flow of oxygen-rich blood. This is called secondary injury, which is ofttimes more damaging than the primary injury.

Figure 1. During impact to the head, the soft brain crashes dorsum and along confronting the inside of the hard skull causing bruising, bleeding, and shearing of the brain.

Traumatic brain injuries are classified according to the severity and machinery of injury:

• Mild: person is awake; eyes open up. Symptoms can include defoliation, disorientation, memory loss, headache, and brief loss of consciousness.
• Moderate: person is lethargic; eyes open to stimulation. Loss of consciousness lasting 20 minutes to 6 hours. Some brain swelling or bleeding causing sleepiness, simply nonetheless arousable.
• Severe: person is unconscious; eyes do not open, even with stimulation. Loss of consciousness lasting more than 6 hours.

Types of traumatic brain injuries

• Concussion is a mild head injury that can cause a brief loss of consciousness and usually does not crusade permanent brain injury.
• Contusion is a bruise to a specific area of the encephalon caused past an impact to the head; likewise called coup or contrecoup injuries. In coup injuries, the encephalon is injured directly under the expanse of impact, while in contrecoup injuries it is injured on the side contrary the impact.
• Diffuse axonal injury (DAI) is a shearing and stretching of the nerve cells at the cellular level. It occurs when the brain quickly moves back and forth inside the skull, tearing and dissentious the nerve axons. Axons connect one nerve prison cell to another throughout the encephalon, like telephone wires. Widespread axonal injury disrupts the brain's normal transmission of information and can event in substantial changes in a person's wakefulness.
• Traumatic Subarachnoid Hemorrhage (tSAH) is bleeding into the space that surrounds the brain. This infinite is normally filled with cerebrospinal fluid (CSF), which acts equally a floating cushion to protect the brain. Traumatic SAH occurs when minor arteries tear during the initial injury. The blood spreads over the surface of the encephalon causing widespread furnishings.
• Hematoma is a claret clot that forms when a blood vessel ruptures. Blood that escapes the normal bloodstream starts to thicken and clot. Clotting is the body's natural way to cease the bleeding. A hematoma may be small or information technology may grow large and compress the brain. Symptoms vary depending on the location of the clot. A jell that forms between the skull and the dura lining of the brain is chosen an epidural hematoma. A clot that forms between the encephalon and the dura is chosen a subdural hematoma. A clot that forms deep inside the brain tissue itself is called an intracerebral hematoma. Over time the body reabsorbs the jell. Sometimes surgery is performed to remove big clots.

Although described as private injuries, a person who has suffered a TBI is more than probable to have a combination of injuries, each of which may have a dissimilar level of severity. This makes answering questions like "what part of the brain is hurt?" difficult, as more than one area is usually involved.

Secondary brain injury occurs as a event of the body's inflammatory response to the primary injury. Extra fluid and nutrients accumulate in an effort to heal the injury. In other areas of the body, this is a good and expected effect that helps the body heal. However, brain inflammation can be dangerous because the rigid skull limits the space available for the extra fluid and nutrients. Encephalon swelling increases pressure within the head, which causes injury to parts of the brain that were not initially injured. The swelling happens gradually and can occur up to v days after the injury.

What are the symptoms?

Depending on the type and location of the injury, the person'south symptoms may include:

• Loss of consciousness
• Confusion and disorientation
• Retentivity loss / amnesia
• Fatigue
• Headaches
• Visual problems
• Poor attention / concentration
• Sleep disturbances
• Dizziness / loss of balance
• Irritability / emotional disturbances
• Feelings of depression
• Seizures
• Airsickness

Lengthened injuries (such equally a concussion or diffuse axonal injury) will typically crusade an overall decreased level of consciousness. Whereas, focal injuries (such as an ICH or a contusion) will have symptoms based on the brain surface area affected (Fig. 2).

Figure 2. The brain is composed of three parts: the brainstem, cerebellum, and cerebrum, which is divided into lobes. The tabular array lists the lobes of the brain and their normal functions every bit well every bit problems that may occur when injured. While an injury may occur in a specific expanse, it is important to understand that the brain functions as a whole by interrelating its component parts.

