Head Injury

In a head injury, the brain may hit the inside of the skull. This force can occur as a result of a car accident or a fall. A blow to the head also can cause it. If the head breaks open, it is called an open head injury. If the head does not break open, it is called a closed head injury.

A head injury can damage the brain. These are terms used to describe head injuries. The doctors and nurses will help to explain these terms.

  • Broken or cracked bones of the skull or face are called skull or facial fractures.
  • A blood clot in the brain is called a hematoma (heem-ah-TOME-ah).
  • Swelling of the brain is called cerebral(sir-EE-bral) edema (eh-DEEM-ah).
  • A bruise on the brain is called a contusion (con-TOO-zhun).
  • A tear in the brain tissue is called a laceration(lass-er-AY-shun).

Skull fractures may sometimes cause pressure on the brain. Many skull fractures heal by themselves. Some skull fractures need surgery to relieve pressure on the brain.

Hematomas may cause pressure on the brain. The pressure slows or stops flow of blood and oxygen to some areas of the brain. Surgery may be needed to remove the hematoma and relieve the pressure.

Swelling of the brain is very common after a head injury. When the brain swells, it pushes against the skull and causes pressure to build. This is called ICP, or intracranial (in-tra-CRANE-ee-ul) pressure. The doctors may want to monitor the ICP with special equipment. If the doctors order this test, the patient will be taken either to an ICU (intensive care unit) or a neuro step-down unit (read below to learn more).

Coma is common for people with head injuries. When a patient is in a coma, he or she is unconscious. The patient is unable to respond to people and activity. During this time, a patient may have movements that are involuntary. The patient may open his or her eyes and appear to be awake. But there still will be no response to words or touch or even a beam of light in the eyes. This is called a vegetative state.

Slowly, over time, the patient may start to “wake up.” This means that the patient becomes aware of what is happening around him. Eventually, the patient may start to follow simple commands. For example, the patient may be asked to “hold up two fingers” or “wiggle your toes.”

Effects of head injury

Effects of brain injury may be temporary or permanent and may include the following:

  • Memory loss or decreased concentration
  • Learning disabilities
  • Agitation
  • Decreased judgment about safety
  • Changes in personality
  • Changes in vision
  • Change in the ability to read or understand written information

The effects listed above are called cognitive (COG-nah-tiv) problems. The patient also may have motor problems. This means the patient may have trouble walking or moving his or her arms or legs properly. The patient may also have difficulty with daily living activities such as grooming, dressing, and bathing.

Health care team

  • Patient: The patient is the most important member of the health care team. All care is based on the patient’s needs.
  • Family: It is the job of the patient’s family to help support the patient. The family can also help the doctors by telling them information about the patient’s medical history.
  • Attending physician is the doctor who is the team leader. It is the job of the attending physician to make all decisions related to the patient’s care.
  • CCM physician (critical care medicine doctor) is a doctor who specializes in the care of patients in the ICU. He or she works closely with the attending physician.
  • PM & R physician (physical medicine and rehab doctor) is a doctor who specializes in the rehabilitation of a patient.
  • PNCC (primary nurse care coordinator) is a nurse who works with all the team members to make sure that the patient’s needs are being met.
  • Nurse cares for the patient on a daily basis and notifies the doctor frequently about changes in the condition of the patient.
  • Physical therapist helps the patient to improve strength, balance, and coordination.
  • Occupational therapist helps the patient with activities of daily living, like dressing and eating.
  • Speech therapist helps the patient with language skills and speech. The speech therapist will also evaluate the patient for any swallowing problems.
  • Respiratory therapist provides treatments to help the patient breathe better.
  • Registered dietitian determines the patient’s nutritional needs and monitors the patient’s diet.
  • Social worker gives support to the patient and family.

 

Tests and procedures

The doctor may order some or all of the following tests and procedures.

Neuro Exam

The doctors and nurses will examine the patient frequently. If the patient is awake, the health care team will ask some questions to see how aware the patient is of his or her surroundings. For example, does the patient know the day or the month? The patient’s eyes will be checked with a flashlight to see if the pupils respond to the light. The doctors and nurses will also test the strength of the patient’s arms and legs. The nurses will do this neuro exam very often. It is important to know if there are any changes in the patient’s condition from exam to exam.

