As promised, this is the second part of our three-part blog series about traumatic brain injury. This blog post will focus on how this type of brain injury is diagnosed and treated within the UK healthcare system. Our final blog post, which we will publish next week will focus on recovery and outpatient services.
As we mentioned in our previous post, which you can read here, if you have any of the symptoms of a severe head injury, you must call 999 or go to your local A&E. If you do not experience any symptoms and do not think you need emergency assistance, you should contact your GP. They will advise accordingly, however, in all cases you must ensure you have sought some medical advice.
Steps leading to a diagnosis:
Please note that this is not always the exact protocol that is followed and the healthcare professionals will make the decision on how to diagnose based on each individual case.
1. Understanding the injury: When entering A&E, depending on your level of consciousness, healthcare professionals may ask you some questions after hearing from the paramedics on the scene. This is the quickest way to diagnosis as they will have a very clear background to your injury and circumstances/events surrounding it. If this is not possible, as the person is not conscious or able to answer the questions, any family or friends present can answer the questions to the best of their abilities.
2. CT scan: This is a brain scan that produces a detailed image of inside your head and shows if there is any bleeding or swelling. This scan helps determine the extent of the injury and assess the risk of developing complications. For more information on the types of complications, read our previous post here. Depending on the scan results, you may be able to go home, but in most cases people are kept for observation.
3. Glasgow Coma Scale (GCS): This is a scale used to assess the severity of damage to the brain. It scores on verbal responses, physical movements and how easily a person can open their eyes. There are different versions based on age but is usually scored out of 15, where the highest score of 15 suggests no damage. A score of 13 or 14 is indicative of mild damage, a score between 9-12 is usually indicative of moderate damage, a score 8 or lower is indicative of severe damage. The lowest possible score is 3 is generally given to someone who is unconscious and unresponsive.
4. Care decision: The consultant that has overseen your care up until this point will decide where you will recover.
- As mentioned previously, you will be allowed to go home if the CT scan results are not concerning and the consultant believes that you are at low risk of developing any complications or symptoms. You will be given some care advice, such as having an initial 24-hour supervision from a family member or friend, getting rest, avoiding drinking or taking sedatives, not driving, playing sports or returning to work immediately. You will also be advised on medical situations that might occur and mean that you need to seek emergency medical assistance.
- If there are some concerns, you may be admitted into hospital for observations. Concerns include a problem with the scan, persistent display of neurological symptoms, GCS score that does not return to 15, other injuries (physical usually) that need treating, alcohol/drug intoxication or no guarantee of 24-hour supervision at home. Depending on what the concern for admission is, and how the observation progresses, the duration of your stay can vary.
In the case of a severe head injury, it is always treated in hospital to minimise the risk of complications.
Other injuries, not related to the brian trauma, are treated. It is up to the healthcare professional to decide what the primary concerns are and when to manage these other injuries. External cuts and grazes are usually cleaned and treated relatively quickly to prevent further bleeding and infection.
Whilst you are being observed, the healthcare professionals will regularly check:
- Vitals including breathing, heart rate, blood pressure, temperature and level of oxygen in the blood.
- Level of consciousness and how alert you are
- Size of pupils by testing how well they react to light
- Mobility by seeing how well you can move your arms and legs.
- Pressure changes in the skull using an ICP monitor. This is only used if there is bleeding or swelling found on the CT scan as fitting this monitor is relatively invasive (thin wire inserted into the space between the skull and brain through a small hole drilled into the skull).
You may undergo neurosurgery which is carried out to treat nervous system (brain, spinal cord or nerve) problems. Whether this is necessary or not is usually identified during testing (above) and CT scans. However, possible reasons include a subarachnoid haemorrhage, which puts pressure on the brain and causes brain injury or possibly death, a subdural hematoma (blood clot), bruises to the brain or a skull fracture. In most cases a neurosurgeon will discuss this with you or your family but in some cases they deem it too urgent and must be carried out immediately.
You may undergo a craniotomy, which is a surgery used in cases where the injury to the brain is severe. This surgery involves a hole being made into the skull so a surgeon can access the brain and is carried out under general anaesthetic. The surgeon will remove any blood clots that may have formed in the brain and repair damaged vessels. Once any bleeding in the brain has stopped, any part of the skull that was removed will be replaced and reattached using metal screws.
Skull fractures as a result of the brain injury need to be treated. In most cases, especially with simple linear fractures, it will heal itself but can take many months. If you have an open fracture, you may be prescribed antibiotics to prevent an infection from developing. If you have a severe or depressed fracture, surgery may be necessary to prevent brain damage.This type of surgery usually involves removing any pieces of bone that have been pressured inwards, correcting the position of some bones or, if necessary, placing a metal wire to reconnect pieces of the skull.
After any of these surgeries, you will usually be placed in an Intensive Care Unit for constant monitoring and you may also be placed in a ventilator. Once you are well enough, you will be moved to a high-dependency unit (or another similar ward) for monitoring until you are well enough to go home…but more on that next week.