Every patient is unique and some injuries can involve more than than one surface area or a partial section, making information technology hard to predict which specific symptoms the patient will experience.

What are the causes?

Common causes include falls, car or motorcycle crashes, vehicular accidents involving pedestrians, athletics, and assaults with or without a weapon.

Who is afflicted?

Approximately 1.5 to 2 million adults and children suffer a traumatic brain injury (TBI) each year in the United States. Most people who experience a caput injury, about ane.1 one thousand thousand, will accept a mild injury that does non require an admission to the hospital. Another 235,000 individuals will be hospitalized with a moderate to severe caput injury, and approximately 50,000 will die.

How is a diagnosis made?

When a person is brought to the emergency room with a caput injury, doctors volition acquire as much as possible most his or her symptoms and how the injury occurred. The person's condition is assessed quickly to determine the extent of injury.

The Glasgow Coma Score (GCS) is a 15-point test used to form a patient'due south level of consciousness. Doctors assess the patient'due south ability to 1) open his or her eyes, 2) ability to respond accordingly to orientation questions, ("What is your proper name? What is the date today?"), and iii) ability to follow commands ("Concur up two fingers, or give a thumbs upwardly"). If unconscious or unable to follow commands, his or her response to painful stimulation is checked. A number is taken from each category and added together to get the full GCS score. The score ranges from 3 to 15 and helps doctors classify an injury as mild, moderate, or severe. Mild TBI has a score of thirteen-15. Moderate TBI has a score of ix-12, and severe TBI has a score of 8 and below.

Diagnostic imaging tests will be performed:

Effigy 3. CT scan shows a blood clot (hematoma) collecting under the bone (red arrows) and displacing brain (yellow arrow) to the other side of the skull.

• Computed Tomography (CT) is a noninvasive X-ray that provides detailed images of anatomical structures within the brain. A CT scan of the head is taken at the time of injury to speedily identify fractures, haemorrhage in the brain, claret clots (hematomas) and the extent of injury (Fig. 3). CT scans are used throughout recovery to evaluate the development of the injury and to help guide controlling almost the patient's care.
  
• Magnetic Resonance Imaging (MRI) is a noninvasive test that uses a magnetic field and radiofrequency waves to give a detailed view of the soft tissues of the encephalon. A dye (contrast agent) may exist injected into the patient'southward bloodstream. MRI tin can notice subtle changes in the brain that cannot be seen on a CT scan.
• Magnetic Resonance Spectroscopy (MRS) gives information almost the metabolism of the encephalon. The numbers generated from this scan provide a general prognosis most the patient's ability to recover from the injury.

What treatments are bachelor?

Mild TBI commonly requires rest and medication to salvage headache. Moderate to severe TBI require intensive care in a infirmary. Bleeding and swelling in the brain can become an emergency that requires surgery. Withal, there are times when a patient does not require surgery and can exist safely monitored past nurses and physicians in the neuroscience intensive care unit (NSICU).

The goals of treatment are to resuscitate and support the critically ill patient, minimize secondary encephalon injury and complications, and facilitate the patient'south transition to a recovery environment. Despite significant research, doctors simply have measures to control brain swelling, merely practice not have a fashion to eliminate swelling from occurring.

Neurocritical care
Neurocritical care is the intensive care of patients who take suffered a life-threatening brain injury. Many patients with astringent TBI are comatose or paralyzed; they also may have suffered injuries in other parts of the body. Their care is overseen by a neurointensivist, a specialty-trained medico who coordinates the patient's complex neurological and medical care. Patients are monitored and awakened every hour for nursing assessments of their mental status or brain part.

Effigy four. In the NSICU, the patient is connected to numerous machines, tubes, and monitors. The monitoring equipment provides information about body functions and helps guide care. Some equipment may take over sure functions, such as animate, nutrition, and urination, until the patient's torso is able to do these things on its own.

Seeing a patient who has suffered a severe TBI tin be shocking. It is possible that your loved one's appearance will be altered because of facial injury and equipment that is used for monitoring. Numerous tubes, lines, and equipment may be used to closely monitor his or her heart rate, blood pressure, and other critical body functions. (Fig. 4)

Effigy 5. A encephalon oxygen and cerebral blood flow monitor is inserted into the brain tissue and secured to the skull with a bolt. A catheter is inserted into the ventricle of the brain to monitor intracranial force per unit area (ICP). If pressure is also loftier, the CSF fluid can exist tuckered from the ventricles.

