Severe Head Injury explained by Dr Deepak Agrawal professor in Neurosurgery (AIIMS)
What is a severe head injury?
Severe Head injury is patients having a very severe head injury.
There are three grades of head injury-mild, moderate, and severe based on a grading system called Glasgow coma scale or GCS. So without going into technicalities, what is important to remember is that you should always be aware of the GCS of a patient while communicating to a doctor for a second opinion.
So what are the aims or objectives in managing head injuries, especially severe head injuries?
What happens at the time of impact is that very nanosecond that cannot be changed because brain cells or neurons are the only cells in the body that do not regenerate. So whatever cell dies, dies forever and that is the reason any injury to the brain leads to irreversible loss to some part of the brain.
In severe head injury obviously, the loss is more and makes us come back to the original point that whatever impact results in injury to the brain cells cannot be undone. What we can do as doctors and neurosurgeons is to prevent secondary brain injury.
What a secondary brain injury is?
Secondary brain injury is preventing the bad effects or the side effects of raised intracranial pressure. If you imagine the head of a person is like a pressure cooker you understand that it is completely closed on all sides and the only difference being that the pressure cooker has a whistle. So if the pressure inside increases the whistle can be blown to maintain a constant pressure.
However, this doesn’t happen with the brain as there is no outlet for the pressure and this is the reason when the pressure inside increases due to any cause the brain gets cooked inside its own head. so it is very important to deal with secondary brain injury to prevent damage to whatever live cells are there in the brain.
What are the principles of management?
Now, the most important principle of management is NOT a neurosurgeon looking after the patient. The principles of management is the initial care of the patient which involves managing the airway, breathing, and circulation.
Now you may ask what is the relevance of airway, breathing, and circulation in severe head injury patients.
In head injury patients the two biggest killers are hypoxia or otherwise known as lack of oxygen and hypercarbia or increase in carbon dioxide.
If oxygen doesn’t go into the body and to the brain, brain cells will die within three minutes. So it is extremely important that we continue giving oxygen to a patient to prevent this hypoxia. The other thing is raised carbon dioxide in the body. You may be amazed to know that carbon dioxide is the most potent vasodilator known to man.
What is the vasodilator?
A vasodilator is a drug or a chemical that causes the vessels anywhere in the body to dilate. And when they dilate the volume of the blood inside will increase. So if we increase the carbon dioxide there will be more blood inside the brain compounding the already raised intracranial pressure.
And the biggest problem today in our society is that when a severe head injury patient comes to any nursing home clinic or a smaller hospital, the nurses and doctors panic and say that they do not have neurosurgical facilities and to take the patient somewhere else.
This is the worst that can be done for a patient. Even in the most primitive health setup airway management, breathing management, and circulation management can be done and should be done.
Only after stabilization of the patient with all these three steps, should the patient be referred to a neurosurgeon. And whenever you send a patient from a smaller center to a higher center or transfer the patient, airway control is the most important.
You should not send them just on room air (Mask etc) because an unconscious patient is very liable to aspirate (take the vomit inside the airway) because the reflexes are impaired. So they must always have airway control before being shifted to any other facility.
What is the outcome of these patients?
Because that is the first thing on the mind of all relatives and they ask the doctor as to what will happen to their patient. Now just by labelling a patient ‘severe’ based on his admission GCS score, one can predict the outcome of the patient- 30% of the patients with a severe head injury will die in the hospital. That is how bad this problem is. Another 40% will remain vegetative for life.
What is a vegetative state?
A Vegetative is a patient who does not respond to commands but can open their eyes and look around, although cannot fix their gaze.
So these patients keep lying on the bed for life and they have to be fed. They will eat when fed but are like a vegetable. They do not respond to anything. So it is a life worse than death.
We are left with only 30% of the patients who will go back to society and maybe be independent to a certain degree. But remember they will never be normal, they will continue to have major deficits, like calculation problems and cognitive issues which will remain throughout life. So never take any head injury lightly.
What is the long-term outcome?
This is another common question after we discharge the lucky 30% of patients from the hospital. Relatives ask will their patients improve? Yes, definitely patients will continue to improve but only to a certain extent or to up to a certain time. Generally accepted is that improvement occurs up to six months in adult patients. In children, however, this is different because the brains are very plastic and improvement can be seen up to two years also.
I will end with the final words: obviously, nobody can accept a patient not coming back to the pre-head injury levels and there is no solution to this problem currently. I know of cases in which the doctors did a very good job and the patient could be discharged. But although he was conscious there were so many mood changes and anger with an increase in appetite so much so that it is almost like being dependent on the caregiver, which is obviously your parents, your spouse, or your children.
I remember there was a Colonel from the army whose only son got injured and had a severe head injury and they got him to AIIMS, Delhi and we did as we’re supposed to do (all the treatment) and we could discharge the patient and he was conscious, moving around- which we consider as a good outcome, but he was very violent which increased over time, Also, his appetite increased because of the effects of head injury. His parents were finding it more and more difficult to take care of him and the father actually filed a case against AIIMS as to why they saved his child, and he said that because he is old there is no one else to look after him, what will happen to him after we die.
So, these are certain problems that, without any kind of a social support system in India, become extremely complex to handle, and as doctors, we find it sometimes very difficult to know how to balance out the emotions, expectations, and outcomes.
I think that ‘Dharamsankat’ is always there within us and although we want to do our best in the other aspect, we also cannot act like gods and decide to let a patient go. We are always, and always been trained to do the best possible and the final outcome is never in our hands.
So the only way to treat a head injury is to prevent it. And I think that despite all the literature and despite all the media, people do not understand the significance of wearing helmets, safe driving, and making sure that you avoid all kinds of issues that may lead to a head injury. Prevention is the best, safest, and most consistent way to avoid any kind of injury. Because your brain is the most important part of your body and unless you also take care of it don’t expect the doctors to do miracles on you. Thank you so much
Content Credit: Dr Deepak Agrawal