Tuesday, March 29th
On March 29th 1994, Shawn’s Toyota Corolla was broadsided on the passenger side by a truck at an intersection. The accident was not Shawn’s fault and he was wearing his seat belt as he always did. It was at a very troublesome intersection where there was at least one accident per day. The truck that hit Shawn was going too fast and could not stop. An off duty police officer, who was on the scene in two minutes, administered CPR on Shawn. Shawn was not breathing and had no heartbeat and it took the team twenty five minutes to start his heart. His temperature was only 72 degrees when he reached the hospital.
The doctors gave Shawn about a 5% chance to live saying if he did survive he would be severely brain damaged. At one point, thinking Shawn would only have an hour or two to live, they brought the family in with a minister to say goodbye. At one point while the family was holding hands and praying the numbers on the monitor began to change. There was hope.
Shawn's family held out hope that Shawn would somehow come back to them any way he could and would proudly embrace the tough road ahead. Shawn was a fighter and he fought hard over the next four and a half years even though his body remained in an unresponsive state.
The head injury Shawn sustained was considered then to be a “closed head injury”. It wasn’t very long ago that doctors made the distinction between open and closed head injuries. In an open head injury the skull is fractured and physicians assumed this type of injury would produce a severe head injury. In a closed head injury the skull is NOT fractured and the thought was that these produce less severe injuries. That wasn't the case. What physicians have since found out is in a closed head injury pressure can build up, damaging brain tissue. However, if you fracture the skull you may let off excess pressure which can save the brain from further damage. Because of the wide variation in patients these terms are no longer used.
Traumatic Brain Injury (TBI) occurs when the brain is damaged from the result of a blow to the head. Some injuries can be considered minor, with little to no lasting effects, to extreme, resulting in permanent disability and even death. Medical advances today have improved the odds for surviving TBI, more so than what was available in 1994. However, those who suffer TBI can still be faced with life-altering challenges that can effect family, friends, and day to day living.
How common is TBI?
The Brain Injury Association of America's statistics say:
Other statistics found that TBI occurs twice as often in men as it does in women and the ages for highest risk are between 15 and 24 years, and 75 years or older. Studies have shown that half of all victims of TBI were injured through accidents caused by motor vehicle, bicycle, or vehicle/pedestrian accidents.
More studies showed that the greatest risk occurs during weekends and summer months from mid-afternoon to early evening. Children were found to be at risk after school and half of children’s injuries occur in roads, followed by the home and other recreational areas.
According to the CDC, in the United States the cost of TBI is estimated at $48.3 billion annually. Hospital costs alone are $31.7 billion while other facilities costs are another $16.6 billion. The CDC estimates the total costs of acute care and rehab for TBI victims is $9 - 10 billion per year. None of that includes costs to victims and families for lost earnings, costs for caregivers or social services, and overall time. It’s estimated that the total lifetime cost for a survivor of severe TBI can be between $600,000 - $1.8 million.
Anatomy of the Brain
The brain is what controls all functions of the body and processes and is considered the “hub” of the central nervous system. The brain, surrounded by cerebrospinal fluid (CSF) and protective bone called the skull or cranium, on average weighs around three pounds. It’s soft gelatin texture is held together by three layers of membranes – the dura, pia, and arachnoid. The subarachnoid, the space between the pia and arachnoid, holds a network of arteries and veins through which blood is carried to and from the heart. When these blood vessels are injured it can lead to blood clots that can exert pressure against the brain’s soft tissue.
The brain stem is the lower part of the brain which passes through a hole at the base of the skull and then merges with the spinal cord and other parts of the nervous system. The brain stem carries signals to and from all parts of the body. It regulates blood pressure and heart rate. When the stem is damaged it can cause concussion of the brain, or loss of consciousness. The nerve tissues that provide our balance and coordination of motor skills is called the cerebellum. The cerebellum allows an athlete to move with speed and prescion or shoot a basketball with accuracy.
The largest part of the brain is the cerebral cortex which joins the right and left cerebral hemispheres. The right hemispheres is what controls the left side of the body, and the left hemisphere controls the right side. The left hemisphere controls language and speech in most people while the right side controls skills such as playing the piano or drawing a picture. When the right side of the brain is damaged it can effect movement on the left side of the body, even hearing and vision on the left side. Damage to the left side of the brain can effect movement in the right side of the body as well as speech.
The cerebral cortex is divided into several area called lobes. The frontal lobes, located just behind the forehead, controls our personality traits, behavior, as well as our emotions. It also controls our ability to solve problems and organize. The temporal lobes, which sit behind and below the frontal lobes - just behind the ears, controls our speech, comprehension, and our memory. Located at the back of the head and above the ears sits the parietal lobes. They control our ability to read and write and the area between the frontal and parietal lobes provides our movement and sensations. Our eye sight is controlled by the occipital lobes that sit at the back of the head.
In the middle of the cerebral cortex are several white nuclei called the diencephalons. The hypothalamus regulates our temperature, thirst and appetite. Some of our emotions and moods are also controlled by the limbic system which is also located in these nerve centers.
The importance in keeping pressure off parts of the brain is once they are damaged they can impair all the different functions they control. That’s not to say once someone has injured part of their brain the abilities are impacted forever. Each case and injury is different.
There are three stages of treatment for TBI:
Acute level patients need to be stabilized immediately after the injury.
Subacute level patients are then rehabilitated for return to community.
Chronic level patients are rehabilitated long term to treat and repair impacted abilities.
Until recently doctors believed patients who sustained TBI should receive no fluids. The thought was that denying fluids would eliminate potentially damaging edema (an excessive accumulation of serous fluid in tissue spaces) or swelling. Patients with TBI would actually go days without nourishment. Recent studies showed that TBI victims need at least 40 percent more calories than normal. That means TBI patients need MORE food and fluids and should not be dehydrated.
Other treatments involved hyperventilating patients to reduce pressure inside the skull. It reduced pressure by decreasing blood flow which also reduced oxygen to the brain. Today physicians can monitor the amount of oxygen to the brain through a probe in the jugular vein. Not every injury is the same and monitoring each patient's individual need for oxygen is what is physicians and specialists practice today. Sadly, some of the common treatments practiced yesterday on TBI patients would actually be considered harmful today.
The original monitors of intracranial pressure were fluid-filled catheters inserted into the ventricles of the brain. The monitors today are miniature pressure transducers that only need to be inserted about a centimeter into the brain. The risk of complications is much lower than what was previously used. Also, moving patients with TBI to and from different floors for CT scans can be dangerous. Today portable CT scanners are used so that critical patients don't have to endure the elevators or hallways as even the slightest movement can be harmful to brain injuries.
The main objective in dealing with TBI is to prevent damage and that starts as soon as the patient arrives at the hospital. Today physicians can use microdialysis to determine what chemicals are accumulating in the brain. After injury the brain releases glutamate which kills neurons. If swelling or edema occurs it can shut off blood flow killing more cells. After a few days inflammation can occur that release cell-killing chemicals. Monitoring what is happening with neurotransmitters and other chemicals of the brain can give physicians advantages to determine any underlying injury processes so that they can prevent further damage to the brain.