• Intracranial pressure (ICP) monitor. A catheter is placed through a modest hole in the skull and positioned inside the ventricle (fluid-filled area deep inside the brain) to measure pressure within the head (Fig. v). The ICP monitor allows the NSICU team to intervene apace if the pressure becomes likewise high. Typical intracranial pressure is less than 20 mmHg. However, there are times when a college number is prophylactic and acceptable.
• Encephalon oxygen monitor (Licox). A catheter is placed through a small hole in the skull and positioned within the brain tissue. The Licox measures the oxygen level and temperature within the encephalon. Adjustments in the amount of oxygen given to the patient are often made to maximize the encephalon'due south oxygen level. A cognitive blood flow monitor, called a Hemedex, is a newer monitor that is placed with the Licox and helps the NSICU squad evaluate claret flow through the encephalon.
• Ventilator. Some patients may crave a ventilator, a machine that helps them breathe. The ventilator is connected to the patient by the endotracheal tube, or ET tube. The tube is placed into the patient's mouth and down into the trachea, or windpipe. The tube allows the machine to push air into and out of the lungs, thereby helping the patient breathe.
• Feeding tube. When patients are on a ventilator or have a decreased level of alertness, they may non exist able to consume or go sufficient nutrition to see their needs. A nasal-gastric feeding tube may be inserted through the patient'due south nose and passed down the throat into the tum. It delivers liquid diet also every bit any medication that is required.
• Seizures and EEG monitoring. A seizure is an aberrant electrical discharge from the encephalon. Approximately 24% of patients who suffer a TBI will have a seizure that is undetected unless they are monitored by an electroencephalogram (EEG). Seizures that are non visible to the human eye are referred to as not-convulsive seizures. Because these seizures are serious, all patients with a severe TBI are monitored with continuous EEG for 24 to 72 hours after injury.

Medication

• Sedation and hurting. Afterwards a head injury information technology may be necessary to continue the patient sedated with medications. These medications can be turned off quickly in order to awaken the patient and check their mental status. Considering patients often accept other injuries, hurting medication is given to go along them comfy.
• Decision-making intracranial pressure. Hypertonic saline is a medication used to control pressure within the brain. Information technology works past cartoon the extra water out of the brain cells into the blood vessels and allowing the kidneys to filter information technology out of the blood.
• Preventing seizures. Patients who've had a moderate to severe traumatic encephalon injury are at college risk of having seizures during the first week subsequently their injury. Patients are given an anti-seizure medication (levetiracetam or phenytoin) to foreclose seizures from occurring.
• Preventing infection. Although every try is fabricated to prevent infection, the risk is e'er present. Whatsoever device placed inside the patient has the potential to innovate a microbe. If an infection is suspected, a test will be sent to a laboratory for analysis. If an infection is present, it will exist treated with antibiotics.

Surgery

Surgery is sometimes necessary to repair skull fractures, repair bleeding vessels, or remove large blood clots (hematomas). Information technology is also performed to relieve extremely high intracranial force per unit area.

• Craniotomy involves cutting a hole in the skull to remove a bone flap so that the surgeon can admission the brain. The surgeon and so repairs the harm (e.grand., skull fracture, bleeding vessel, remove large blood clots). The bone flap is replaced in its normal position and secured to the skull with plates and screws.

Figure 6. A large decompressive craniectomy is removed and the dura is opened to allow the brain to aggrandize. Claret clots are removed and bleeding vessels are repaired. The bone flap is frozen and replaced about half-dozen weeks later.

• Decompressive craniectomy involves removing a big department of bone so that the brain tin swell and expand. This is typically performed when extremely high intracranial pressure level becomes life threatening. At that fourth dimension the patient is taken to the operating room where a large portion of the skull is removed to requite the brain more room to groovy (Fig. half-dozen). A special biologic tissue is placed on superlative of the exposed encephalon and the pare is airtight. The bone flap is stored in a freezer. One to 3 months after the swelling has resolved and the patient has stabilized from the injury, the os flap is replaced in another surgery, called cranioplasty.

