what recovery to expect after a severe head injury

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Severe Traumatic Brain Injury

A astringent traumatic brain injury (TBI) affects more than simply the injured person. It also affects family members and friends who love and are close to the person who is injured. As one of these people, you play a very important role in caring for a loved i with a astringent TBI. For many, this role is new and comes with a lot of questions.

What is severe TBI?

TBI occurs when an exterior force disrupts the brain'southward normal role. Falls, motorcar crashes, assaults, and a blow or strike to the head are the about common causes of TBI. Severe TBI always includes a menses of unconsciousness (uhn-KON-shuh s-nis). During this time, the person volition not be able to stay awake. He or she will not be able to interact with surroundings in a purposeful way, such every bit reaching for an object. Here are the levels of impaired consciousness oft seen in people with a astringent TBI are the following:

• A coma is a state of complete unconsciousness. People in this country can't be awakened. They can't see because their eyes are airtight, and they may not reply to sound, touch, or pain. They can't communicate, follow commands, show emotions, or appoint in purposeful behaviors.
• People in a vegetative state are all the same unconscious merely may be awake at times. They may start to open their eyes. This is also known as "Unresponsive Wakefulness Syndrome." They may react briefly to sounds, sights, or affect and may even cry, grinning, or make facial expressions. But these responses are reflexes and are non nether the person's control. As with a coma, people in a vegetative state tin't bear witness emotions or engage in purposeful behaviors. People in a vegetative state aren't aware of themselves or their surroundings. They can't communicate or follow commands. The word vegetative doesn't hateful the person is a "vegetable." It refers to the "vegetative" or automated functions still beingness controlled by the brain, such as breathing, heart function, and digestion.
• People in a minimally conscious country begin to regain consciousness. They may have some awareness of themselves or their surroundings but not all the time. People in a minimally witting country may engage in purposeful behaviors from time to fourth dimension. For example, they may follow a simple command, look at people or objects around them, or go along their eyes focused on people or objects that are moving. They may reach for or try to apply a mutual object, like a hairbrush. They may testify advisable emotional responses or try to communicate through gestures or talking.
• Emerged from the minimally conscious state refers to people who can communicate consistently or use at least two objects in a purposeful fashion. During this stage, they may be able to answer simple questions correctly by saying or gesturing responses like "aye" and "no." They may also be able to follow instructions and perform simple tasks.
• When people regain consciousness, they may enter a post-traumatic confusional country. This state of recovery may include a status known equally post-traumatic amnesia (am-NEE-zhuh). People in this state are confused and have problems forming new memories. They may non be able to walk or talk, recall memories, or recognize people they know. Typically, people can't recall where they are or what happened. They can't remember day-to-day details or events. They can't perform lengthy tasks. They may sleep a lot during the solar day merely find it hard to sleep at nighttime. They may exist restless and/or agitated. People in this state may as well do dangerous things, like pull on feeding and breathing tubes or try to go upwards without help.

What happens during the acute hospital stay?

Each TBI is unique. Most people with a TBI need a combination of intensive medical treatments. These may include neurological, surgical, and rehabilitative treatment. In the acute care setting, doctors and other healthcare professionals outset address life-threatening injuries. Side by side, they accost and care for other injuries and medical issues that ascend. Finally, doctors make certain the injured person is medically stable. Many other health intendance providers and specialists may be involved also. This can be overwhelming. The following is an overview of the wellness care team members who volition likely be involved. Aside from providing care, the members of this team are an important source of information and support to family members and friends during this hard time:

• General medical team: This team of doctors, nurses, and nursing assistants provide care daily to people with TBI. This team treats medical atmospheric condition and manages medicines.
• Intensive care specialists: One or more medical professionals who specialize in trauma care and recovery may exist a part of the health care squad:
  • Surgeons – Depending on the injuries, surgeons may exist a part of the squad. Examples include trauma surgeons, neurosurgeons, orthopedic surgeons, and plastic surgeons.
  • Disquisitional intendance doctors – These medical doctors treat people who require intensive care. They monitor a person's medical condition closely. They also help diagnose and care for medical problems.
  • Critical care nurses – These nurse specialists do frequent (in some cases hourly) rounds. They perform informal bedside neurological exams. They may as well help doctors perform procedures. Because they interact oft with the patient and family, they are oft the "kickoff line" of communication, educational activity, and support for families.
  • Neurologists – These medical doctors evaluate and care for disorders of the brain. They may perform tests to help decide the extent of a brain injury. They may also perform bedside evaluations to guide diagnosis and monitor neurological recovery.
  • Pulmonologists or respiratory (RES-per-uh-tohr-ee) therapists) – These specialists diagnose and care for animate problems. They determine whether a person needs a breathing tube or machine to aid them breathe.
  • Dieticians or nutritional specialists – These professionals monitor a person'due south nutritional status and manage their dietary needs. They may too help make up one's mind whether a feeding tube is needed to provide nutrition.
• Pharmacists: In a hospital setting, these specialists work closely with the doctors to monitor a person's medications. They help with medication dosing and prepare medications. They may also provide education to the medical team and sometimes directly to families. They can explain the purpose of the medications being given and provide information on medication side effects.
• Physiatrists (fiz-ee-A-trists OR fi-ZAHY-uh-trists): These doctors help diagnose and treat medical conditions—including hurting, muscle, joint, and nerve problems—during the rehabilitation (rehab) process. They besides direct and oversee a team of brain injury rehab specialists, including concrete therapists, occupational therapists, and/or spoken communication therapists.
• Rehab therapists: These specialists provide various types of therapies, for instance, concrete, occupational, or spoken communication-language. People with TBI may receive these rehab services while they are in the intensive- or acute care unit. These services assistance foreclose muscle loss and go along the range of motion in arms and legs. They can besides help with swallowing, feeding, and advice difficulties.
• Neuropsychologists: These psychologists evaluate and diagnose changes in beliefs, thinking, and emotion caused by TBI. They may perform bedside assessments to assist diagnose levels of consciousness. They may educate and support family members of people with TBI.
• Case managers and social workers: These providers coordinate the health care plan by handling insurance benefits and other financial matters too as overseeing belch planning. They are a valuable resource for families and tin can provide both emotional support and information about TBI. These providers can also programme for time to come phases of care.
• Other professionals: A psychologist, chaplain, and/or patient representative may be available to provide spiritual and emotional support to people with TBI and their family members.

Throughout the recovery procedure, people with TBI undergo tests and procedures to assess the location and level of brain damage. This will help with diagnosis, prognosis, and treatment decisions. Such tests and procedures may include the following:

• Neuroimaging studies: These tests use computed tomography (tuh-MOG-ruh-fee) (CT scans) or magnetic resonance imaging (MRI). They help identify bleeding and injured parts of the brain. Doctors can as well use the results of these tests to help make up one's mind if surgery is needed.
• Electroencephalograms (ih-lek-troh-en-SEF-uh-loh-gram) (EEGs): These tests measure electrical activity in the brain. Results of EEGs can be used to diagnose seizures. They tin can also show the location and extent of a brain injury.
• Neurological monitoring/neuromonitoring: Devices such equally intracranial pressure level monitors track the amount of pressure in the brain and help manage encephalon swelling. These devices require placing a tube in the brain that is attached to wires and a monitoring screen. If needed, the tube device can be used to drain excess fluid and salve excess force per unit area in the brain. Neuromonitoring also helps diagnose and treat hydrocephalus (an excess of fluid buildup in the brain) and tin can help decide if surgical placement of a more than permanent pressure valve, called a shunt, is needed.
• Informal bedside neurological exams and formal behavior cess scales: Doctors may employ these tests to diagnose a disorder of consciousness caused past a TBI. They can help make up one's mind a person's level of impaired consciousness. A typical test tests basic reflexes; doctors look at how the optics react to light and they assess a person's response to audio, voice, touch, and pain. Doctors also wait for signs of purposeful behaviors, similar following a moving object with the eyes. This is called visual tracking. Other signs doctors look for are following commands and communicating.

What is known most recovery of consciousness and outcomes afterwards a severe TBI?

Some doctors consider certain severe TBIs to be beyond promise. However, this can't be determined in the start few days after an injury. It may take weeks—or even months—for a doctor to determine how or if a person will recover over time. Many people (but non all with a disorder of consciousness related to a TBI) will eventually regain consciousness. The following are some important facts to keep in mind about recovery from a disorder of consciousness caused past a severe TBI.

