Family doctor

The Accident

Acceleration Injury

Most head injuries occur because the head is suddenly forced to stop or start moving, or to turn rapidly. These are called 'acceleration' injuries. Running a motor vehicle into a power pole, being hit from behind when you are stopped at traffic lights, or a punch on the jaw that swings the head round are examples of this. As the brain is forced to follow the movements of the head it gets pulled out of shape and stretched, so that its nerve fibres, together with the arteries and veins that run through it, are torn across. Damage of this sort is usually widespread throughout the brain, though some areas are worse affected than others.

Local Injury

A weapon used in an assault, the handlebar of a motorbike in a traffic accident, or just falling against the sharp edge of the curb can tear the scalp, break through the skull and injure the brain directly. This sort of injury often affects only quite a small area of brain and though it can have serious results it may cause less problems than an acceleration injury, in which the damage is widespread. Both sorts of injury may occur at once, especially in traffic accidents.

Multiple Injury

In many accidents the brain is damaged more than once. The victim may be flung out of the car and injure their head again as they land on the road. They may be trapped in the car and pinned down so that they can't breathe properly and their brain becomes starved of oxygen and some of its cells die.

Often there are fractures of the limbs and damage to the chest and abdomen. So much blood may be lost from these injuries that the circulation of blood to the brain fails, and again parts of it will die.

Brain swelling and intracranial pressure

The brain swells when it has been injured, just as other parts of the body do. Normally the brain fits closely inside the skull, with only a little space to spare. When it swells, this space is soon taken up; and if swelling continues, the pressure inside the skull - 'the intracranial pressure' - rises and the brain is compressed. If the pressure goes on rising, the arteries of the brain are squeezed shut, the circulation to the brain stops and the brain dies.

Causes

Brain Oedema

The most important cause of brain swelling is the fluid that accumulates in the damaged brain - brain oedema. This can be reduced by controlling the amount of water and salt in the body, and by making sure that the brain has all the oxygen and food it needs, and is able to get rid of waste products like carbon dioxide. Managing this situation is one of the most important tasks of the hospital team, and you will see later how it is done.

Blood clots

Another important cause of increased intracranial pressure is a leak of blood from a vein or an artery in the brain, torn at the moment of the accident. This forms a clot, which may lie inside the brain or over its surface, and which compresses it. Often the clot can be removed by an operation.

Causes of increased intracranial pressure that can happen later

Subdural haematoma

Occasionally, a week or a month after injury, someone who seems to be making a good recovery stops getting better and slips back. Two common causes are: A blood clot located in the space around the brain, not big enough to cause trouble at first, may grow with time and cause symptoms several weeks later. This is called a 'chronic subdural haematoma'. It can usually be removed successfully by an operation.

Hydrocephalus following head injury

The normal circulation of fluid round the brain may be blocked by the effects of injury, and weeks or months later the fluid can build up and cause a rise of intracranial pressure. Again this can be treated quite simply by an operation.

Coma

Rescue

Earlier we described damage to the brain being made worse if the victim was trapped and unable to breathe, and also by the loss of large amounts of blood. Getting the ambulance staff to the accident as soon as possible is therefore vital. They will free the victim, stop the bleeding, and give a transfusion if it is needed. This will prevent further damage and make the patient safe for the journey to hospital.

Arrival at hospital

As the patient arrives at the door of the accident department, the emergency team again makes sure that breathing is free and that lost blood has been replaced by transfusion. Because unconscious people cannot keep their throats clear, a tube will usually be threaded through the mouth or nose into the windpipe. This 'endotracheal tube' is connected to a 'ventilator', which takes over breathing mechanically. This ensures that the brain is well supplied with oxygen.

Assessing the 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.

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.

The Family's share in treatment

To begin with, the people who give the treatment and care will be the hospital staff, but the time they have is limited and soon the family will have to take over some of this responsibility. They will have to learn from the professionals how to give the treatment that is needed. To this they must add the support and caring that will get their family member through the tedious and tiring months ahead.

If you, the family, are going to do this well, you will need to understand how a head injury affects the way people think and act, and to appreciate the sorts of difficulty that the patient faces.

How the Family can cope with a severe head injury

Getting an emergency call from the hospital, seeing someone who is dear to you unconscious and surrounded by the equipment of Intensive Care, and spending days sitting by them and waiting, can be worse than anything that has happened to you before.

It may be more than you can deal with on your own, yet you may find it difficult to ask for help; many people feel this way. Try to share the burden - bring in other members of your family, and don't be reluctant to ask the staff for help.

You will be thinking all the time what the end result is going to be. Try to accept that in the early stages it's just not possible for anyone to say. The staff can tell you what the injuries are, but they can only guess whether the patient will live, and what kind of recovery they will make. Don't expect anything more definite than this.

Grief is natural at this stage, and you should not be ashamed to express it. Be careful, though, that you don't waste your energy in anger or looking for someone to blame. This only increases the stress, and can stop you dealing with the real needs of the situation.

If you don't seem to be getting anywhere, don't hesitate to ask the hospital staff to arrange for you to see an experienced counsellor.

Stress and how to deal with it

For your own health, and so that you can be most use to the person you are caring for, you must know what the signs of stress are, and know when you are not coping with it properly. Are you:

• Sleeping badly and being tired all day
• Not looking after yourself
• Losing your temper with your best friends
• Turning your problems over and over without getting anywhere
• Using drink or sleeping pills to forget
• Feeling alone, and that no-one understands or cares
• Insisting on doing everything yourself
• Looking for someone to blame

If you answered yes to some of these question, stress is probably getting to a serious stage, and you need to do something to deal with it.

Try to stand back from your problems and look at them as if you were someone else. You may find then that you can deal with them yourself.

Perhaps you can look at the help you are getting from other people and find where it could be increased.

If you think you need help, don't deny yourself because you're too proud to ask, or too shy. It's not only for your good, but for the people who depend on you.

Many people find it's useful to get help from outside. This could be talking things over with someone close to you whom you trust, or it may be easier with a stranger, such as a professional counsellor.

Getting help

Counselling

Confidential counselling can usually be arranged with hospital social workers and psychologists. It should be able to help you both with the personal problems that we have mentioned, like dealing with stress and grief, and also the practical ones, such as finance and compensation.

ACC

ACC is there to help you too. You should make a claim as soon as possible after the accident. The hospital staff will have a "Claim for Cover" form to fill in. They will show you how to do this.

After the claim has been accepted, a "Case Manager" will be assigned to the patient. Their role is to help manage the patient's claim and recovery. They will be your personal contact at ACC and will help ensure the patient receives the right treatment, compensation and rehabilitation.

The patient and family may be entitled to several different types of assistance from ACC including weekly compensation, independence allowance, transport, attendant care, housing modification, and aids and appliances.

The Head Injury Society

This society was started by people who had suffered head injuries, and by their families, to help others in the same situation to cope. Get in touch with them; the hospital staff or the ACC Case Manager will be able to give you a telephone number to call, and you will be able to find out what support is available in your area. If you have any difficulty with this, contact the Neurological Foundation.

The Neurological Foundation

PO Box 68 402, Newton, Auckland. Ph (09) 302 0367.