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What is Traumatic Brain Injury (TBI?) What Causes Traumatic Brain Injury? Symptoms What are the Effects of TBI? What types of TBI are there? What physical problems occur after TBI? What communication problems occur after TBI? What cognitive problems occur after TBI? How is TBI diagnosed? What other organizations have information about TBI? What causes TBI? How common is TBI? How effective are speech-language treatments for TBI? What does a speech-language pathologist do when working with people with TBI? Glasgow Coma Scale |
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What is Traumatic Brain Injury (TBI?) Traumatic brain injury, also known as TBI or intracranial injury, is generally the result of a sudden, violent blow or jolt to the head. The brain is launched into a collision course with the inside of the skull, resulting in possible bruising of the brain, tearing of nerve fibers and bleeding. TBI may also be caused by objects, such as bullets or a smashed piece of skull penetrating brain tissue. Causes of TBI may include falls, vehicle accidents, and violence. TBI severity varies enormously, and depends on which part of the brain is affected, whether it occurred in a specific location or over a widespread area, as well as the extent of the damage. In mild cases the patient may experience only temporary confusion and headache. Serious TBI can result in a period of unconsciousness, amnesia, disability, coma and even death. A head injury usually refers to a traumatic head injury, but is a broader category. Head injury may also involve damage to other structures (apart from the brain), such as the scalp or skull. According to the CDC (Centers for Disease Control and Prevention), USA: About one third of injury related American deaths are linked to TBI About 230,000 hospitalizations occur annually in the USA as a result of TBI 1.1 million Americans are treated for TBI and released from an emergency department Almost 2% of the US population lives with TBI-related disabilities About 2 million American adults and children suffer from traumatic brain injury annually 50,000 patients die annually in America as a result of TBI Every 15 seconds one American man, woman or child sustains a significant traumatic brain injury The total number of individuals with TBI who are not seen in an emergency department, or who do not receive any care is unknown Direct medical costs and indirect costs, such as lost productivity of TBI totaled an estimated $60 billion in the USA in 2000 Among American children aged up to 14 years, TBI results in an estimated: 2,685 deaths 37,000 hospitalizations 435,000 emergency department visits annually Scientists have not managed thus far to identify effective medications to improve outcomes for such patients, despite the extent of the problem. What are the signs and symptoms of traumatic brain injury (TBI)? A symptom is something the patient feels and reports, while a sign is something other people, such as the doctor detect. For example, pain may be a symptom while a rash may be a sign. After an impact to the head, a person with a brain injury can experience a variety of symptoms. Common symptoms of a traumatic brain injury can include but are not limited to: •Spinal fluid (thin water-looking liquid) coming out of the ears or nose •Loss of consciousness; however, loss of consciousness may not occur in some concussion cases •Dilated (the black center of the eye is large and does not get smaller in light)or unequal size of pupils •Vision changes (blurred vision or seeing double, not able to tolerate bright light, loss of eye movement, blindness) •Dizziness, balance problems •Respiratory failure (not breathing) •Coma (not alert and unable to respond to others) or semicomatose state •Paralysis, difficulty moving body parts, weakness, poor coordination •Slow pulse •Slow breathing rate, with an increase in blood pressure •Vomiting •Lethargy (sluggish, sleepy, gets tired easily) •Headache Confusion •Ringing in the ears, or changes in ability to hear •Difficulty with thinking skills (difficulty “thinking straight”, memory problems, poor judgment, poor attention span, a slowed thought processing speed) •Inappropriate emotional responses (irritability, easily frustrated, inappropriate crying or laughing) •Difficulty speaking, slurred speech, difficulty swallowing •Body numbness or tingling •Loss of bowel control or bladder control TBI signs and symptoms may sometimes be subtle and might not appear for days or weeks after the injury. Some patients may look well, even though they may feel or behave differently. Our brain controls our movements, thoughts, sensations and behaviors. A TBI can have several different physical and psychological effects. Initial physical effects are bruising and swelling. When injured brain tissue swells up pressure is increased; the injured brain tissue presses against the skull causing additional damage. The most common signs and symptoms of TBI include: Confusion Fatigue (tiredness) and lethargy Getting lost easily Persistent headaches Persistent pain in the neck Slowness in thinking, speaking, reading or acting Moodiness - suddenly feeling sad or angry for no apparent reason Sleep pattern changes - this may include either sleeping much more or much or less than usual, or having trouble sleeping Light headedness, dizziness Becoming more easily distracted Increased photosensitivity (sensitivity to light) Increased sensitivity to sounds Loss of sense of smell or taste Nausea Tinnitus (ringing in the ears) Children - the same signs and