Trauma: Traumatic Brain Injury
Guest: Dr. Angela Hays - Neurosciences
Host: Dr. Linda Austin – Psychiatry
Linda Austin: I’m Dr. Linda Austin. I’m interviewing Dr. Angela Hays who is
Assistant Professor of Neuroscience here at the Medical University of South
Carolina. Dr. Hays, let’s talk, today,
about an area that’s an interest of yours.
I know that you are a neurological intensivist and, as such, you take
care of a lot of patients who have had bumps on the head, who have what we call
traumatic brain injury or TBI. Let’s
talk about that. What would make you suspect,
first, that a person might have had an injury to their brain?
Angela Hays: Well, usually the best clue
is the history that get from the patient or from the people who’ve brought them
to the emergency department. The most
common causes of traumatic brain injury are motor vehicle accidents, falls,
people getting hit by various objects, for instance, a falling brick, or
something like that, and, lastly, assaults, which are responsible for about 10
or 11 percent of traumatic brain injury.
The symptoms that people most commonly present with are loss of
consciousness, headache, confusion, dizziness, blurry vision and sometimes
nausea and vomiting.
Linda Austin: Now, is loss of
consciousness an essential component of this?
For example, can one have sustained injury, actually, without losing
Angela Hays: Absolutely. People classify head injury according to a
variety of different criteria but, generally speaking, a mild head injury can
occur without loss of consciousness. Those
are the patients that might present with a story of having been hit on the head
and then find that they are a little bit confused, maybe have some short-term
memory loss. Nausea and vomiting are
very common. They may complain of
ringing of the ears or a sense of imbalance.
But, that would qualify as a mild symptomatic traumatic brain injury and
that’s probably the most common type that people see in the community.
moderate or severe head injury would be characterized, typically, by loss of
consciousness. If it’s less than 30
minutes, that might fall into the moderate category. People that remain comatose or unconscious
for a longer period of time are usually characterized as having severe brain
injury, just generally speaking.
Linda Austin: So, even, say, a couple of
hours would qualify, then, as a severe case?
Is that right?
Angela Hays: Yes. That’s one of the criteria. Usually you have to have one of several in
order to qualify as severe brain injury.
Other things that we would look for, aside from loss of consciousness
lasting more than 30 minutes, would be amnesia, which is a common consequence
of traumatic brain injury. And the
amnesia that we talk about, almost always, people will forget the actual
accident if the head injury has been severe enough, but what we’re really
interested in is what’s called anterograde amnesia, meaning, can’t lay down new
memory. So, frequently what we’ll see
when we’re assessing somebody who’s had a significant bump on the head, as you
put it, is that we’ll introduce ourselves, leave the room, come back in and
they don’t remember having seen us before.
Or, for instance, we’ll tell them, you
had a car accident, leave the room, come back in and they say, how did I get here? If that lasts for more than 24 hours after
the event then that’s another criteria, even if they didn’t have prolonged loss
of consciousness, that would qualify them for a severe traumatic brain injury.
Linda Austin: So, you get worried if
that really persists?
Angela Hays: Yeah.
Linda Austin: Dr. Hays, given, then,
that sometimes even without loss of consciousness; a person may have sustained
an injury, what are some of the symptoms to watch for that would make someone
think that they really ought to get to the emergency room?
Angela Hays: I would say that if a
person has persistent trouble with memory, lasting more than several minutes, I
would certainly consider being seen.
Another thing that you need to watch out for is a worsening level of
arousal. For instance, if somebody seems
sleepy, that might be normal, but if they continue to get sleepier then that
person, absolutely, needs to be assessed.
Any weakness or numbness on one side or the other needs to be
evaluated. If the person has any nausea
of vomiting ought to signal somebody to be seen by a physician. And the main reason for that is because
nausea and vomiting can be early symptoms of what we call intracranial
pressures. That can be a symptom of, for
instance, bleeding inside the skull, which can be dangerous and sometimes even
life threatening. That’s the main thing
that we want to rule out whenever somebody has had a head injury.
Linda Austin: So, that’s what you’re
really worried about, that they have a bleed?
Angela Hays: Absolutely.
Linda Austin: Now, if there is a bleed,
what part of the brain is that bleed occurring in?
Angela Hays: There are several different
types of intracranial hemorrhages that you might run into after traumatic brain
injury. Probably the most concerning is
what’s called an epidural hemorrhage.
And that occurs, usually, in association with a skull fracture. It most commonly results from a tear in one
of the arteries running along the surface of the brain. And that’s what makes it so dangerous,
because, obviously, if you tear an artery, the bleeding is under much higher
pressure than hemorrhages that result from tearing of a vein.
epidural hemorrhage usually presents with what’s called a lucid period, meaning
that the person may look just fine for the first several minutes to hours after
the injury and then they become sleepy after that. And that’s why I commented that a worsening
level of arousal is something is a very concerning sign. And that’s a type of hemorrhage that can be picked
up very easily on a CAT scan. And, if it
is found, sometimes it requires surgical drainage, but sometimes it be just
watched, depending on how big it is and how severe the symptoms are.
second most serious type of hemorrhage we worry about is what’s called a
hemorrhage, and that results from tearing of the veins that cross from the
skull to the surface of the brain. So,
because it’s the veins that are bleeding, in this case, those hemorrhages grow
much more slowly and result in a blood clot that lays over the surface of the
brain. As the hemorrhage grows, people
can develop headaches. They can develop
nausea. They can develop vomiting. And sometimes, they get sleepy as well. They may also have symptoms such as tingling
or weakness on one side of the body or the other. And, again, these are the kind of hemorrhages
that can be very easily picked up on a CAT scan and sometimes might require
surgery, depending on severe they are.
last thing that we sometimes run into with traumatic brain injury is what’s
called a cerebral contusion, which is like bruising of the brain. That results from broken blood vessels within
the brain tissue itself. Those are pretty
common and, again, can cause symptoms like numbness or tingling, but, very
frequently, don’t cause any symptoms at all.
These are the kinds of things that are dangerous more because of the
swelling that sometimes accompanies them, rather than because of the bleeding
itself, and only really require medical treatment if the swelling gets severe
enough that their brain pressures start to increase. Frequently those can just be observed in the
hospital for 24 to 48 hours, and if they remain stable or start to get better,
the person can go home and doesn’t need any further treatment.
Linda Austin: So, then if somebody has a
bump on the head, let’s say, in the evening or before bedtime, would you advise
that, perhaps, somebody set an alarm for three or four hours later and just
make sure they’re arousable? Otherwise,
how do you assess if they’re getting sleepier or not?
Angela Hays: It’s a very difficult
thing. We often used to say that
somebody shouldn’t go to bed in the hours following a head injury and should be
watched very closely. I would advise
that, if there’s any doubt, the person really ought to be seen by a physician,
because a CAT scan is a quick simple test that can rule out most of those
concerning things pretty definitively without too much investment of time and
it’s a noninvasive test. If the patient
is really resistant to going to the emergency room, I wouldn’t leave them
alone. I would keep the person up for
the next several hours, make sure that they continue to be arousable, and,
certainly, see if you can convince them get seen by a physician if those things
don’t continue to be true.
Linda Austin: Because a hemorrhage can
be a very serious thing.
Angela Hays: Absolutely. It can be life threatening. And, in the case of the epidural form, it can
progress very rapidly.
Linda Austin: Dr. Hays, I want to talk
some more about the long-term consequences of traumatic brain injury, but let’s
do that in another podcast.
Angela Hays: Okay.
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