Other surgical procedures may be performed to aid in the patient's recovery:

• Tracheotomy involves making a small incision in the cervix to insert the breathing tube direct into the windpipe. The ventilator will then exist connected to this new location on the neck and the onetime tube is removed from the oral fissure.
• Percutaneous Endoscopic Gastrostomy Tube (PEG) is a feeding tube inserted directly into the stomach through the intestinal wall. A modest photographic camera is placed down the patient's throat into the stomach to aid with the procedure and to ensure correct placement of the PEG tube (see Surgical Procedures for Accelerated Recovery).

Clinical trials

Clinical trials are enquiry studies in which new treatments—drugs, diagnostics, procedures, and other therapies—are tested in people to encounter if they are safety and constructive. Research is always being conducted to improve the standard of medical care. Information about electric current clinical trials, including eligibility, protocol, and locations, are institute on the Web. Studies can be sponsored by the National Institutes of Health (run across ClinicalTrials.gov) as well equally private industry and pharmaceutical companies (see CenterWatch.com).

Recovery & prevention

The recovery procedure varies depending on the severity of the injury, but typically progresses through stages: coma, confusion / amnesia, and recovery.

• When a patient is in a coma, his or her eyes are closed and they testify minimal reaction when spoken to or stimulated. Movements that may exist seen at this time are bones reflexes or automated responses to a stimulus. The brain wave activity in a comatose person is very different from that of a sleeping person.
• When a patient begins to awaken, the first natural response is that of bodily protection. Patients at this phase volition move away from whatsoever stimulus or tend to pull at items attached to them in an attempt to remove anything that is uncomfortable or irritating. His or her optics may exist open more often, just they may not exist enlightened of their beliefs or exist able to interact in a meaningful way. It is common for a patient to respond to each stimulus (hearing, seeing, or touching) in the same way. Responses may include increased rate of breathing, moaning, moving, sweating, or a rise in blood pressure.
• As the patient continues to wake upwardly, their interactions may become more than purposeful. They may look at a person and follow them around the room with their eyes, or follow elementary commands such as "Agree up your thumb." Patients tend to be dislocated and may have inappropriate or agitated behaviors.

Not all head injuries are the aforementioned. Patients recover at different rates and to varying degrees. It is difficult to make up one's mind at what betoken a patient volition start understanding and interacting with their caregivers or family in a meaningful style. It is important to have patience; recovery from a brain injury tin can take weeks, months, or even years.

The Family unit's Office
Many family members express feelings of helplessness when their loved ane is in the NSICU. You lot are non alone. Delight take intendance of yourself and use your free energy wisely.

Visiting hours are limited in the NSICU. Too much stimulation can arouse the patient and heighten his or her blood pressure. You lot can well-nigh finer convey your concern by sitting quietly and belongings your loved one's hand. Be aware that the patient, though silent, may hear anything you say. Never speak as if the patient were not in that location.

As patients recover, they need assistance understanding what has happened to them during this "lost catamenia of fourth dimension." Keep in mind that the recovery of consciousness is a gradual process – non just a thing of waking upwards. Progress is commonly tracked in iii areas: move, thinking, and interacting. You can assistance by keeping a diary of their progress. Family photos may assist with regaining memory.

Rehabilitation
Most patients are discharged from the hospital when their condition has stabilized and they no longer require intensive care. A social worker will work closely with the family equally preparations are made for a return dwelling or for transfer to a long-term intendance or rehabilitation centre.

• A long-term acute care (LTAC) facility is a place for patients who accept stabilized from their initial injury simply who still require a ventilator or frequent nursing intendance. Many patients are discharged to an LTAC to continue being weaned from the ventilator. Once off the ventilator, they can exist moved to a rehabilitation or skilled nursing facility.
• A rehabilitation facility is a place for patients who practise not require a ventilator but who withal require help with basic daily activities. Physical and occupational therapists work with patients to aid them achieve their maximum potential for recovery. Rehab facilities are either Acute Inpatient Rehab that require patients to participate in 3 hours or more of rehab a 24-hour interval or a Skilled Nursing Facility (SNF) that provide one-three hours of rehab a twenty-four hour period depending on what the patient can tolerate.