• Recovery usually follows a stride-by-step path. Almost people progress through the stages of coma, vegetative state, minimally conscious land, emerged from minimally conscious state, and post-traumatic confusional state. So, people frequently keep to better slowly over time.
• There is a lot of variation in how people move through these stages and how long each stage lasts. Non anybody goes through every stage. Some people move through the stages quickly or skip stages. Others may get stuck in a phase.
• Recovering from a severe TBI tin can take a long time. Some people regain consciousness within a few days or weeks and recover apace. Others progress more than slowly and may remain in a state of impaired consciousness for months or years. Every injury is different and follows its own timeline.
• Equally a general dominion, the longer a person remains in a coma or in a state of dumb consciousness, the more than likely it is that they will be severely disabled.
• Visual tracking is a sign of improvement. It is ofttimes one of the starting time meaningful behaviors seen when a person moves from a blackout or vegetative country to a minimally witting country.
• The earlier a person improves from a coma or vegetative land to the minimally witting land, the better the long-term outcome. For example, if a person can follow uncomplicated, i-pace commands by 2–3 months subsequently the injury, the better the consequence is likely to be. This is true even if the responses are delayed or inconsistent.
• People with disorders of consciousness that last for several months after a astringent TBI tin still meliorate. They may do good from specialized TBI rehab.
• Age also plays a role in recovery outcomes. Among those with a prolonged time of impaired consciousness, younger people are more likely to return to living more independent, productive lives.
• An accurate diagnosis well-nigh level of consciousness is essential. It helps predict short- and long-term outcomes. It can assistance when deciding if specialized rehabilitation is needed. An accurate diagnosis is also helpful for family members and decision makers every bit they sort through hard decisions like whether to stop care.

What tin I practice to help?

You lot may feel powerless, helpless, and afraid. But yous play an essential part in the intendance of your loved one. Y'all tin do many things to motion treatment along and support ongoing recovery:

• Be ready to answer questions from the health care team. These could be about your loved 1's medicines, allergies, or other medical weather condition. The more information you lot can provide, the ameliorate prepared the medical team will exist in preventing new problems.
• Your loved i won't be able to make decisions near medical procedures. If yous are not the legal decision maker your loved 1, then find out who is. Other family members and loved ones can support the legal decision maker during this tough and emotional time. If your loved ane has an accelerate directive, discuss with the medical team his or her wishes about resuscitation. Severe Traumatic Brain Injury: What to Await in the Trauma Center, Hospital, and Beyond iii
• It might be helpful for you or someone else to become the legal guardian for your loved i. A guardian is someone the courtroom assigns to manage personal, legal, and financial matters for a person who tin can't make their own decisions. Having a guardian appointed may aid when making decisions almost your loved ane'southward medical care. Elder law attorneys are lawyers who can assist with this process. These lawyers tin also assist with financial planning and other legal matters for people with long-term care needs.
• Learn about changes that may occur in people later on a astringent TBI. These include cognitive, physical, behavioral, and psychological changes. This will help you know what to await as your loved i recovers.
• Learn well-nigh the skills needed to take intendance of your loved one. This volition assist you feel more set up during the treatment and recovery phases.
• Don't forget to accept care of yourself. When in crisis mode, family members ofttimes put their own needs last. But it is important to take breaks, eat regularly, and get a proficient night's sleep. Trust the care team to be there while you rest. By taking intendance of yourself, you lot can be a better back up for your loved one.
• Family and friends are ofttimes the first ones to notice changes in their loved 1's status. Noticing these changes is very helpful to the medical team. It'southward important to ask questions, enhance concerns, and share your observations.
• Understanding how to collaborate with your loved one may help his or her recovery. It can also help you to rapidly recognize signs that may indicate a change in his or her condition.

Here are some suggestions on how to interact with a loved i with a severe TBI:

• Remainder periods of residual and stimulation. Don't provide too much stimulation at in one case. For case, limit the number of visitors to simply a few at a time. When people are visiting, turn off the TV and make sure the room is at-home and serenity. Ever follow the intendance team's recommendations virtually how much and what type of stimulation is advisable for your loved one.
• Even if your loved 1 can't respond, physical contact is important. Agree his or her mitt. If the bedside nursing staff permit it, gently massage your loved one'due south hands, arms, legs, or feet.
• Stimulate your loved ane'due south senses. Offer unlike smells, sounds, things to look at, and things to affect. Show pictures of friends and family. Play his or her favorite music. Bring in a favorite blanket, stuffed toy, or piece of clothing.
• Talk to your loved one as if he or she tin can hear and empathize you. Read him or her a book or a paper. Recall important, special, or funny life events; or put on his or her favorite TV evidence.
• Occasionally "test" your loved one's ability to brand center contact or sentry people move effectually the room. Ask him or her to follow uncomplicated commands like "clasp my hand," "raise your arm," or "open your mouth." Ask him or her to answer unproblematic "yes" or "no" questions. It may take several seconds for him or her to respond each time. Let your loved one rest briefly between questions.
• Don't pressure your loved 1 when he or she doesn't evidence yous the behaviors you lot're hoping for, or if he or she only shows them some of the time. Your loved one tin can't command changes in consciousness. Equally recovery continues, you may run across these behaviors more oft.
• When your loved 1 regains consciousness, he or she may be confused, and behavior problems may develop. Tell your loved one often that he or she is in a safe identify and that people are there to help. Remind him or her of what happened; where he or she is; and the current day, appointment, and time. Keep a clock and easy-to-read agenda in clear view.
• Aid identify things that trigger any behavior trouble in your loved one. Write downwardly what was going on just before the problem occurred.

