A traumatic injury devastates the lives of survivors and their families; the injured person’s needs are complex: they must learn new ways to physically carry-out daily activities and/or emotionally cope with being more dependent on others for basic needs (like feeding or toileting). On top of the pains of recovery and rehabilitation, the injured person and their families or care-givers will need to navigate the healthcare system, interfacing with doctors, lawyers, government agencies, etc. Navigating the “system” can be confusing and demanding; the uncertain outcomes and constant pressure puts a strain on everyone’s ability to cope, and has a negative effect on the survivor’s recovery.

Medical Case Management

Medical Case Management refers to the planning and coordination of healthcare & other professional services; it may include, but is not limited to, evaluating the status of a person’s medical condition, developing and implementing a plan of care, coordinating medical resources, communicating healthcare needs, monitoring an individual’s progress, and facilitating cost-effective care.

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Social Work Support

Anyone facing a life-altering event, chronic condition, disability, or everyday stressors may benefit from social work; it helps a person to resolve emotional and mental concerns, manage on-going or recurring challenges, and overall maximize their quality of life. A social worker addresses an individual’s physical and social needs to minimize the negative effects of life’s difficulties and complications.

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With a traumatic brain injury, damage may occur directly at the site of impact (coup injury), or it may occur on the side opposite the impact (contrecoup injury). When a moving object impacts the stationary head, coup injuries are typical, while contrecoup injuries are usually produced when the moving head strikes a stationary object.

Primary and Secondary Injury

Primary brain injury is the damage that occurs at the moment of trauma (e.g., a blow to the head) when tissues and blood vessels are stretched, compressed, and torn. Secondary injury is the damage that occurs in the minutes to days following the initial trauma. Secondary injury can dramatically worsen the damage caused by primary injury; problems such as ischemia (insufficient blood flow); cerebral hypoxia (insufficient oxygen in the brain); cerebral edema (swelling of the brain); and raised intracranial pressure (the pressure within the skull) account for a large percentage of TBI deaths.

How does the Brain Get Injured?

The brain is a soft organ (like gelatin) that is surrounded-by and floats-in cerebrospinal fluid within the skull. Normally, the fluid around the brain acts like a cushion that keeps the brain from colliding with the walls of the skull; but, if the head is struck or jolted with enough force, the brain can crash into the inner walls of the skull causing the brain to bruise, bleed, tear, or swell.

When a traumatic brain injury occurs, the injured person may experience physical, cognitive, or behavioral effects. Symptoms are dependent on whether the injury is localized or widespread, the severity of the injury, and the part(s) of the brain that are affected.

Mild, Moderate, and Severe TBI

With mild TBI, a person may remain conscious or may lose consciousness for a few seconds or minutes. Outside of losing consciousness, other symptoms may not be present or noticed at the time of the injury; it may take days or weeks before they appear. The symptoms are often subtle and may be missed by the injured person, family, friends, or medical professionals. A person with moderate to severe TBI may have the same symptoms as found in mild TBI, but to a greater degree; for example, a headache that does not go away, repeated vomiting or nausea, an extended loss of consciousness (more than 30 minutes), dilated pupils, or slurred speech.

Physical Effects

• Headaches
• Difficulty speaking
• Blurry eyesight
• Trouble hearing
• Loss of energy
• Change in sense of taste or smell
• Dizziness or trouble walking
• Stiffness/weakness
• Lack of coordination/balance
• Problems with sleep/fatigue
• Seizures
• Slurred speech/no speech
• Bladder/bowel control

Cognitive Effects

• Difficulty concentrating
• Trouble with attention
• Forgetfulness
• Difficulty making decisions
• Repeating things
• Slowed thinking
• Trouble completing tasks
• Difficulty with learning
• Impaired judgment
• Altered smell/taste/hearing/vision
• Difficulty sequencing
• Loss of personal safety skills

Behavioral Effects

• Becoming angry easily
• Getting frustrated easily
• Acting without thinking
• Irritability/impatience
• Anxiety
• Depression
• Low self-esteem
• Difficulty reading social clues
• Mood swings
• Inability to cope
• Self-centeredness

