Traumatic Brain Injury: What it does to people and their families

 Traumatic Brain Injury   

What it does  to people and their families  

Catherine W. Britell, M.D.

              
Traumatic brain injury (TBI) results from hitting the head directly (such as falling and hitting the ground or hitting the windshield in a car accident), a shockwave (such as an explosion occurring nearby where the pressure wave passing through the brain significantly disrupts brain function), or a penetrating object that destroys brain tissue (such as a bullet or piece of broken skull bone),

The effects of TBI may be temporary pain and disability, permanent disability, or death. 
TBI can have wide-ranging physical and psychological effects. Some signs or symptoms may appear immediately after the traumatic event, while others may appear days or weeks later.
With a mild traumatic brain injury (also called “concussion”), there can be:

• Loss of consciousness for  seconds to a few minutes
• No loss of consciousness, but a state of being dazed, confused or disoriented
• Severe constant or recurring headache
• Nausea and vomiting 
• Fatigue or drowsiness
• Slurred speech or difficulty finding words.
• Insomnia
• Dizziness, incoordination or loss of balance
• Blurred vision, ringing in the ears, a bad taste in the mouth or changes in the ability to smell
• Hypersensitivity to light or sound to the point of causing pain
• Inability to concentration or remember things
• Depression or anxiety

These symptoms may resolve over a few days to weeks to months, but in some cases may persist over the person’s lifetime.   The effect of these symptoms include:

• Inability satisfactorily to perform in a job
• Inability to interact appropriately with family, resulting in inadequate parenting, spousal abuse, and dissolution of the family unit.
• Inability to interact appropriately in social settings, resulting in loss of friends and social support system
• Susceptibility to addiction and suicide.

If the TBI is more severe, it is most often permanent, and can include any of the problems associated with mild injury described above, in addition to  these symptoms that may appear within the first hours to days after a head injury (this is due to delayed bleeding, swelling or inflammation):

• Loss of consciousness from several minutes to hours
• Persistent severe headache 
• Severe vomiting or nausea - often inability to nourish adequately
• Seizures (may be difficult to control)
• Dilation of one or both pupils of the eyes with severe vision problems
• Clear fluids draining from the nose or ears due to disruption of the sac that holds the cerebrospinal fluid.  This can lead to infection and death
• Inability to awaken from sleep
• Weakness or numbness in fingers and toes
• Loss of coordination
• Persistent ringing in the ears
• Difficulty recognizing objects
• Impaired hand-eye coordination
• Blind spots or double vision
• A bitter taste, a bad smell or difficulty smelling
• Skin tingling, pain or itching
• Trouble with balance or dizziness
• Agitation, combativeness or other unusual behavior
• Slurred speech or inability to think of words to express ideas

Of course, if the TBI is very severe the patient will likely not survive or will have significant long-term disability .   A person with a very severe TBI who is in a coma is unconscious, unaware of anything and unable to respond to any stimulus.   The patient may die, or after a few days to a few weeks, a person may emerge from a coma or enter a vegetative state. 

In a vegetative state,  the person is unaware of what’s happening around him/her, but he or she may open his or her eyes, make sounds, respond to reflexes, or move.    A vegetative state can become permanent, but sometimes people progress to a minimally conscious state.  A few patients either stay that way, some recover somewhat, and some pass away from other complications.   In a minimally conscious state the patient has severely altered consciousness but shows some signs of self-awareness or awareness of his/her environment. It is sometimes a transitional state from a coma or vegetative condition to greater recovery.

The patient may also get worse, and when there is no measurable activity in the brain and the brainstem, the patient is brain dead.  In a person is brain dead,  breathing devices are removed and the patient dies. 

There are some short-term and long-term complications that develop from TBI.  Oftentimes TBI victims will develop seizures. They may occur only in the early stages, or years after the injury.  They may or may not be able to be treated with medications.  They often keep the patient from being able to drive, and sometimes limit more activities.