What should I ask the doctors and other wellness professionals who are treating my loved one?

• What is my loved one's level of consciousness, and what information and tests were used to determine the diagnosis and prognosis?

You or other decision makers may accept to make decisions well-nigh treatment in the first hours and days after the injury. These decisions may demand to exist made based on unclear information. This can be scary and overwhelming. You lot may feel more than confident when a disorder-of-consciousness diagnosis is based on both bedside exams and objective tests (e.g., results of an EEG). Doctors may deliver a poor prognosis "with certainty." Enquire questions about what this ways. Ofttimes, more specialized bedside exams, tests, and time are needed. This is specially of import when deciding whether to remove your loved one from life support. If a definite poor prognosis is given, inquire the health care team to give you the full range of possible outcomes, and ask what information they are basing the prognosis on. Yous may besides want to consult a disability specialist with expertise and experience in TBI rehab. Consider what they say forth with information from the health intendance squad. These specialists can offer an expert opinion about your loved i's diagnosis and prognosis. They can also assistance match your loved one with the correct rehab services.

• Are there any other medical conditions that tin can be treated to help promote my loved one's recovery?

Factors other than the main injury may brand it tough for your loved one to collaborate with his or her surroundings. For instance, medicines may make him or her sleepy. He or she may be having seizures. In that location could besides be an infection or a build-up of fluid on the brain. Enquire the doctors to look for these and other factors that can bear on recovery.

• What are the care options for people with severe TBI?

When your loved one is medically stable, treatment will focus on preparing him or her for the side by side level of intendance. At this point in the recovery process, many people withal demand specialized, inpatient services including rehab. Specialized rehab services are offered in many settings. These include acute care or inpatient rehab hospitals or subacute rehab facilities. However, many health insurance plans won't pay for these services if your loved ane can't actively appoint with surroundings. Your loved one could also receive care at a skilled nursing facility, just specialized TBI services are oft limited in that type of setting. To decide on the side by side level of care, doctors will look at your loved one's medical status and diagnosis and at brain injury programs in your expanse. The search for the right placement and services tin can be hard. Social workers and/or case managers tin can aid you explore the available options. Boosted data and resources to help find the right placement for your loved ane may also be available through your local, land, and national brain injury associations. Whatever the adjacent level of care is, you should look for a program with feel in caring for people with severe TBI. If your loved ane is in a vegetative or minimally witting state, look for facilities with experience in caring for patients with disorders of consciousness. Hither, your loved one volition go care and be observed for a longer menses of time. This can help achieve an accurate prognosis and guide long-term care planning. Such settings are also best prepared to monitor progress, prevent complications from developing, and assistance with a discharge abode when advisable. If your loved i doesn't get placed in a facility with specialized TBI services, you may want to stay in touch with a neurologist, rehab medicine md, and/or a rehab case manager so someone with TBI expertise remains involved in the care of your loved i.

• How is my loved ane progressing, and what is the care squad doing today to manage his or her condition?

 Particularly in the early phases of recovery, your loved one'southward condition may change apace and often. You lot may experience as if you are in a abiding state of worry about his or her medical stability. This can exist extremely stressful for families. It may assistance to stay informed most your loved one'due south daily status and the progress that the care team is observing. Enquire questions to assistance you better understand his or her care needs, what is being done to manage his or her condition, and what the next days and weeks might look similar based on the intendance team's observations. Data, education, and regular advice with the care team may reduce your stress level and help you experience actively involved in your loved 1's care.

