By MICHAEL SAMOGALA, RN, CRRN, CBIS
As we know, brain injury in its multiple forms, continues to be a major health issue in the United States and is becoming consistently more complicated as time and effort continues to define its complexity. Brain injury as many of us understand today, is also known as, "The Silent Epidemic." In spite of its staggering number of occurrences, the true effects of a brain injury are often invisible to a common observer. We must understand that someone who has sustained a brain injury appears the same and often completely "normal," however, there are many different occult effects of brain injury that cannot be specifically, conclusively and consistently observed by the untrained eye.
Keeping in mind that in 2013, the CDC stated in the U.S approximately 2.8 million traumatic brain injuries resulted in emergency department visits, some resulting in hospitalization, or death. Brain injury effects all age groups in every social and economic status; this cannot be ignored.
In discussing brain injury in a basic, systematic fashion, we can define what is universally referred to as Acquired Brain Injury. An Acquired Brain Injury (ABI) is further subclassified by relative causes (Traumatic or Non-traumatic). Traumatic brain injury (TBI) is a nondegenerative, noncongenital insult to the brain from an external mechanical force. (Medscape 2017). As defined, we must also include inertial injury within the cranial vault. Non-traumatic ABI most often occurs due to CVA; however, injury can be caused by any form of impending or sustained cellular hypoxia (Inflammatory or Physical) or other various causes including substance/chemical abuse and/or exposure, and infective processes.
The mechanisms of ABI are often thought of as primary which include the injury itself whether mechanical as in coup-contrecoup and/or diffused axonal injury. Secondary mechanisms and their process are now becoming the focus of research with the known concept of secondary cascade, including the action of free radical release originated by the cells of initial injury into the surrounding cells and tissues. Current literature targets this process as progressive and is possibly considered to be unpredictable. Specifically, this process influences apoptosis and random cell death.
Understanding these processes may allow us to consider those latent effects of brain injury which we as health care providers so often attribute to non-compliance or blatant refusal to conform to medical or social regimen. Recent statistics show that if an individual sustains a brain injury, the likelihood of a second injury is three times that of the general population and after the second injury, is eight times more likely to occur again; thus, we have a reoccurring injury by initial occurrence.
In further discussing ABI, familiarity with the levels of severity, mild, moderate and severe, are consistently scrutinized. The categorization/determination of severity is currently initiated utilizing three main factors relating to the incident of injury. These include the initial Glasgow coma scale, the period of post-traumatic amnesia and the length of any period of unconsciousness. As we know, in current practice, often the information received on initial assessment may be tainted. Failing to consider, "the injured individual not being able to remember what they don't remember?" simply stated is what happened actually what occurred, or is it what the individual was told throughout questioning, transport and/or the initial treatment process? "Since there was no loss of consciousness!"
This question also generates attention to what we now know regarding concussion as a true form of a mild brain injury. The health care system of the past considered concussion as an incident that frequently occurred within the context of sports, athletics or minor incidence of impact - having your "bell rung." We now know concussion in itself is defined as an injury characterized by immediate and transient alteration in brain function, including alteration of mental status and level of consciousness, resulting from mechanical force or trauma (2017 AANS).
Post concussive syndrome as defined by NIH 2012, refers to cognitive deficits in attention or memory and three or more of the following symptoms: fatigue, sleep disturbance, headache, dizziness, irritability, affecting disturbance, apathy or personality change (behaviors).
Conclusively, the risk of post-concussion syndrome doesn't appear to be associated with the severity of the initial injury. There does not have to be any loss of consciousness. In most individuals, symptoms occur within the first 7-10 days and resolve within 3 months, however, we now know they can persist for a much longer period of time, exceeding a year or more. (Mayo 2017)
In fully assessing an individual with a possible ABI our thoughts need to be not only focused on immediate care but also on the discharge sequelae. In doing so, we must relate what is known about the area or areas of brain injury and the relative basic function as related to what could be great challenges to the individual's significant others/caregivers or the community in general, primarily safety issues and impulsive behavior.
As we understand behavior in general as a response to stimuli, the present acute health care arena at times focuses on over efficient treatment and discharge. As often behaviors and deficits associated with ABI are not always immediately observed, these individuals fail in their homes and communities, sometimes long after the initial injury. In addition, these individuals often become involved in our corrections systems due to the corrections systems' no-fault inability to screen and recognize brain injury related behaviors and functional deficits in many of these individuals.
In summary, as health care providers, we must be diligent in advocating for the individual who has sustained an ABI in any form. Due to the ongoing research and continued definition of acquired brain injury and results of that injury as related to the individual's specific needs within our community, it is imperative this advocation begin on the onset of the individual's assessment and care and progress throughout what might be a life change vs an injury. As new information is discovered and processed, the communication and recognition of brain injury as the silent epidemic, to and by all health care providers, is essentially everyone's responsibility. We, at NeuLife Neurological Services, fully support this concept.
Michael Samogala RN, CRRN CBIS has been directly involved in providing professional nursing and education services to the healthcare community for over 40 years. Most notably receiving board certification in rehabilitation nursing and as a brain injury specialist, he continues to provide professional credited continuing education programs to multiple professionals across the country, and remains in the position of Director of Corporate Education, NeuLife Neurological Services.