Cerebrospinal fluid may build up in the spaces in the brain (cerebral ventricles) of some people who have had traumatic brain injuries, causing increased pressure and swelling in the brain. This is called “post-traumatic hydrocephalus”.

Also, blood vessels in the brain may be damaged in TBI. This damage could lead to a stroke, blood clots or other problems.

Severe  headaches are very common after a traumatic brain injury. They may begin within a week after the injury and could persist as long as several months.  Many people also experience vertigo, a condition characterized by dizziness, after a traumatic brain injury.  Often these symptoms will persist, and are known as “post-concussion syndrome”.

TBI involving the base of the skull can cause nerve damage to the  cranial nerves which may result in  paralysis of facial muscles or losing sensation in the face, loss of or altered sense of smell, loss of or altered sense of taste. loss of vision or double vision, swallowing problems, dizziness, ringing in the ears, or hearing loss.

Cognitive loss is for many the most disabling result of TBI.  This might be manifest in problems with the following: 

• Multitasking
• Organization
• Planning
• Decision-making
• Beginning or completing tasks
• Memory
• Learning
• Reasoning
• Judgment
• Attention or concentration
• Problem-solving

Communication  problems are common following traumatic brain injuries, and often are what cause frustration, conflict and misunderstanding for people with a traumatic brain injury, as well as family members, friends and care providers.  A patient with these problems is likely to have difficulty maintaining work, family and social relationships.  They may include:

• Inability to organize thoughts and ideas
• Trouble following and participating in conversations
• Trouble with turn taking or topic selection in conversations
• Problems with changes in tone, pitch or emphasis to express emotions, attitudes or subtle differences in meaning
• Difficulty understanding nonverbal signals
• Trouble reading cues from listeners
• Difficulty understanding speech or writing
• Difficulty speaking or writing
• Trouble starting or stopping conversations
• Inability to use the muscles needed to form words (dysarthria)

Of course, the behavioral changes associated with TBI patients are some of the most difficult for the patient, his/her family and society to deal with.  They might include:

• Difficulty with self-control
• Lack of awareness of abilities
• Risky behavior
• Difficulty in social situations
• Verbal or physical outbursts

Emotional changes associated with TBI are most devastating to the patient; but also they rip apart their families, and require ongoing individual and family counseling.  They may include:

• Anger
• Depression
• Anxiety
• Mood swings
• Irritability
• Lack of empathy for others

 So, these are a few of the effects of Traumatic Brain Injury.  Because TBI has such multifaceted effects, many health professionals need to be involved in the care of these individuals. They are likely to include:

Emergency Response: Paramedics/medical corps personnel, hemodynamic and ventilator support, ambulance or helicopter transport.

Acute care phase: Neurointensivist,  Anesthesiologist, Neurosurgeon, Other Surgical Specialties,  Neurologist and Other Medical Specialties, Intensive Care Nurse, Respiratory Therapist, Speech Pathologist, Clinical Pharmacologist, Psychologist, Family Counselor,  Chaplain

Acute Rehabilitation phase:  Physiatrist, Medical and Surgical Consultants,  Rehabilitation Nurse, Respiratory Therapist, Clinical Pharmacologist, Speech Pathologist, Physical Therapist, Occupational Therapist, Neuropsychologist, Social Worker, Family Counselor, Recreation Therapist, Chaplain

Chronic Care/Rehabilitation phase: Primary Physician, Independent Living Specialist,  (Nursing Attendant),  Vocational Counselor,  Neuropsychologist,  Social Worker,  Assistive Technology Specialist, Driver Evaluator/Trainer, Vocational/Job Educator/Facilitator, Family Counselor. 

While costs vary according to the extent of the injury and its specific long-term effects, it is estimated that the cost of caring for a survivor of  traumatic brain injury is between $600,000 and $1,875,000 over a lifetime. This does not include indirect costs to society as well as to families, including costs associated with lost earnings, work time, and productivity, as well as the costs linked to providing social services.


Yes, traumatic brain injury is more than a "headache"!