Traumatic Brain Injury Part IV: Classification, Prognosis & Treatment

In the final installment to our series on Traumatic Brain Injury and Litigation, we will be discussing the processes of classification, prognosis, and treatment plans.

We discussed brain anatomy and function, the specific signs and symptoms of brain injury, and the screening and the diagnosis process for TBI in Part I (found here), Part II (found here), and  Part III (found here.)

Any insult to the brain, whether minor or significant, is a severe and potentially life-changing event.

Health care providers must consider multiple factors when planning care for a Traumatic Brain Injury (TBI) patient. These processes include the classification of the injury, evaluation of the prognosis for the injury, and developing a treatment plan.

Traumatic Brain Injury Classification

Mild, Moderate, and Severe are general classifications of TBI. However, there are other, more precise methods to describe brain injuries.

Glasgow Coma Scale

The most prevalent method of determining the severity of a brain injury is the Glasgow Coma Scale, with a score of 8 or less (out of 15) indicating a severe injury.

Pathoanatomic

Pathoanatomic classification describes what part of the brain is injured and where it was injured. Some descriptors for this method include scalp laceration and contusion, skull fracture, epidural hemorrhage, subdural hemorrhage, brain contusion and laceration, and diffuse axonal injury (injury to the nerve axons in more than one place in the brain).

Etiological

Etiological classification is a description of the physical mechanism of injury (car crash versus being hit by a baseball):

• Impact loading describes an injury that occurs when the head is struck or strikes an object. This type of force causes fracture and contusions.
• Noncontact or “inertial” loading injury occurs when the brain moves within the skull. Inertial loading generally causes more diffuse injuries such as a concussion or diffuse axonal injury.

Health care providers consider all the above information when formulating an opinion regarding the severity of the TBI. Prognostic indicators may be developed once appropriate descriptors have been applied to the individual patient.

Prognosis

The prognosis of a traumatic brain injury varies with the classification and severity of the injury. Although most individuals can recover from a mild traumatic brain injury in 3-12 months, other individuals develop long term problems and disability even with a mild injury.

Additional factors impact recovery from a traumatic brain injury:

• Prehospital treatment (maintenance of appropriate oxygen and blood pressure levels) has been shown to double the survival of severely brain-injured patients.)
• While the length of recovery is longer in those over 55, patients with a moderate to severe concussion eventually recover to about the same degree as younger patients.
• The location of brain injury determines how the person is impaired. For instance, a frontal lobe injury may cause impulsiveness, aggression, or personality changes.
• Length of time spent unconscious or in a coma may influence the length of the recovery period.
• Repetitive head injuries, such as from car accidents or falls may increase the risk for delayed onset of problems such as memory loss or difficulty in reasoning
• Comorbidities such as high blood pressure and diabetes may elevate the risk for delayed recovery from TBI.
• Post-injury alcohol consumption negatively impacts mental and physical health, vocational and educational functioning, and overall quality of life.
• Chronic cigarette smoking has been associated with diminished recovery after TBI in several neurocognitive domains.
• Physiologic instability, or additional injuries, may influence the outcome of TBI.
• Even mild head injuries may lead to continued, long term neurodegenerative processes in the form of axonal (white matter) degeneration.
• TBI may increase the risk for development of Alzheimer’s disease later in life

The prognosis for TBI is never clear cut. The type of TBI, mechanism of injury, and risk factors noted above will all come into play to suggest the outcome of the injury.

On a more hopeful note, many patient-specific factors impact individual recovery. While TBIs are the leading cause of death and disability globally, all TBI patients will not necessarily suffer the most tragic outcome.

Treatment and Rehabilitation for TBI

There are several phases of treatment and rehabilitation for TBI. Each phase -acute inpatient treatment, inpatient rehabilitation treatment and residence-based rehabilitation and community reintegration – differs substantially from the next.

Acute inpatient treatment focuses on maintaining physiologic functions that prevent further damage and support brain healing. Intracranial pressure monitoring and various medications are used to treat brain swelling due to hemorrhage in the hospital setting. Patients may be placed on a ventilator to maintain appropriate oxygenation. Hyperventilation is sometimes induced to increase cerebral perfusion. An intracranial catheter may be placed to drain CSF (cerebrospinal fluid). Surgical evacuation of an intracranial mass such as an expanding hematoma (collection of blood from a bruised brain) may be necessary. Nursing staff must place the unconscious patient in a position that is optimal for cerebral blood flow or drainage of fluids from injured tissues.

Additional treatments may include medications to prevent seizures, induced hypothermia (lowering body temperature) to decrease increased swelling in the brain, and even barbiturate coma therapy for severely increased pressure in the brain.

Deep Brain Stimulation (DBS) is a more recent therapy involving the placement of electrodes to stimulate the level of consciousness. However, no large-scale studies are available to confirm its effectiveness.

Post-acute inpatient treatment is designed to assist with physical, cognitive, and behavioral recovery. A team of healthcare professionals, including physicians, nurses, physical therapists, occupational therapists, speech therapists, and neuropsychologists is employed to assist the patient in achieving maximum function before returning to community living. A patient must be able to participate in and tolerate 3 hours of therapy per day, 5 to 7 days per week, to meet admission criteria for inpatient rehabilitation treatment. Post-acute inpatient treatment at a rehab facility for a brain injury can last from 30 to 90 days, depending on the type and severity of the injury. Patients with severe brain injuries and a limited recovery may be admitted to long term care units or a nursing home for maintenance therapy.

Residential and outpatient treatment. Referral to a social work case manager can help the patient identify appropriate post-acute resources for the transition into a community setting. Patients who are well enough to return home may receive home-based therapies or may attend outpatient therapies. These therapies focus on maintaining and improving both cognitive and physical functioning. A community reintegration specialist can assist the patient in relearning self-care tasks and how to function independently in the home. A rehab driving specialist can ensure the injured individual drive safely again. A vocational rehabilitation specialist assists the patient in finding appropriate employment.

Unfortunately, the statistics for TBI reintegration into the community are mediocre:

• 50% of moderate to severely brain-injured patients can return home 2 years after the injury

• 50% drive again, although the response time may diminish

• 30% work again

TBI is a multifaceted injury. Any traumatic brain injury – whether mild or severe- should not be taken lightly. Attorneys who are litigating cases involving this complex subject need a thorough understanding of anatomy, the mechanics of injury, the diagnostics, treatments, and the rehabilitation process.

Do you have a TBI case with voluminous medical records?

Our NPUSA nurses would love to help you decipher the medical jargon and illuminate case events with a comprehensive medical records summary. Call 504 236-5435 or contact [email protected] at any time with questions.