Treatment Guidelines for Traumatic Brain Injury

Among the various injuries that someone could suffer in a traumatic accident, neurological damage is one of the worst consequences an individual can sustain. The brain is responsible for almost all of the body's vital functions. A traumatic brain injury (TBI) can be life-altering for the individual and family members. Therefore, everyone needs to understand some of the guidelines that have been put in place to diagnose and treat them. A neurosurgeon typically performs this if someone requires determining surgery following a TBI. Furthermore, the American Association of Neurological Surgeons (AANS) has put forth some statistics regarding TBIs.

• More than five million people live in the United States with some form of disability stemming from a TBI.
• Over 1.5 million traumatic brain injuries occur in the United States every year.
• A quarter of a million people must be admitted to a medical center.
• Around a third of these will develop a long-term disability due to their injuries.
• Males sustain brain injuries at around four times the rate of females.
• Among traumatic causes of traumatic brain injury, auto accidents are the most common.
• About a fifth of all TBIs in children and adolescents occur while playing sports, such as football, lacrosse, and soccer.
• About 30 out of every 100,000 people who suffer a traumatic brain injury will die.
• Most individuals will die within the first two hours of sustaining the injury.

Based on these numbers, it is essential to quickly diagnose and treat TBIs to save people's lives. The American College of Neurosurgeons has released a set of guidelines to help everyone understand what to do when someone sustains a blow to the head. Proper management could prove lifesaving in these situations.

The first step in treating a traumatic brain injury is accurately identifying the symptoms. There are a few common mechanisms through which somebody might suffer a TBI. These can be classified as either:

• Blunt Trauma: The impact does not break the surface of the skin.
• Penetrating Trauma: The impact has broken the surface of the skin.

Both injury types are capable of causing severe, even fatal, injuries to the brain tissue. Common mechanisms of brain injuries include:

• Car crashes, motorcycle wrecks (particularly if the rider is not wearing a helmet), and truck accidents.
• Contact sports such as soccer, football, and lacrosse.
• Slip and fall injuries on slick surfaces, including ice and wet floors.
• Tumbles down a flight of stairs, particularly without a banister or railing.

If someone has suffered a TBI, there are a few signs and symptoms for which medical professionals will watch. These include:

• A severe, unrelenting headache that is considered to some as the "worst headache of my life" or a "thunderclap."
• Waxing and waning consciousness, or a permanent loss of consciousness
• Disorientation, confusion, and an altered mental status
• Extensive trouble with vision or hearing
• Numbness or tingling of one or more limbs
• Chronic pain
• An inability to move one or more limbs
• Fear of loud noises and bright lights

In conjunction with the proper mechanism, any of the symptoms above heightens the concern for a traumatic brain injury. The next step is figuring out where the injury is located in the head.

The video below discusses traumatic brain injury, its causes, effects, and classifications.

Imaging scans identify where the injury is located in the head. This is important because it helps predict the prognosis of the injury while also giving a trained neurosurgeon a target. Two scans are commonly ordered to identify and localize a TBI. These include:

• CT Scan: This is a 3D X-ray that is fast and relatively cheap. On the other hand, it does use a large amount of radiation.
• MRI Scan: This scan produces a more detailed image and does not use radiation. Unfortunately, generating an image takes a long time and is very costly.

In an emergent setting, the CT scan is typically ordered first. If more detail is needed, an MRI can be ordered later if the patient is stable. Once the location is identified, the neurosurgeon has a target.

The guidelines published by the American Association of Neurosurgeons include recommendations on several different treatment options. One of the popular topics of discussion is decompressive craniectomy. If the brain is injured, it swells in a response similar to someone banging a knee on a hard object. When the brain swells inside of the skull, it could herniate. This can lead to severe, permanent disabilities or death. The goal of a decompressive craniectomy is to:

• Give the brain a place to swell without being enclosed by the skull.
• Prevent herniation by removing a portion of the skull.
• Help to reduce intracranial pressure (ICP) to prevent further damage to the brain.

In this procedure, a portion of the skull is removed and preserved to be reattached later. This allows the brain to swell without the risk of herniation. Based on the guidelines published by the American Association of Neurosurgeons, this procedure has been shown to reduce ICP and the number of days an individual has to spend in an intensive care unit (ICU). On the other hand, individuals who arrive with a low Glasgow Coma Scale score do not appear to have many benefits from this surgery.

