TRAUMATIC BRAIN INJURY: Moderate to Severe Traumatic Brain Injury
A “moderate” to “severe” traumatic brain injury is typically diagnosed in a person who sustained concussion, hemorrhage, a significant loss of consciousness, coma, and/or skull fractures. Injuries such as these are usually detected on radiological studies such as a CT scan, MRI, and other imaging devices. In many of these cases, the injuries are life-threatening with brain swelling, contusion and edema as likely complications.
A person who suffered a “moderate” to “severe” traumatic brain injury victim may experience paralysis, loss of taste or smell, decreased muscle control, problems with sleep, speech or swallowing, as well as issues with memory or word-recall. These symptoms vary from person to person depending on what area of the brain was injured.
Moderate Traumatic Brain Injury:
Medical literature shows us that, statistically, between 8% – 10% of all traumatic brain injuries are “moderate traumatic brain injuries”. Many experts feel that this is a very conservative estimate and moderate traumatic brain injury may account for as much as 28% of all traumatic brain injuries occurring. As indicated earlier when discussing mild traumatic brain injury, estimates of severity of injury based on post-traumatic amnesia duration (PTA), can be utilized. Where the post-traumatic amnesia lasts between 1 hour and 24 hours, the injury rating is generally listed as being moderate. Neuroimaging, including CT scan, MRI (functional as well as T-3 and other strength ratings, gradient echo and other software applications), SPECT scan and PET scans are often used as diagnostic tools for the purpose of rating moderate traumatic brain injury. Another test commonly utilized to rate injury is that of the Glasgow Coma Scale (GCS) which is used to describe all post-traumatic states of altered consciousness.
Glasgow Coma Scale (GCS)
The scale comprises three tests: eye, verbal and motor responses. The three values separately as well as their sum are considered. The lowest possible GCS (the sum) is 3 (deep coma or death), while the highest is 15 (fully awake person). A GCS score of 13-15 is considered a “mild” injury; a score of 9-12 is considered a “moderate” injury; and 8 or below is considered a “severe” brain injury.
The GCS is beneficial since it can be utilized by the various medical providers involved in the treatment of a person who has a traumatic brain injury; from the emergency medical technicians in the field to the emergency room physicians and nurses. However, the use of the GCS has its problems. The ratings are subjective evaluations and may vary from medical provider to medical provider. Patients that have ingested alcohol or drugs or are sedated may lower their GCS or produce unreliable GCS scores.
Statistics vary on the outcome of individuals sustaining moderate traumatic brain injury. At least one study indicated that as many as 28% of those individuals seen in an emergency room and in an intensive care unit diagnosed with a moderate traumatic brain injury made a “good recovery” on the Glasgow Outcome Scale. Changes in sleep patterns, fatigue, judgment, headache, multitasking, memory, concentration, word selection, attention deficits, processing speed problems, and problems with independent living were nonetheless found to persist. Most individuals sustaining moderate traumatic brain injury will find it extremely difficult to return to their pre-morbid vocation.
Severe Traumatic Brain Injury:
Severe traumatic brain injury victims comprise approximately 10% of all traumatic brain injuries. Due to the fact that severe traumatic brain injury victims are unlikely to ever return to work or independent living, and because their rehabilitative needs are so great and expensive, and because almost all are unable to return to independent living, this group represents a growing problem for society and for the health care profession. Families of individuals sustaining severe traumatic brain injury are subjected to severe financial and emotional burdens. It is not uncommon for the following deficits to persist in varying levels of severity over the course of a severe traumatic brain injury victim’s life:
1) Motor function problems;
2) Executive function problems : Difficulty with self control, regulation, self-direction, planning, organization, and self determination;
3) Attention and memory deficits;
4) Speech and language deficits;
5) Loss of smell or taste;
6) Seizure disorder; and
7) Emotional and psychiatric issues.
Recently there has been much criticism within the research community on the way TBI is classified. Geoffrey Manley, M.D. a UCSF professor of neurological surgery who co-direct the UCSF Brain and Spinal Injury Center and is Chief of Neurotrauma at UCSF-affiliated San Francisco General Hospital stated that studies over the past two decades have revealed much about biological mechanisms behind traumatic brain injury, but there has been a serious lag when it comes to translating that knowledge into a successful clinical trial and improved patient care. “Even the way we classify TBI is completely outdated.”
The current classification system, known as the Glasgow Coma Scale (GSC), divides a patient’s TBI into the extremely broad categories of mild, moderate and severe, and fails to take into account the specifics of each patient’s condition, Manley said. What is needed is a new classification system and an overall standardization of treatment and research efforts, he said. “If we can start to standardize, we can really change the field,” Manley said. “Only by standardizing can we make things more efficient, streamlined and economical.”
Manley and other TBI experts from nearly 50 agencies and institutions will be tackling these issues at a consensus conference in Silver Spring, MD, on March 23-24. The conference is co-sponsored by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, the National Institutes of Health, and the U.S. Department of Veterans Affairs. Manley said he hopes the conference will produce real results that can be immediately applied to TBI clinical trials.
Cases involving moderate traumatic brain injury and severe traumatic brain injury are complicated cases necessitating a need for immediate acute care, intermediate acute rehabilitative care, and long-term rehabilitative care.
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