SEVERE HEAD INJURY

 Treatment of Head and Brain Injuries

In most severe accidents there are multiple injuries, and though in the long run the head injury may be the most important, to begin with the others may need to be attended to first, to save the patient's life. The neck or the spine are often damaged, legs and arms may be broken and injuries to the chest and abdomen are common. All these possibilities must be checked out quickly, and treatment started for them if it is needed.

Initial treatment
At this stage in most cases what the injured brain needs most is a good supply of blood, with plenty of oxygen in it, no coughing or straining to disturb it, and time to recover.

Possible Complications
In a few people bleeding will continue inside the skull, and clots will form that may be fatal if they are not removed. Usually ordinary examination will show that this is happening, but in some cases more tests are needed. X-rays will help, but are only able to show if the skull has been fractured. In hospitals where it is available, a 'CT scan' will be done, which not only shows the bone but the brain itself, and will detect a blood clot if there is one there.

Surgery
If there is a blood clot big enough to damage the brain, an operation to remove it will be needed. A flap of bone is cut out of the skull over the site of the clot, the clot washed out and the bone fastened back. The bone rapidly heals and leaves no weakness. Many people are especially worried about operations on the head, and this is only natural. In fact, the surgery itself is usually straightforward and without much risk; the important thing is the damage that made the operation necessary.

An operation will also be needed if there is a wound that goes through the skull and into the brain. Wounds of this sort look frightening, but with proper treatment they heal well. Their special importance is that they may be followed by a tendency to epileptic seizures - post traumatic epilepsy. It may be wise to take medication after recovery to reduce the risk of this occurring.

Intensive Care
After the patient has been assessed in the accident department and any surgery that is needed has been done, they will be taken to Intensive Care. Here they will be looked after twenty-four hours a day by highly trained staff, using special equipment to assess and treat them. Just as in the early stages, treatment for the injured brain mostly consists in giving it the conditions it needs to recover:

• A good circulation of blood

• Rest, with sedatives to stop coughing and straining

• The mechanical ventilator to control breathing

• Food - to begin with essential food and fluids are given in the transfusion. Later a special solution of food is given through a fine tube passed down the nose and into the stomach or small bowel, a 'naso-gastric tube'.

The main danger at this stage is the swelling of the brain that follows injury, and the increase in 'intracranial pressure' that results.

It is possible to get an idea of how high the pressure is from ordinary observations, but sometimes a more exact measurement is needed. To do this, a fine tube is threaded through a small hole in the skull and into the fluid spaces in the brain. This is connected to an electronic gauge that shows the pressure constantly on a screen. In this way the result of each treatment can be followed quickly and easily.

Controlling the pressure
To control the brain swelling, the quantity of fluid given each day and the amount of salt it contains are carefully adjusted. If the pressure goes on rising in spite of this, substances that will suck excess water out of the brain can be given in the transfusion (an example is a special kind of sugar called mannitol). The intracranial pressure can also be brought down if the amount of carbon dioxide in the blood is reduced by increasing the rate of breathing by the ventilator.

Tracheotomy
This stage of management can take a week or even more. After three or four days, the endotracheal tube that was inserted in the accident department may start to irritate the throat. A minor operation may then be done to place a plastic tube directly into the windpipe through the skin of the neck, a 'tracheostomy'. As soon as the tube is no longer needed, it can be slipped out and the hole will heal up.

Recovering consciousness
When it seems that the brain is starting to get over the effects of injury, the dose of sedatives being given is cut down. When the patient begins to move their arms or legs, to open their eyes, or to make some response to voice, it will show the staff that they are recovering consciousness, and will soon be ready to do without the ventilator. The amount of help it gives is gradually reduced, and when the patient is able to breathe on their own, the endotracheal tube or tracheostomy is taken out. Patients are now ready to go on to the next stage of treatment - recovery, coming out of coma, and beginning to communicate and to look after themselves.

Recovery
When the danger to life is over, the problems of recovery have to be tackled. Patients have to learn again how to take notice of the world around them, to think and talk, to look after themselves, and to get back to strength and mobility.

This process starts with the move from the Intensive Care Department to an ordinary hospital ward. Patients will still need expert nursing care. They may not yet be able to swallow properly and may still need the naso-gastric tube. They may not have got enough strength back to hold their head up or sit on their own, and they may not yet be saying anything with meaning. They will however know, even if it is in a confused way, that their family and friends are with them, and this will be a comfort and a source of strength.

With time, treatment and care, function will slowly return - speech, swallowing, movement, sitting and eventually standing and walking.

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Last updated 14/01/08
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