The goal of cooling is to reduce the metabolic needs of the body's tissues. If their metabolic needs drop, they are less likely to become starved for oxygen or nutrients following a severe injury. This has been the subject of intense debate in the medical field. The recommendations from the AANS are as follows:

• The evidence does support using hypothermia to protect brain tissue if the individual also suffered a heart attack or cardiac arrest with the injury.
• Hypothermia has also been used to reduce ICP.
• Early use of hypothermia has not improved outcomes in patients with diffuse, severe injuries.

Therefore, hypothermia and cooling after a TBI have a place in the treatment plan. Remember that hypothermia also has numerous risks, including reducing the function of the immune system, increasing the chances of blood clot formation, and can induce cardiac arrhythmias.

As noted in the two prior sections, one of the significant dangers of a traumatic brain injury is the idea of herniation. Herniation in the brain results from increased intracranial pressure. This increased intracranial pressure (ICP) comes from brain swelling within a finite volume (defined by the skull). Therefore, in addition to surgery, medications can also reduce swelling and prevent herniation from taking place. Some of the medicines that can do this include:

• Mannitol
• Hypertonic (or hyperosmolar) saline
• Steroids, such as prednisone and methylprednisolone

In their most recent guidelines, the AANS addressed the use of these medications based on research studies that have been published. Some of their recommendations include:

• Drugs, such as mannitol and hypertonic saline, effectively reduce intracranial pressure because they draw liquid out of the brain, reducing the liquid volume and lowering pressures inside the skull.
• Reducing intracranial pressure is beneficial in individuals who have suffered a traumatic brain injury.
• Studies are still ongoing addressing whether or not these medications improve the outcomes of patients suffering a traumatic injury to the brain.

While these statements could be confusing, they say these medications work, but the definitive and objective proof is still being researched. These medications are used routinely in individuals with increased ICP (such as those who have suffered a TBI) and will likely continue to be used.

One of the other topics that the AANS guidelines addressed was the use of a CSF drainage system. As discussed above, the management of ICP is one of the cornerstones of medical therapy following a TBI. With this in mind, all measures must be considered when lowering ICP. After discussing surgical decompression and medical management, another option is implanting an EVD device. This stands for external ventricular drainage, and these systems are used to drain excess fluid off of the brain. This device is implanted surgically; therefore, the procedure does not come without risks. Based on the guidelines, the following recommendations were made:

• An EVD system placed in the brain to offer continuous CSF drainage can help individuals following a traumatic brain injury.
• The device is most effective in individuals with a Glasgow Coma Scale score of 6 or less.
• The sooner the device is implanted, the more effective it will be.

Studies regarding CSF drainage devices, such as EVDs, are ongoing, and a consensus has not yet been determined. Future studies will track the usage of EVDs in patients with various Glasgow Coma Scale scores. These studies aim to determine whether or not an EVD system leads to superior outcomes across all types of traumatic brain injuries.

Traumatic brain injuries are among the most severe consequences of an accident. The neurons in the brain do not regenerate and often leave individuals with permanent complications. It is easy to see how this can place families under tremendous stress. Because of this, everyone needs to ask for help when it is needed. Meeting with an experienced traumatic brain injury attorney in San Francisco can help families find relief. An injury lawyer can help by:

• Serving as an experienced and helpful guide to make objective decisions during a challenging time.
• Meeting with professionals in accident recreation to examine the collision mechanism, ensuring that nothing has been missed.
• Making sure that the liability following an accident has been appropriately assigned.
• Speaking with insurance companies to maximize the payout someone can receive under his or her insurance policy.
• Assisting families in seeking damages related to their traumatic brain injuries, complications, emotional pain, and suffering.
• Taking the case to court or trial if this is needed.

Take the time to contact a traumatic brain injury lawyer in San Francisco. You and your family members could be deserving of a financial award.

Everyone needs to follow the guidelines regarding traumatic brain injuries. If you or a family member have suffered a traumatic brain injury in an accident, please contact our injury attorneys at (415) 805-7284 or (800) 404-5400 for free, friendly advice.

^{Editor's Note: updated for accuracy and relevancy [cha 6.26.23] Photo by Pixabay.com dr [cs 1782]}