tbi_patient_hospitalMedical care usually begins when paramedics or emergency medical technicians arrive on the scene of an accident or when a TBI patient arrives at the emergency department of a hospital. Because little can be done to reverse the initial brain damage caused by trauma, medical personnel try to stabilize the patient and focus on preventing further injury.

Primary concerns include insuring proper oxygen supply to the brain and the rest of the body, maintaining adequate blood flow, and controlling blood pressure. Emergency medical personnel may have to open the patient’s airway or perform other procedures to make sure the patient is breathing. They may also perform CPR to help the heart pump blood to the body, and they may treat other injuries to control or stop bleeding.

Because many head-injured patients may also have spinal cord injuries, medical professionals take great care in moving and transporting the patient. Ideally, the patient is placed on a back-board and in a neck restraint. These devices immobilize the patient and prevent further injury to the head and spinal cord.

Medical professionals take great care in moving and transporting head-injured patients. Often back-boards and neck restraints are used to immobilize patients and prevent further injury.

As soon as medical personnel have stabilized the head-injured patient, they assess the patient’s condition by measuring vital signs and reflexes and by performing a neurological examination. They check the patient’s temperature, blood pressure, pulse, breathing rate, and pupil size in response to light.

They assess the patient’s level of consciousness and neurological functioning using the Glasgow Coma Scale, a standardized, 15-point test that uses three measures – eye opening, best verbal response, and best motor response – to determine the severity of the patient’s brain injury.

Glasgow Coma Scale

The eye opening part of the Glasgow Coma Scale has four scores:

  • 4 indicates that the patient can open his eyes spontaneously.
  • 3 is given if the patient can open his eyes on verbal command.
  • 2 indicates that the patient opens his eyes only in response to painful stimuli.
  • 1 is given if the patient does not open his eyes in response to any stimulus.
The best verbal response part of the test has five scores:

  • 5 is given if the patient is oriented and can speak coherently.
  • 4 indicates that the patient is disoriented but can speak coherently.
  • 3 means the patient uses inappropriate words or incoherent language.
  • 2 is given if the patient makes incomprehensible sounds.
  • 1 indicates that the patient gives no verbal response at all.
The best motor response test has six scores:

  • 6 means the patient can move his arms and legs in response to verbal commands.
  • A score between 5 and 2 is given if the patient shows movement in response to a variety of stimuli, including pain.
  • 1 indicates that the patient shows no movement in response to stimuli.

The results of the three tests are added up to determine the patient’s overall condition. A total score of 3 to 8 indicates a severe head injury, 9 to 12 indicates a moderate head injury, and 13 to 15 indicates a mild head injury.

Imaging tests help in determining the diagnosis and prognosis of a TBI patient. Patients with mild to moderate injuries may receive skull and neck X-rays to check for bone fractures or spinal instability. The patient should remain immobilized in a neck and back restraint until medical personnel are certain that there is no risk of spinal cord injury. For moderate to severe cases, the gold standard imaging test is a computed tomography (CT) scan. The CT scan creates a series of crosssectional X-ray images of the head and brain and can show bone fractures as well as the presence of hemorrhage, hematomas, contusions, brain tissue swelling, and tumors. Magnetic resonance imaging (MRI) may be used after the initial assessment and treatment of the TBI patient. MRI uses magnetic fields to detect subtle changes in brain tissue content and can show more detail than X-rays or CT. Unfortunately, MRI is not ideal for routine emergency imaging of TBI patients because it is time-consuming and is not available in all hospitals.

Approximately half of severely head-injured patients will need surgery to remove or repair hematomas or contusions. Patients may also need surgery to treat injuries in other parts of the body. These patients usually go to the intensive care unit after surgery.

Sometimes when the brain is injured swelling occurs and fluids accumulate within the brain space. It is normal for bodily injuries to cause swelling and disruptions in fluid balance. But when an injury occurs inside the skull-encased brain, there is no place for swollen tissues to expand and no adjoining tissues to absorb excess fluid. This increased pressure is called intracranialpressure (ICP) .

Medical personnel measure patients. ICP using a probe or catheter. The instrument is inserted through the skull to the subarachnoid level and is connected to a monitor that registers the patient’s ICP. If a patient has high ICP, he or she may undergo a ventriculostomy , a procedure that drains cerebrospinal fluid (CSF) from the brain to bring the pressure down. Drugs that can be used to decrease ICP include mannitol or barbiturates, although the safety and effectiveness of the latter are unknown.

tbi_tomography_scanA computed tomography scan creates X-ray images of the head and brain.

This imaging test can show bone fractures, hemorrhages, hematomas, contusions, brain tissue swelling, and tumors, and can help determine the prognosis of TBI patients.