After the Injury:
TBI and Acute Care
Moderated by
Doris McMillon
Featuring
Jeffrey Bazarian, MD
an emergency physician with a strong research interest in traumatic brain injury. He
is associate professor of Emergency Medicine, Neurology, and Neurosurgery at the
Center for Neural Development and Disease, University of Rochester Medical
Center.
James M. Ecklund, MD
a neurosurgeon and currently the chairman of the Department of Neurosciences at
Inova Fairfax Hospital, Virginia’s largest Trauma Center. His research interests
include neurotrauma with an emphasis on blast and penetrating injury.
Maria Mouratidis, PsyD
a clinical neuropsychologist and the command consultant and subject matter expert
for traumatic brain injury and psychological health at the National Naval Medical
Center. She is regarded as a national expert and lectures widely on the areas of
traumatic brain injury and psychological health.
After the Injury: TBI and Acute Care
Featuring
Jeffrey Bazarian, MD
an emergency physician with a strong research interest in traumatic brain injury. He is
associate professor of Emergency Medicine, Neurology, and Neurosurgery at the
Center for Neural Development and Disease, University of Rochester Medical Center.
James M. Ecklund, MD
a neurosurgeon and currently the chairman of the Department of Neurosciences at
Inova Fairfax Hospital, Virginia’s largest Trauma Center. His research interests include
neurotrauma with an emphasis on blast and penetrating injury.
Maria Mouratidis, PsyD
a clinical neuropsychologist and the command consultant and subject matter expert for
traumatic brain injury and psychological health at the National Naval Medical Center.
She is regarded as a national expert and lectures widely on the areas of traumatic
brain injury and psychological health.
After the Injury: TBI and Acute Care
In ER, main causes of TBI
• Car and motorcycle crashes
• Falls
• Most TBIs seen in the ER are on the more mild end of the
spectrum.
After the Injury: TBI and Acute Care
Short video on what happens to the brain at point of
impact and injury
This clip from “Understanding Traumatic Brain Injury” was
produced by the Defense and Veterans Brain Injury Center.
www.dvbic.org
After the Injury: TBI and Acute Care
What ERs need for best outcome
• Ability to perform CAT scan
• Staff neurosurgeon on stand-by to remove blood clots, if
necessary (Blood clots can be life threatening.)
After the Injury: TBI and Acute Care
First concerns when someone is brought into ER
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Securing the person’s airway so he or she can breathe
Maintaining blood pressure
Performing CAT scan, if necessary
Performing physical and cognitive tests, if person is able
After the Injury: TBI and Acute Care
Current research for diagnosis of TBI
Research is being done on creating a blood test — a
biomarker — that would determine if there has been an injury
to the person’s brain.
After the Injury: TBI and Acute Care
Ways medical team can help families
It is important for the medical team to include the family immediately
when a loved one is in the ER. The team can do this by
• educating the family about brain injury, the recovery process, and
treatment.
• recognizing and validating their feelings and anxieties during this
time of crisis.
• helping them manage their expectations about the outcome for their
loved one.
• involving them as much as possible in the treatment plan for their
loved one.
• connecting them with resources like chaplains, counselors, and
others on the multidisciplinary team.
After the Injury: TBI and Acute Care
First steps neurosurgeons take when someone is
admitted into ER with TBI
• Perform neurologic exam
• Check person’s level of consciousness, pupil reaction, and
whether there is weakness on one side of the body or the
other
• Evaluate CAT scan
• Review tests and scans to determine next best course of
care
After the Injury: TBI and Acute Care
First steps neurosurgeons take when someone is
admitted into ER with TBI (con’t)
• Make sure person’s oxygenation is optimized
• Make sure blood pressure is maintained
• Check and recheck the basics of airway, breathing,
circulation
• Determine level of pressure in skull
• Create as healing an environment as possible
After the Injury: TBI and Acute Care
When is surgery necessary?
• If a blood clot or other mass is causing too much pressure
on the brain
• If the Glasgow Coma Scale is significantly low, a brain
monitor will be surgically placed in the brain to measure the
pressure.
• If the brain is swelling too much, a surgeon can drain some
of the fluid from the fluid sac.
• If the brain is swelling intensely — as it can from blast
injuries — a surgeon may perform a craniectomy. This
procedure entails removing part of the skull to allow the
brain to swell into that portion to save the person’s life and
provide the ability to recover.
After the Injury: TBI and Acute Care
Similarities between blast injuries and car crashes
• Impact injury if the head strikes an object
• Deceleration/acceleration-type injury or rotation-type injury
After the Injury: TBI and Acute Care
Differences between blast injuries and car crashes
• Penetrating injuries can be associated with blast injuries.