Recovering from a brain injury relies on the brain's plasticity—the ability for undamaged areas of the brain to have over functions of the damaged areas. It also relies on regeneration and repair of nerve cells. And most importantly, on the patient's difficult work to relearn and compensate for lost abilities.

• A physical therapist helps patients rebuild and maintain force, balance, and coordination. They can piece of work with the patient in whatsoever facility.
• An occupational therapist helps patients to perform activities of daily living, such as dressing, feeding, bathing, toileting, and transferring themselves from one place to another. They also provide adaptive equipment if a patient has difficultly performing a task.
• A oral communication therapist helps patients by monitoring their power to safely consume food and helping with communication and cognition.
• A neuropsychologist helps patients relearn cognitive functions and develop compensation skills to cope with memory, thinking, and emotional needs.

Prevention

Tips to reduce the hazard for a head injury:

• Always habiliment your helmet when riding a bicycle, motorcycle, skateboard, or all-terrain vehicle.
• Never drive under the influence of alcohol or drugs.
• E'er wear your seat chugalug and ensure that children are secured in the appropriate child safety seats.
• Avoid falls in the home by keeping unsecured items off the flooring, installing rubber features such equally non-slip mats in the bathtub, handrails on stairways, and keeping items off of stairs.
• Avert falls by exercising to increase force, balance, and coordination.
• Store firearms in a locked cabinet with bullets in a dissever location.
• Clothing protective headgear while playing sports.

Sources & links

If y'all take questions, please contact Mayfield Brain & Spine at 513-221-1100.

Support groups provide an opportunity for patients and their families to share experiences, receive back up, and learn about advances in treatments and medications.

Sources

1. Brain Trauma Foundation: Guidelines for the Management of Severe Traumatic Encephalon Injury. J Neurotrauma 24 Suppl 1:S1-106, 2007
2. Johnson G. Traumatic Encephalon Injury Survival Guide, 2004. www.tbiguide.com

Links
Brain Injury Association of America, BIAusa.org
Encephalon Injury Clan of Ohio, BIAoh.org
Brain Trauma Foundation, Braintrauma.org

Glossary

closed head injury: brain injury from an external impact that does not break the skull.

coma: a state of unconsciousness from which the person cannot be aroused; Glasgow Blackout Calibration score of eight or less.

concussion: widespread injury to the encephalon caused by a hard blow or vehement shaking, causing a sudden and temporary impairment of brain function, such as a short loss of consciousness or disturbance of vision and equilibrium.

contusion: a bruise to a specific area of the encephalon; caused by an bear upon and broken blood vessels.

diffuse axonal injury (DAI): injury to the nervus cell axons from rapid rotational or deceleration of the brain. DAI is often seen in motor vehicle accidents or shaking injuries. The nerve axons, which compose the white matter of the brain, are twisted or torn by shearing forces.

edema: tissue swelling caused past the aggregating of fluid.

hematoma: a blood clot.

hydrocephalus: an abnormal build-up of cerebrospinal fluid usually caused by a blockage of the ventricular arrangement of the encephalon. Increased intracranial pressure can compress and impairment brain tissue. As well chosen "water on the brain."

intracranial pressure (ICP):pressure inside the skull. Normal ICP is 20mm HG.

ischemia: a low oxygen state ordinarily due to obstruction of the arterial blood supply or inadequate blood period in the tissue.

open head injury: penetration of the skull pushing skull fragments or  objects (bullet) into the encephalon.

ventricles: hollow areas in the heart of the brain containing cerebrospinal fluid. There are four ventricles: two lateral ventricles (one on each side of the encephalon), the third ventricle, and the fourth ventricle.

updated > 7.2018
reviewed by > Michael Kachmann, MD, Mayfield Clinic, Cincinnati, Ohio

Mayfield Certified Health Info materials are written and developed by the Mayfield Dispensary. We comply with the HONcode standard for trustworthy wellness information. This information is non intended to replace the medical advice of your wellness care provider.

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