Frequently Asked Questions About Head Injury



Ruth Hutchison, M.S. and Terry Hutchison, M.D., Ph.D., and The Texas Head Injury Association State Chapter of the National Head Injury Foundation, in collaboration with members of the Texas Head Injury Association, provide the following answers to questions frequently asked by head injured people, their families and friends, and professionals.



WHAT IS A HEAD INJURY?

The term HEAD INJURY refers to an injury to the BRAIN which is usually the result of an accident, or sometimes an assault. Often the injury results froma blow to the head such as may be suffered in an automobile accident, a fall or a gunshot wound. The injury may also occur as a result of lack of oxygen (such as in drowning), or as a result of lack of blood supply to the brain (such as following a cardiac arrest). People with multiple injuries (as in serious auto accidents) often suffer brain injury by more than one of these mechanisms. The term HEAD INJURY is preferable to the term BRAIN DAMAGE because the brain has tremendous powers of recovery. Furthermore, shortly after a head injury, it is usually impossible.

WHAT HAPPENED?

You may never know the exact cause of the accident or injury, and chances are the head injured person will never remember what happened.

WHEN WILL HE/SHE WAKE UP?

No one can tell you when he/she will wake up. You can only WAIT and SEE. Furthermore, head injured persons rarely wake up all at once. Rather the process of full recovery of consciousness is gradual and takes hours in the mildest cases, and may take months or even years in the worst cases, and may take months or even years in the worst cases. Some people improve only to a point and never fully regain awareness of their surroundings.

IS RECOVERY FROM HEAD INJURY POSSIBLE?

Yes, in contrast to the short time it takes to injure the brain, recovery is measured in weeks, months and even years. Recovery is most rapid shortly after the injury and slows down with the passage of time. Many people with severe head injuries end up with almost no noticeable problems, but others require constant care for the rest of their life.

WHAT WILL BE THE ULTIMATE OUTCOME?

Most people who survive a serious head injury eventually wake up from coma, that is, they begin to open their eyes. In the best cases recovery proceeds from this point to NEARLY COMPLETE RECOVERY. In worst cases there is no recovery beyond opening their eyes. People who wake and sleep but have no meaningful interaction with the world around them are said to be in PERSISTENT VEGETATIVE STATE. This is probably the worst possible outcome. In between these extremes is a very wide range of outcomes, some fortunate, and some tragic. It is very important to know that the outcome may remain UNKNOWN for many months.

WHEN WILL WE KNOW HOW BAD THE HEAD INJURY IS?

It may seem cruel and uncaring when the doctor says we just have to WAIT and SEE but this is the accurate answer. In general terms, the longer a person remains in coma, the less likely he/she is to recover completely. The process of recovery almost always takes much longer than the family and friends expect. A few people may eventually become essentially normal after several months in coma, whereas others may suffer devastating permanent injury after only a brief period of coma. As would be expected, people with head injuries generally do better if just their head is injured and they do not also have serious injuries to other parts of their bodies.

WILL MY LOVED ONE DIE?

No one can accurately predict whether a head injured person will die. Head injuries are often serious enough themselves to cause death. There are two critical periods in the immediate recovery of a head injured person. The first is in the first day or two after the injury when the injuries may be so overwhelming as to cause death in the face of the most intensive trreatment. Those who survive this period face another critical period beginning a few days later and continuing for two weeks or more. This critical period results from swelling of the injured brain.




WHAT IS BRAIN SWELLING?

BRAIN SWELLING (also called cerebral edema) is unavoidable and is the end result of many different kinds of injury to the brain. If it cannot be controlled, brain swelling may cause death by producing excessive INTRACRANIAL PRESSURE (pressure in the head, also called ICP).

HOW CAN BRAIN SWELLING BE CONTROLLED?

Control of intracranial pressure depends on intensive monitoring and control of every bodily function; this requires around-the-clock attention and usually takes place in an intensive care unit. It is usually necessary to control breathing by a machine called a ventilator or respirator. Very strong medications are given to temporarily paralyze the head injured person, and even deepen his level of unconsciouness, in order to control his breathing, blood pressure and other vital functions. In some cases removal of small amounts of fluid from around the brain may help. In some cases surgical procedures may be of benefit.