CT Scan

CT stands for computerized tomography (toe-MAH-gruh-fee). This is a picture made by using x-rays and a computer. The CT scan lets the doctors see the structures inside the patient’s head. The CT will show if there is bleeding in the head.

The CT scanner is like a large donut. A large table moves the patient through the center hole. Staff will watch the patient carefully through a window as the scan takes place. A CT scan usually takes less than 30 minutes to complete.

MRI Scan

MRI stands for magnetic resonance imagery. MRI uses radio waves and a magnet to create 3-dimensional pictures of the body. An MRI may be used for some patients to get a better view inside the skull.

The MRI machine is shaped like a long tube. The patient lies on a table in the middle of the tube. The magnet inside the machine will attract all metal items.

For this reason, all jewelry must be removed before the scan. If the patient has a metal object that cannot be removed (for instance, a pacemaker or heart valve), it's important to tell the doctor before the scan. The MRI scan takes about 30 to 90 minutes to complete.

Tracheostomy

A tracheostomy (tray-kee-OSS-toh-me) is done when a patient’s airway is not working. Surgery is done to make a small opening in the front of the neck. This opening is called a stoma (STOW-ma). A short tube called a trach tube (TRAKE) is placed into this opening. When the patient breathes, the air passes through the trach tube.

Tube Feedings and Feeding Tubes

Tube feedings are needed if a patient is not able to swallow safely or if a patient is not awake enough to eat. Tube feedings are given to a patient through a feeding tube. The feeding tube is put into the nose, and it drops down into the patient’s stomach. When the patient no longer needs the feeding tube, it can be easily removed at the patient’s bedside. If a patient needs tube feedings for a long time, the doctor may decide to place a different type of feeding tube.

Hospital stay

When a patient with a head injury is admitted to the hospital, he or she will be placed in one of 3 types of units. These units are the ICU, the neuro step-down unit, and the neuro floor.

  • Case manager helps the patient and family with insurance questions. He or she also helps to plan a patient’s transfer to rehabilitation and for services after inpatient rehab is completed.

When the patient is first admitted to the hospital, he or she may need to stay in the ICU. The patient will be connected to many machines and monitors. There is no reason for alarm — this is common. The ICU nurses will watch the patient very closely and do neuro exams at least every hour. Visiting hours are limited in the ICU because the health care team needs time to care for the patient.

When the patient is more stable and not using a breathing machine (ventilator), the doctor will transfer the patient to another unit. If the patient goes to the neuro step-down unit, he or she will still be connected to many monitors. For example, the patient will still be connected to a heart monitor and to a monitor that measures the oxygen level in the blood. Family will be able to visit the patient more often on this unit. The nurses will do a neuro exam at least every 2 hours.

When the patient is transferred to the neuro floor, it means the patient no longer needs to be connected to the monitors. The nurses will continue to do neuro exams, but not as often. After the patient goes to the neuro floor, the health care team will work with the patient and the family to make arrangements for after the hospital stay. Most patients will go to either a rehabilitation facility or a skilled nursing home.

Rehabilitation

Many patients with head injuries need to go to a rehabilitation hospital after the acute care hospital. It is important that the patient and family choose a rehab facility that has a program related to the patient’s specific injury. For example, most patients with head injuries will need a TBI (traumatic brain injury) program. The social worker or case manager will help the family select a place that meets the patient’s needs.

A patient who is awake, alert, and able to follow simple commands may go to an acute rehab facility. Acute rehab facilities provide inpatient care. Generally, acute rehab means that the patient can tolerate 3 or more hours of therapy per day. The acute rehab lasts an average of 3 weeks. After that, the patient may need several more weeks of outpatient therapy or therapy at home.

If a patient is not able to follow simple commands, he or she may need to go to a skilled nursing home. These patients need a somewhat slower paced rehab program. When the patient improves, it may be possible to transfer him or her to an acute rehab facility.

Resources

The Dana Alliance for Brain Initiatives
New York, NY 212-223-4040
http://www.dana.org

Brain Injury Association of America McLean
VA703-236-6000
Family Helpline – 1-800-444-6443
http://www.biausa.org

The Central Nervous System Injury Foundation
P.O. Box 3870
Rancho Santa Fe, CA 92067

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