• In “primary blast injuries,” over-pressure waves are
involved. These kinds of waves can affect air-filled cavities
in the body like the lungs and bowel; there is research being
done on their effect on solid organs like the brain.
• Other influencing factors in a blast injury can include toxic
effects, electromagnetic pulse, and heat that is generated
from the blast.
• The brain swells far more from a blast injury than from a car
crash.
After the Injury: TBI and Acute Care
Promising areas of research
Current studies are looking into
• why there is more (edema) swelling to the brain after a blast
injury, and more increased blood flow on the surface of the
brain in comparison with other brain injuries.
• the use of functional MRI, which would provide a more
multi-layered image for more successfully determining
prognosis.
• the use of a Transcranial Doppler, a measure of blood flow
that would help determine prognosis and ultimately improve
care.
After the Injury: TBI and Acute Care
Short video on group of teenagers who met in
rehabilitation after sustaining TBIs
This clip from “The Other Breakfast Club” was produced by the
National Road Safety Foundation.
www.nationalroadsafety.org
After the Injury: TBI and Acute Care
Role of neuropsychologists
Neuropsychologists play a key role in the
multidisciplinary medical team by helping people with
TBI and their families
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get educated.
develop appropriate expectations.
find some semblance of normalcy during the time of crisis.
focus forward, focus on their strengths and what they can
do and less on who they used to be.
• find support on as many fronts as possible.
After the Injury: TBI and Acute Care
Role of neuropsychologists (con’t)
• Neuropsychologists also help
• assess the person’s cognitive and emotional functioning …
how his or her brain is working — from thinking and feeling
to working on challenges with memory and attention.
• create a treatment plan for the person with TBI to restore
function or to compensate for lack of function in various
areas — from walking and learning balance to developing
strategies for short-term memory loss.
After the Injury: TBI and Acute Care
How are symptoms different for TBI and PTSD?
• A lot of research is still being done on the subject.
• What is most important is treating the symptoms and
addressing the difficulties the person is having regardless of
the cause.
After the Injury: TBI and Acute Care
In reaction to current wars, have protocols or tests
changed?
Several tests have become mandatory when soldiers
return from theater.
• Audiology testing (blasts can damage ear drums)
• Dental examinations (blasts can cause cracked teeth or
expose nerves in teeth)
• Eye examinations
• Full mental health evaluations
• Full neuropsychological testing
Protocols for pain management are also being looked at
carefully.
After the Injury: TBI and Acute Care
Depression, divorce, and sexual dysfunction
It is important to educate families about issues like
depression, divorce, and sexual dysfunction which can
result after TBI.
• Families need to be aware of these issues so they can
recognize them, find resources, and take action if
necessary.
• Every person and family is different; issues can arise in
the short- or long-term.
After the Injury: TBI and Acute Care
Questions from the audience
When is someone with a severe brain injury considered out of
the woods?
After the Injury: TBI and Acute Care
Questions from the audience (con’t)
Does talking to someone while they’re in a coma help, and can
he or she hear?
After the Injury: TBI and Acute Care
Questions from the audience (con’t)
How can early diagnosis help improve how someone does
over the long term?
After the Injury: TBI and Acute Care
Questions from the audience (con’t)
What plans are in the works to provide long-term community
support services for military veterans and how will that support
be funded?
After the Injury: TBI and Acute Care
Questions from the audience (con’t)
What long-term issues do you think veterans from the current
wars will be dealing with down the road?
After the Injury: TBI and Acute Care
Final thoughts
• Although most people recover rapidly from a concussion,
not all mild TBIs are mild. Long-term symptoms can persist,
which is why it is important for people to go to the ER as
quickly as they can after a TBI to get a CAT scan and/or
educational advice.
• Although TBI continues to be a significant problem in both
civilian and military populations, there have been
ameliorations in care and outcome in the last few decades.
With continued innovation and research, outcome for people
with TBI will continue to improve.
• There is hope, and hope is renewed everyday. The ability of
the body, mind, and spirit to overcome is tremendous.
After the Injury: TBI and Acute Care
Learn more
To learn more about traumatic brain injury, signs and symptoms,
treatment options, and ways to prevent it, please visit
BrainLine is funded by the Defense and Veterans Brain Injury Center,
the primary operational TBI component of the Defense Centers of
Excellence for Psychological Health and Traumatic Brain Injury,
through a subcontract award with the Henry M. Jackson Foundation
for the Advancement of Military Medicine.
After the Injury: TBI and Acute Care
Acknowledgment of Support and Disclaimer
This material is based upon work supported by the USAMRAA under
Contract Number W81XWH-07-C-0089.
Any opinions, findings and conclusions or recommendations expressed in
this material are those of the author(s) and do not necessarily reflect the
views of the USAMRAA.
© Greater Washington Educational Telecommunications Association, Inc., 2008