WHAT HAPPENS IF BRAIN SWELLING CANNOT BE CONTROLLED?

Too many times the most heroic efforts to control intracranial pressure fail, and the head injured person dies. As stated above, the presence of multiple injuries complicates the management of brain swelling and adds the risk of dying from other causes.

WHAT IS BRAIN DEATH?

Brain death is defined by law in Texas as the total absence of any brain function, whether or not the person's heart is still beating. The time of death is defined as the time at which the physician determines that there is no longer any brain function. There are a number of medical criteria which physicians use to determine that there is no longer any remaining brain functioin. Once this has been deetermined, then the head injured person is legally dead. No decision is required to turn of f the machines which are maintaining breathing and heart beat.

In rare instances a decision must be made whether to continue intensive care of a person who is not brain dead but, in the opinion of the attending physician, is hopelessly damaged. These are very difficult decisions and most physicians try to involve the family as much as possible in making them. Such decisions are never properly made on the spur of the moment.




WHAT REACTIONS MAY I EXPECT IN MYSELF AND OTHER FAMILY MEMBERS AND FRIENDS?

Most normal people experience some thoughts and feelings which may be disturbing to them. Some examples of these feelings are:

GUILT is a common reaction to a loved one's head injury. You may feel irrationally that if only you had done something different the injury wouldn't have happened. The best thing often is to acknowledge your feelings and then put them aside until they can be viewed more in perspective.

DENIAL occurs in almost everyone who hears of a loved one's injury. This is manifested as a refusal to believe what one is hearing. Sometimes people secretly refuse to believe what the doctors are telling them; other openly refuse to hear what they are being told. Still others manifest their denial by becoming angry at the bearer of bad news. Hope is important, and even irrational hope can be helpful so long as it doesn't lead to inappropriate actions.

ANGER is often directed at the doctors, the persons perceived as causing the accident, ourselves, and even God. Anger is a strong emotion and sometimes justified. Often, however, the anger one feels after a loved one is injured is inappropriate and not helpful. The best thing to do if this happens to you is to be aware of your anger, acknowledge it, but not act on it until you have had time to see things more in perspective.

SHOCK affects people differently. Some show their emotions outwardly; others appear calm. Most people are anxious and hae a feeling of unreality, like they are in a bad dream. Forgetfulness is common and people may have to ask the same questions over and over. It is important to know that the way someone reacts to shock does NOT indicate whether he/she is 'good' or 'bad.' There is usually plenty of time for people to grieve in their own way. Shock is a normal and healthy reaction, and most people manage to find the inner strength necessary to make good decisions when they need to be made.




WHAT IS COMA?

COMA is a sleep-like state in which the injured person does not open his/her eyes, does not speak, and cannot obey commands like "Stick out your tongue!" or "Hold up one finger!". There are several levels of coma. A number scale called the Glasgow Coma Scale is often used to describe the responses of people in coma. There is nothing magic about this scale, it just attaches numbers to the responsiveness of the head injured person in terms of eye-opening, speaking, and moving his/her extremities. People are usually no longer considered to be in coma if they open their eyes, speak, or can obey simple commands.

CAN'T THEY GIVE HIM/HER SOMETHING SO HE/SHE WILL WAKE UP?

There are currently no medicines known that will shorten the duration of coma. In fact, some medicines are used which actually deepen the state of unconsciousness. Other medicines temporarily paralyze the body. The effects of the medicines may have to be tolerated for the overall well being of the patient.

HOW CAN SOMEONE BE IN COMA IS HE/SHE IS MOVING?