Signs of Traumatic Brain Injury in Small Children

Infants and young children with brain injuries may lack the communication skills to report headaches, sensory problems, confusion and similar symptoms. In a child with traumatic brain injury, you may observe:

• Change in nursing or eating habits
• Persistent crying
• Unusual or easy irritability
• Change in ability to pay attention
• Inability to be consoled
• Change in sleep habits
• Sad or depressed mood
• Loss of interest in favorite toys or activities

Dealing with a Brain Injury

Soon after the injury, most people tend to focus on the abilities that have been lost. Emotionally, the experience can be overwhelming, confusing, and frustrating. But as time goes on, everyone begins to grapple with their injury in both productive and non-productive ways. One common response is to deny the significance of the injury; unfortunately, a brain injury can’t simply be “walked off.” Brains are notoriously slow to heal, which only compounds the frustrating aspects of TBI. Brain injury also has a tendency to bring a lot of emotional challenges and may affect mental health. Depression, anger, and anxiety are common repercussions of brain injury, so people with TBI should be vigilant to seek out qualified care and support if they experience mental health problems. As people begin to regain lost abilities or acquire new coping skills, they also begin to accept the realities of their injury. At this stage, a person might express that they are no longer fighting the injury but rather seeking ways to integrate their TBI into their lives. For most people who experience a brain injury, life will return to a similar pace. But for many others, a TBI may mean months, years, or even a lifetime full of changes.

Moving Forward After TBI

A brain injury sets off a clear chain of medical events, all of them around the injured person’s healthcare: the emergency room, intensive care, hospital recovery, and then rehabilitation. But there isn’t a roadmap for all the aspects of life that fall outside of medical care as life marches on despite the injury. While most people who sustain a TBI recover quickly, for those with moderate to severe TBIs — and their families — life may need to be reinvented, reinterpreted and accepted as something different.

Communicating with TBI Survivors

• Speak in short sentences
• Give time to respond
• Repeat information
• Avoid over stimulation
• Put things in writing

Returning to Play After a Head/Brain Injury

The decision about when a player can safely return to play must be made by a doctor. Doctors and other concussion specialists agree that a player must not return to play until symptoms are completely gone, both at rest and during exercise or exertion; children and teens have longer recovery times, so they may have to wait longer before they can return to play. Brain functions are likely disrupted for approximately 30 days after a Mild Traumatic Brain Injury. A graduated return to cognitive and general physical activity can be undertaken once there are no symptoms, but the patient should not return to activities that risk a blow to the head for at least 30 days after the initial injury. Returning to sports activity should be done only under the advice of a physician who specializes in Mild Traumatic Brain Injury.

Most people who have had a significant brain injury will require rehabilitation. They may need to relearn basic skills such as walking, eating, or talking; the goal is to improve their abilities to function at home and in the community.

Acute Rehabilitation

As early as possible in the recovery process, individuals who sustain brain injuries will begin acute rehabilitation. The treatment is provided in a special unit of the trauma hospital, a rehabilitation hospital or another inpatient setting. During acute rehabilitation, a team of health professionals with experience and training in brain injury work with the patient to regain as many activities of daily living as possible. Activities of daily living including dressing, eating, toileting, walking, speaking and more.

Post-Acute Rehabilitation

When patients are well enough to participate in more intensive therapy, they may be transferred to a post-acute rehabilitation setting, such as a residential rehabilitation facility. The goal of post-acute rehabilitation is to help the patient regain the most independent level of functioning possible. Rehabilitation also involves learning new ways to compensate for abilities that have permanently changed due to brain injury.

Sub-Acute Rehabilitation

Patients who cannot tolerate intensive therapy may be transferred to a sub-acute rehabilitation facility. Sub-acute rehabilitation programs are designed for persons with brain injury who need a less intensive level of rehabilitation services over a longer period of time. Sub-acute programs may also be designed for persons who have made progress in the acute rehabilitation setting and are still progressing but are not making rapid functional gains. Sub-acute rehabilitation may be provided in a variety of settings, often a skilled nursing facility or nursing home.

