Feb. 05, 2022
When people think of adult traumatic brain injury (TBI), often sports figures such as Aaron Hernandez, Bubba Smith and Brett Favre come to mind. While sport is a TBI mechanism, motor vehicle crashes with or without substance use and falls also play major roles, says Erica Bellamkonda, M.D., a physiatrist at Mayo Clinic's campus in Rochester, Minnesota. She says her team sees a range of patients with TBI, from mild to severe.
"TBIs are common," she says, "especially if you think about how many patients with possible mild TBI or concussion injuries never present to health care providers."
According to John L. Atkinson, M.D., a neurosurgeon at Mayo Clinic in Rochester, Minnesota, head injuries prompt 1 million emergency department visits yearly in the U.S., with 250,000 classified as moderate to severe and 50,000 deaths.
Classifying TBI severity
Many medical centers use the VA/DoD Clinical Practice Guideline for the Management and Rehabilitation of Post-Acute Mild Traumatic Brain Injury (mTBI), based on the Glasgow Coma Scale (GCS), loss of consciousness duration and post-traumatic amnesia.
Mayo Clinic uses the Mayo Classification System for Traumatic Brain Injury Severity, described by James (Jim) F. Malec, Ph.D., an emeritus psychologist at Mayo Clinic in Rochester, Minnesota, and colleagues in a Journal of Neurotrauma publication in 2007. It evaluates numerous criteria, including GCS, loss of consciousness duration, post-traumatic amnesia and neuroimaging irregularities.
Determining TBI severity differs situationally, and event bystanders may offer crucial insights. "It's helpful when there are witnesses to the injury who can provide collateral information," explains Dr. Bellamkonda.
However, factors can confound or delay a concussion diagnosis, such as in a motor vehicle crash where the patient has multiple injuries and requires massive resuscitation and multiple interventions such that providers must postpone assessment until extubation, barring clear neuroimaging evidence. When there's clear injurious evidence on neuroimaging, neurosurgery consultation should occur quickly to determine if intervention is warranted. Providers must prioritize the most life-threatening injuries. If the patient has no identified life-threatening intracranial injuries, providers may assess for mild TBI or concussion, post-stabilization of other major injuries.
Mild TBI or concussion diagnosis may be confounded by alcohol or medication effects such as opiate analgesics, which have potential effects that can mimic head injury symptoms.
If an event has occurred that could result in TBI, Dr. Bellamkonda suggests making an initial assessment and determining appropriateness of a head CT scan. Whether concussion is suspected or diagnosed, it's important to offer concussion education.
Dr. Bellamkonda says most patients will show improvement of concussion symptoms within two weeks. She suggests patients follow physician care recommendations to optimize healing.
If concussion symptoms persist beyond the typical recovery time period, patients may require referral to a brain rehabilitation specialist. The treatment goal is to facilitate healing and functional recovery, which Dr. Bellamkonda describes as developing strategies for symptom management and returning to daily life activities. To prevent concussion, she suggests advising patients to practice safety: wear helmets, appropriate protective sports gear and seatbelts; follow vehicle speed limits; make the home environment safe; and use gait aids and safety equipment to prevent falls.
How to care for concussion
Dr. Bellamkonda recommends mental and physical rest the days right after concussion. While an initial rest period is important, she says limiting activity doesn't mean staying in bed doing nothing. Patients can continue to perform personal care and other activities, providing they don't significantly worsen concussive symptoms.
Patients should not return to daily activities concurrently, but rather gradually, starting with light activities for short time periods. As symptoms improve, she suggests adding more activities, and increasing time and intensity, as tolerated.
She also recommends patients avoid alcohol while having symptoms, as it can affect balance, judgment and reaction time, increasing fall risk and another concussion.
How to address moderate-to-severe TBI
Neurosurgery typically sees TBI in patients with atypical CT scans or irregular neurological exams, such as amnesia for the event, confusion and neurological deficits, minor and major, all the way to coma.
Dr. Atkinson says the mechanism of injury (MOI) is crucial to determine head injury severity. "MOI can tell you a lot — if a crash ejects an individual from a vehicle at high speed and someone finds the person in a ditch with fixed, dilated pupils, this provides clues," he says. "Also, ambulance personnel relay useful information, such as the patient falling off a ladder and unable to move his or her legs."
Significant TBI field experience also offers insights for providers. "The more you see it, the more you recognize it," Dr. Atkinson says. "Many times, you can tell when the patient hits the door that they'll need help with a blood clot."
After moderate-to-severe TBI, 10% of patients improve at the scene with ventilation and oxygen. At the hospital, 20% deteriorate, despite stability upon arrival, because of expanding brain hematoma; 10% to 15% require surgery.
Dr. Atkinson encourages trauma centers to call Mayo Clinic if questioning whether a patient has deteriorated too much for transfer. He acknowledges that some TBI cases may provoke fear in providers, including potential legal ramifications. "We see 60 to 70 patients transported to Mayo Clinic per year who are moribund upon arrival," he says. "The patient is brain-dead — we can't do anything."
Delivering news that Mayo Clinic cannot help a patient in this condition can provoke anger for the patient's family, especially after driving multiple hours when a local provider offered hope of Mayo Clinic treatment. "If you think, 'If this patient were my father, I wouldn't do anything — the patient's too frail,' that's important transfer decision-making information," says Dr. Atkinson. "If it looks hopeless, it probably is."
For patients with moderate-to-severe TBIs who've not reached brain death and are stable for transfer, he recommends rapid transport to a Level 1 or 2 Trauma Center with a staff neurosurgeon. He also suggests not taking time to get scans, as this will only delay getting definitive neurosurgical care for the patients.
Other tips Dr. Atkinson offers for moderate-to-severe TBI care include:
- Evaluate the trauma ABCs: airway, breathing and circulation, including damage control first if exsanguinating.
- Seek information from patients, those accompanying patients or first responders regarding MOI — if a patient went through a windshield, it's useful provider information.
- Determine if the patient has other health problems.
- Check if the patient takes anticoagulation agents requiring reversal.
"At the level of care you can render, render it," he says. "Time is of the essence."
For more information
Malec JF, et al. The Mayo Classification System for Traumatic Brain Injury Severity. Journal of Neurotrauma. 2007;24:1417.
Management and Rehabilitation of Post-Acute Mild Traumatic Brain Injury (mTBI) (2021). VA/DoD Clinical Practice Guidelines.
Refer a patient to Mayo Clinic.