People who are in coma cannot obey commands. They may move, however, in response to touch or pain, or even on their own. EXTENSOR POSTURING is commonly seen in patients in coma. This is characterized by marked stiffness of the legs, arms and neck in a characteristic posture with the legs straight out and feet pointed downward, and the arms straight out at the sides with the wrist bend down and the fist clenched. This posture is often worsened by touch or pain. The head injured person may become so rigid that he quivers from his/her muscles straining. FLEXOR POSTURING is similar except that the arms are bent at the elbow. WITHDRAWAL is a more complex movement in which the head injured person in coma may pull away from a painful stimulus, or may even attempt to push away a source of pain.

DO PEOPLE IN COMA FEEL PAIN?

Being in coma may be compared to being under anesthesia. People in coma may well react to pain by moving, or even groaning, but most often have no memory of pain.

DO PEOPLE IN COMA HEAR?

People in coma sometimes show signs that they are able to hear and understand. Often these signs are just simple reflexes -- like squeezing a hand, or sucking, in response to a touch. Occasionally people in coma seem to become calm when they hear a familiar voice. Since they almost never remember these events, it is impossible to decide if they actually recognized a void or understand what was said. However, as a rule, it is good to talk to and about people in coma as though they could hear and understand what was being said.

WHAT IS BRAIN STEM INJURY?

The brain stem is the part of the brain that connects the larger portion of the brain with the rest of the body. Many functions are tightly packed in the brain stem and consequently it is quite susceptible to injury. Among other things, the brain stem controls consciousness, breathing, heart beat, eye movements, pupil reactions, swallowing and facial movements. Furthermore, all the sensations going to the brain, as well as the signals from the brain to the muscles, must pass through the brain stem. The brain stem is often damaged in severe head injuries, but it is almost never the ONLY part of the brain which is injured.

WHAT CAUSES COMA IN HEAD INJURED PEOPLE?

Coma in head injured people almost always results from injury to all parts of the brain, not just the brain stem. In very rare circumstances the major portion of the brain is spared and only the brain stem is injured. This may result in prolonged coma with rapid and nearly complete recovery when the head injured person wakes up. In the vast majority of cases, however, prolonged coma implies diffuse injury to all parts of the brain, including the brain stem, and recovery is slow. Residual effects of brain stem injury may include prolonged difficulty with movements, vision, swallowing and other functions controlled by the brain stem. Residual effects of injury to the other parts of the brain may include problems with movement, memory, attention, speed of thinking, complex thinking, speech and language, and behavior and personality.




WHAT ARE SEIZURES? -- HOW CAN THEY BE CONTROLLED? -- DO THEY DO ANY HARM?

Seizures are the result of abnormal brain activity and are common in severely head injured people. Seizures are not good for the brain and it is desireable to control them. Medicines such as penytoin (Dilantin) and phenobarbital are commonly used. Some people's seizures cannot be controlled by medicines and the best that can be done is to maintain the other bodily functions are best as possible to minimize any further brain injury from continued seizures. Sometimes the medicines used to control seizures actually deepen the state of unconsciousness, other medicines paralyze the body to prevent the muscle contractions produced by seizures. These effects of the medicines may have to be tolerated for the overall well being of the patient.

HOW LONG IS SEIZURE MEDICATION NEEDED?

Many head injured people continue to take medicine to prevent seizures for several years after their head injury, even if they no longer have seizures. This is to prevent the seizures which sometimes come on a long time after the injury. Seizures which start long after the injury are called Post Traumatic Epilepsy and are most frequent in people who had had a penetrating injury to the brain, who have had blood clots (hematomas) in the brain, and who have had seizures in the first week after the injury. Suddenly stopping seizure medicines may CAUSE seizures in people who would not otherwise hae them . Therefore, it is very important to take the medicine as directed and, when it is time, the dose can be slowly reduced.




WHAT IS SPASTICITY?

Spasticity is abnormally increased muscle tone of some muscles as a result of partial or complete disconnection of the muscles from the brain. Spastic muscles usually have very brisk reflexes and sometimes they will quiver on their own.




CAN THE DOCTORS TELL HOW MUCH BRAIN DAMAGE THERE IS?