Treatment and rehabilitation for traumatic brain-injury (TBI) depends on the severity and effects of the brain damage. Mild TBI may require no treatment other than rest, over-the-counter pain relievers, and close monitoring by a physician for any persistent, worsening or new symptoms. Moderate to severe traumatic brain injury may require emergency surgery and intensive care to stabilize the injured person and minimize secondary injury.

Surgery

Emergency surgery may be needed to prevent or minimize secondary damage to brain tissues; emergency surgical-procedures may include:

Removing Blood Clots

Bleeding outside or within the brain can result in a collection of clotted blood (hematoma) that puts pressure on the brain and damages brain tissues.

Repairing Skull Fractures

Surgery may be needed to repair severe skull fractures or to remove fragments of skull that have penetrated the brain.

Opening a Window in the Skull

A section of bone may be removed to relieve pressure inside the skull by draining accumulated cerebral spinal fluid and/or providing more room for swollen tissues.

Medications

• Medications that may be administered to minimize secondary brain-damage or prescribed for TBI treatment during recovery and rehabilitation may include:
• Analgesics for pain relief and discomfort
• Anti-Coagulants to minimize blood clots
• Anti-Convulsants to prevent seizures
• Anti-Depressants to treat symptoms of depression
• Diuretics to reduce fluid in tissues
• Muscle Relaxers to reduce muscle spasms
• Sedatives to induce sleep
• Stimulants to increase alertness and attention

A concussion is a mild traumatic brain injury (TBI) that alters how the brain functions. Effects are usually temporary, but can include problems with headache, concentration, alertness, memory, judgment, reflexes, speech, balance, coordination, and sleep.

What Causes a Concussion?

The brain is a soft organ (like gelatin) that is surrounded-by and floats-in cerebrospinal fluid within the skull. Normally, the fluid around the brain acts like a cushion that keeps the brain from banging into the walls of the skull. But if the head is struck with enough force, the brain can crash into the inner walls of the skull causing the brain to bruise, bleed, tear, or swell. A concussion can result from a fall, sports activity, car accident, fight, explosion, or anything that causes a forceful impact or trauma to the head. Although concussions usually are caused by a blow to the head, they can also occur when the head or upper body are violently shaken e.g., shaken baby syndrome.

Recognizing a Concussion

A loss of consciousness is a sure sign of a possible concussion, but in some cases, a person may have a concussion and not black out or even realize it. Below are some of the symptoms and warning signs that a person may have suffered a concussion.

• Drowsy or feeling spacey
• Headache
• Memory loss (amnesia)
• Nausea and vomiting
• Seeing flashing lights
• A feeling of lost time
• Convulsions (seizures)
• Muscle weakness
• Unequal pupils
• Unusual eye movements
• Walking problems

The effects of traumatic brain injuries can worsen swiftly without treatment, so doctors and other medical personnel need to assess the injury rapidly. Diagnosing a brain injury involves looking for signs of damage to the brain, either through scanning devices like computerized tomography (CT scans), magnetic resonance imaging (MRIs), and X-rays, or through screening-tests and scoring-systems that measure a person’s speech, movement, memory, and thought.

Glasgow Coma Scale

The Glasgow Coma Scale (GCS) is one of the most commonly used TBI scoring systems; it comprises three assessments: eye, verbal and motor responses. The lowest possible GCS score is 3 (deep coma or death), while the highest is 15 (fully awake). By measuring a person’s ability to move their eyes and limbs, speak coherently, and follow directions, the scale helps emergency medical-personnel to evaluate a person’s level of consciousness and diagnose the initial severity of a brain injury. Persons with GCS scores of 3 to 8 are classified as having a severe traumatic brain injury; those with scores of 9 to 12 are classified as having a moderate TBI, and those with scores of 13 to 15 are said to have a mild TBI.

When to Seek Medical Help

If there are any signs or symptoms of traumatic brain injury, go to the nearest hospital emergency room or call 911 immediately; it is important to begin emergency treatment within the “golden hour” following the injury to stabilize a person and prevent further injury. The terms mild, moderate and severe are used to describe the effect of the injury or the level of damage, but keep in mind that there is nothing “mild” about a brain injury; any injury to the brain is a serious medical condition.