Summary of key points about astringent TBI

• Severe TBIs always involve a period of unconsciousness. When this catamenia lasts for an extended corporeality of time, the term disorder of consciousness is used. Disorders of consciousness include coma, vegetative state, and minimally witting state. Each disorder of consciousness is marked by dissimilar levels of awareness and ability to interact with surroundings in a purposeful way.
• Many people with a astringent TBI regain consciousness; however, recovery is a long procedure and it involves several stages.
• People with disorders of consciousness that final several months after a severe TBI can nevertheless take meaningful recoveries. They ofttimes do good from rehab in programs that specialize in treating people with severe TBI.
• An accurate diagnosis of level of consciousness is essential. It tin help predict short- and long-term outcomes. It can also assistance in treatment planning and informing important decisions early on in recovery.
• Early predictions of long-term recovery are frequently inaccurate. Information technology may have time to make an accurate prognosis. Such a prognosis is based on your loved one's changing status, particularly as the medical condition improves and intendance is simplified.
• The health intendance team should have expertise in managing astringent TBI. These professionals are all-time prepared to handle the many complex bug that may come upwards during your loved i's recovery.

Where can I learn more about severe TBI and DOCs?

• "Facts about the Vegetative and Minimally Conscious States subsequently Astringent Brain Injury": https://www.msktc.org/tbi/factsheets/Vegetative-And-Minimally-Witting-States-After-Severe-Brain-Injury
• "Traumatic Brain Injury and Acute Inpatient Rehabilitation": http://www.msktc.org/tbi/factsheets/Traumatic-Brain-Injury-And-Astute-Inpatient-Rehabilitation
• Encephalon Injury Clan of America: 1-800-444-6443, http://www.biausa.org
• Brainline.org: http://www.brainline.org

References

Giacino, J. T., Zasler, N. D. M., Katz, D. I., Kelly, J. P., Rosenberg, J. H., & Filley, C. One thousand. (1997). Development of practice guidelines for assessment and direction of the vegetative and minimally conscious states. Journal of Head Trauma Rehabilitation, 12(4), 79–89.

Katz, D. I., Polyak, M., Coughlan, D., Nichols, Chiliad., & Roche, A. (2009). Natural history of recovery from brain injury afterwards prolonged disorders of consciousness: Consequence of patients admitted to inpatient rehabilitation with 1–iv year follow-up. Progress in Brain Research, 177, 73–88.

Leonardi 1000., Giovannetti M., Pagani M., Raggi, A., & Sattin D. (2012). Brunt and needs of 487 caregivers of patients in vegetative state and in minimally conscious state: Results from a national written report. Brain Injury,26(x),1201–1210.

Nakase-Richardson, R., Whyte, J., Giacino, J. T., Pavawalla, South., Barnett, South. D., Yablon, South. A., . . . Walker, W. C. (2012). Longitudinal upshot of patients with matted consciousness in the NIDRR TBI Model Systems Programs. Periodical of Neurotrauma, 29(1), 59–65.

Pagani, Yard., Giovannetti, A. Yard., Covelli, Five., Sattin, D., & Leonardi, M. (2014). Caregiving for patients in vegetative and minimally conscious states: Perceived burden as a mediator in caregivers' expression of needs and symptoms of depression and feet. Journal of Clinical Psychology in Medical Settings, 21, 214–222.

Whyte, J., Nakase-Richardson, R., Hammond, F. M., McNamee, S., Giacino, J. T., Kalmar, K., . . . Horn, L. J. (2013). Functional outcomes in traumatic disorders of consciousness: v-twelvemonth outcomes from the National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems. Archives of Physical Medicine and Rehabilitation, 94(10), 1855–1860.

Authorship

Severe Traumatic Brain Injury: What to Expect in the Trauma Center, Hospital, and Across was developed by Amy M. Rosenbaum, PhD; Alan Weintraub, Doc; Ron Seel, PhD; John Whyte, Dr., PhD; and Risa Nakase-Richardson, PhD, in collaboration with the Model Systems Noesis Translation Center.

Source: Our health information content is based on enquiry bear witness and/or professional consensus and has been reviewed and approved by an editorial team of experts from the Traumatic Brain Injury Model Systems.

Disclaimer: This data is not meant to replace the advice of a medical professional. Yous should consult your wellness care provider regarding specific medical concerns or handling. The contents of this fact sheet were adult under a grant from the National Institute on Inability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90DP0082). The contents of this fact sheet exercise non necessarily represent the policy of the U.Southward. Department of Health and Homo Services, and you should not presume endorsement by the federal regime.

Copyright © 2017: Model Systems Knowledge Translation Center (MSKTC). May be reproduced and distributed freely with appropriate attribution. Prior permission must be obtained for inclusion in fee-based materials.

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