Most people with head injuries have extensive DIFFUSE INJURY which involves many parts of the brain. Certain tests such as the CT scan, EEG and BSER provide some information about the extent of the injury. However, in the final analysis, it is the FUNCTION of the brain in thinking, speaking and moving which provides the most useful information about the extent of the damage. Since the function of the brain often continues to improve for months or even years after a head injury, measurements of brain function must be repeated several times as the recovery progresses.

DOES THE BRAIN HEAL ITSELF?

Injured brain tissue can recover over a short period of time. However, once brain tissue is dead or destroyed, there is no evidence that new brain cells can regrow. The process of recovery usually continues even though new cells do not grow. We presume this happens as other parts of the brain take over the function of the destroyed brain tissue. Obviously, the more extensive the damage, the less likely it is that the remaining brain can take over the function of the destroyed areas.




WHAT ARE THE STAGES OF RECOVERY FROM A HEAD INJURY?

The more severe head injuries are followed by a period of COMA lasting from seconds to a few months or more. People begin to wake up from coma when they can open their eyes, speak, or begin to obey commands.

WHAT IS POST-TRAUMATIC AMNESIA?

The next stage in the recovery from head injury is called POST-TRAUMATIC AMNESIA. Coming out of coma is not just waking up as people often imagine. Rather, it is most often a gradual process of regaining contact with the world. One of the most striking things about recovery of conscioiusness is that it take so long to begin to restore memory. The kind of memory that is most often affected is the ability to continuously remember the events of the day. When head injured people are awake but unable to recall what happened jsut a hew hours, or even minues ago, this state called POST-TRAUMATIC AMNESIA. People who are fully recovered from a head injury usually have no memory at all of this stage of their recovery.

WHEN DOES REHABILITATION BEGIN?

Rehabilitation is the process of helping a person achieve his/her maximum functional potential. This process begins immediately. Once memory of the events of the day begins to be restored, the rate of recovery often appears to be much more rapid. However, many problems may persist for a long time. These may be problems related to movement, memory, attention, slowness of thinking, difficulty with complex thinking, difficulties with speech and language, behavior problems and personality changes. These problems are dealt with in the rehabilitation of the head injured person. It should be point out, however, that rehabilitation begins much earlier than this. Some aspects of rehabilitation begin even while the head injured person is in coma.

WHAT HAPPENS AFTER THE INITIAL RECOVERY PHASE?

Continued recovery after discharge from the acute care hospital depends on proper rehabilitation. In some cases rehabilitation can continue at home or on an outpatient basis. In other cases rehabilitation is best accomplished at a rehabilitation center where several hours per day are devoted to specific therapy. Finally, in a few cases, the nursing care requirements are so great, and the rehabilitation potential so limited, that the best placement is in a skilled nursing facility. Where to go next is a complex problem that depends on the needs of the head injured person, his family's needs, and the facilities available. These problems should be worked out toward the end of the head injured person's hospital stay.

WHEN DOES RECOVERY STOP?

Gradual recovery from head injury may continue from several years. Recently some dramatic improvements have been achieved by intensive retraining of people who have regained normal intelligence but are severely handicapped by specific problems in thinking, behavior, and in social and vocational skills. It is important to note, however, that recovery may stop at any age. In the worst cases people may survive for years, totally dependent, and with no awareness of their surroundings.

DOES IT MEAN THAT ALL IS WELL WHEN THE HEAD INJURED PERSON CAN LEAVE THE HOSPITAL AND GO HOME?

Many head injured persons have continued problems when they return to their home and family, particularly after severe head injuries producing prolonged coma. Problems with complex thinking, and with emotional instability and personality changes, are especially common. Both the head injured person and his/her family may be frustrated and disturbed by these continued difficulties. There may be setbacks in self-care and independence, or in progressing to a meaningful life style or livelihood. The rehabilitation team may suggest continued therapy as an outpatient, or as provided by a visiting therapist. Other resources exist which may assist the head injured person and his/her family to overcome the long-term problems which usually become apparent only when he/she returns home. One such resource is the Texas Head Injury Foundation which can provide emotional support to head injured people and their families and can help them find an appropriate rehabilitation setting.

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