Traumatic Brain Injury: Glasco Coma Scale And Acute Management

Medical Perspective:

Standard guidelines based on best medical practices of the acute management of a patient with a severe brain injury have been established that have improved outcomes over the past decade. 'Despite this TBI in North America remains the leading cause of death for individuals between ages 1-45.' Those who survive a severe TBI are faced with severe deficits and faced with the prospect of requiring lifelong care. The are primary effects of a TBI that damages the brain include the tearing of blood vessels and direct contusions to the brain, medical providers have no control of those effect, but attempt to lesson the secondary effects of TBI which further damages the brain. Those effects include increase in intracranial pressure, severe low pressure with inadequate perfusion of blood to the brain, and a lack of oxygen.

Appropriate management of a patient with a severe brain injury begins in the field. The paramedics will assess the patients oxygenation and either intubate the patient or use a bag and mask to oxygenate the patient. In a patient with a low blood pressure, fluids will be provided intravenously to increase the patients blood pressure. These interventions are to decrease the secondary effects of brain damage which may worsen the outcome. The paramedics will assume there is a spinal cord injury and immobilize the spine on a board and transport the patient to the nearest hospital. Once in the emergency room acute management is continued to assess and treat associated injuries, treat low blood pressure if present to allow for adequate cerebral perfusion of blood, treat high blood pressure if present to decrease the risk of increases in intracrainial pressure, and evaluate the patient on physical exam and by CT scan for any evidence of increase in intrarcranial pressure. Every patient with clinical evidence of a TBI will be evaluated by way of the Glasgow Coma Scale to provide a baseline for neurologic function as well as providing prognosis regarding outcome. All of these interventions are designed to decrease secondary causes of brain damage. Once a patient has been stabilized to the patient will be transferred to a hospital with adequate neurosurgical services to manage the complexity of the care.

There are indications for emergency surgery in TBI for conditions related to subdural or epidural hematomas (bleeding within the skull but outside the substance of the brain), intracerebral bleeding (within the the substance of the brain), and procedures required for the management of elevated intracerebral bleeding. In the case of subdural and epidural hemtomas there are indications for surgical intervention based on size of the hematoma, the presence of pressure from the hematoma on the brain, asymmetry of pupils, and clinical status. For intracerebral bleeding the surgical indications are less clear and should be deferred to the treating neurosurgeon. The primary purpose for surgical interventions for bleeding is to decrease the secondary effect damage to the brain by preventing direct pressure on adjacent brain tissue and prevent a rise in intracranial pressure. In the case of an injury involving a injury that cause an object to penetrate the substance of the brain, it will be necessary to utilized IV antibiotics and close the outer layer of the brain to prevent infection, and it may be necessary to clean out the brain of foreign material. Depressed skull fractures may need elevation of the fractured skull and debridement (cleaning out). In cases where it is difficult to control intracranial pressure it may be necessary to remove part of the skull opening the close vault of the skull which decrease the increase in intracranial pressure that may cause secondary brain damage.

There are some unique medications and nonsurgical interventions unique in the management of a TBI. An administration of intravenous mannitol and hyperventilating the patient produces a decrease in intracranial pressure. Agitation, pain, seizures, and fever all can increase intracranial pressure. Patients who have suffered a TBI may require sedation, IV pain medications, and antiseizure medications, and cooling blankets and tylenol to control these causes of increased intracranial pressure.

From my experience from providing consultation services during my training at a Level 1 Trauma center all of the above interventions can be explained to the family and by doing so greatly decreases the anxiety and confusion of the family members and provides a basis for their active participation in the care of their loved one. Level 1 Trauma centers should be encouraged to provide counseling to the families to help cope with the significant stress brought on by this tragic event.

Life Care Planner Perspective:

What is a life care plan?

It is a life care planner’s role to provide a road map for the care of these patients to maximize function, reduce or eliminate complications, and improve the individual's quality of life going forward. All recommendations must be medically necessary and must be appropriate. Individuals and families of a severely brain injured patient will benefit from a life care plan because it is a concise summary of current and future needs and their associated costs. It is essential evidence for the court for damages related to injuries from a negligent act or a product liability case. A life care plan is best devised by a medical profession who is a Certified Life Care Planner. It is best to obtain a life care plan from an experienced professional with extensive experience caring for patients with brain injury who communicates with the treating physicians and other medical providers to develop a comprehensive plan that will provide all the care to the expected life expectancy of the patient.

It would be unusual for a life care planner to be involved in a patient at this stage of injury, but generally the earlier a life care planner is involved the better. A life care planner will be familiar with the most appropriate rehabilitation facility that can meet the needs of the patient. A life care planner will look at available indicators of prognosis such as the Glascow Coma Scale to gain some insight regarding necessary care and future needs of the patient and family going forward. The Glascow Coma Scale score within the first 24 hours has proven reliable regarding future outcomes and correlates with the Glascow Outcome Scale. However, it must be stressed that the best indicator is the clinical findings of the patient and how the clinical status changes over time. It must be stressed that the initial Glascow Coma Scale score can be unreliable for many reasons such as associated injuries causing changes in mental status unrelated to the brain injury, intoxicating agents consumed by the patient or administered by medical professionals, and invasive procedures such as breathing tubes that may make responses inconsistent.

Lawyer Prospective:

At this early stage medical and family support will take precedent over lawsuit related issues. However, it is necessary for a patient and their family to do the following to preserve their rights going forward: 1) Avoid any potentially damaging admissions, 2) Preserve evidence (such as crash scene evidence) for further evaluation, 3) Verify the accuracy of police reports, and 4) Obtain contact information from witnesses, and 4) Discuss your situation with an attorney who is capable of dealing with the complexity of the medical diagnosis and can provide competent representation in the matter. It is unfortunate that a severe brain injury may have catastrophic financial impact on a families future. It is important for the family to seek services of an attorney to discuss the situation and investigate the insurance issues, the negligent parties resources, and the potential for adding a defective product to the claim that may have contributed to the cause of the brain injury which would provide a 'very deep pocket'. Further, an attorney who can identify breaches in the standard of care which may have contributed to the severity of the injury may also provide for another 'very deep pocket'. It is important to secure your rights and protect the interest of the injured family.