symptoms as those listed above are possible. However, children typically are less likely to let others know how they feel. If a child has received a blow or jolt to the head and you notice any of these signs or symptoms, call a doctor: Changes in sleeping patterns Irritability - e.g. the child does not stop crying and is hard to console Listlessness Loss of balance Newly acquired skills, such as toilet training are lost Playing behavior changes The child will not eat There is loss of interest in their favorite activities or toys Tiredness Unsteady walking Vomiting You should see a doctor if you suffered a blow to the head, and should seek emergency medical care if any of the following signs are present: Convulsions Repeated vomiting Slurred speech Weakness or numbness in the arms and/or legs (hands and feet) Mild traumatic brain injury signs and symptoms (concussion) may include: A short period of unconsciousness Blurred vision, tinnitus (ringing in the ears), or a bad taste in the mouth Cannot remember events immediately before and after the injury took place Confusion Dizziness or loss of balance Headache Headache Memory problems Moodiness Problems focusing mentally Moderate to severe traumatic brain injury signs and symptoms may include: Agitation, confrontational Continuous headache Convulsion or seizures Coordination problems One or both pupils of the eyes is/are dilated Patient does not wake up from sleep Persistent nausea and/or vomiting Profound confusion Slurred speech Weakness and numbness in hands, feet, arms or legs What are the causes of traumatic brain injury (TBI)? TBI is caused by a severe jolt or blow to the head, or a head injury that penetrates and disrupts normal brain function. Our brains are like a mass of gelatin which is protected from jolts and bumps by the cerebrospinal fluid around it - the brain literally floats in this fluid inside the skull. A violent blow or jolt to the head can push the brain against the inner wall of the skull, which can lead to the tearing of fibers and bleeding in and around the brain. Not only can a blow cause injury to the brain, sudden and rapid acceleration or significant deceleration may cause TBI well. For military personnel in war zones the leading cause of TBI are blasts. In the majority of cases the skull remains intact and the damage is thought to be caused by a pressure wave from the explosion which passes through the brain causing injury. Non motorized pedal cycles (bicycles, tricycles, etc.) 3% Transport 2% Suicide 1% Child abuse - traumatic brain injury is the third most common injury to result from child abuse in America. Other causes of TBI include domestic violence, and work-related and industrial accidents. Diagnosing traumatic brain injury (TBI) TBIs require rapid diagnosis and treatment because they are frequently medical emergencies which can easily and quickly lead to complications. Glasgow Coma Scale Doctors often use the Glasgow Coma Scale (GCS) before deciding whether to use a CT scan. The GCS is a way for doctors and nurses to assess the severity of brain damage following a head injury. It scores patients according to verbal responses, motor responses (physical reflexes), and how easily they can open their eyes. Eyes - Glasgow Coma Scale Score of 1 - does not open eyes. Score of 2 - opens eyes in response to painful stimuli (when given pain). Score of 3 - opens eyes in response to voice. Score of 4 - opens eyes spontaneously. Verbal - Glasgow Coma Scale Score of 1 - makes no sound. Score of 2 - incomprehensible sounds (mumbles). Score of 3 - utters inappropriate words. Score of 4 - confused, disorientated. Score of 5 - oriented, chats normally. Motor (physical reflexes) - Glasgow Coma Scale Score of 1 - makes no movements. Score of 2 - extension to painful stimuli (straightens limb when given pain). Score of 3 - abnormal flexion to painful stimuli (moves in a strange way when given pain). Score of 4 - flexion/withdrawal to painful stimuli (moves away when given pain). Score of 5 - localizes painful stimuli (can pinpoint where pain is). Score of 6 - obeys commands. Brain injury will be classified in the Glasgow Coma Scale as: Coma = a score of 8 or less. Moderate = a score of 9 to 12. Minor = a score of 13 or more. Imaging scans of the brain - these will help determine whether there is any brain injury/damage, and where. Examples include: CT (computed tomography) scan - also known as a CAT (Computer Axial Tomography) scan. It is a medical imaging method that employs tomography. Tomography is the process of generating a two-dimensional image of a slice or section through a 3-dimensional object (a tomogram). The medical device is called a CTG scanner; it is a large machine and uses X-rays. It used to be called an EMI scan, because it was developed by the company EMI. X-ray - X-rays are still used for head trauma. But experts say they are not so useful. If a head injury is mild no imaging is usually needed, while a severe injury would merit the more accurate CT scan. MRI (magnetic resonance imaging) scan - an MRI machine uses a magnetic field and radio waves to create detailed images of the body, which in this case would be the brain. Most MRI machines look like a long tube, with a large magnet present in the circular area. When beginning the process of taking an MRI, the patient is laid down on a table. Then depending on where the MRI needs to be taken, the technician slides a coil to the specific area being imaged. The coil is the part of the machine that receives the MR signal. MRI scans are good for examining the brainstem and deep brain structures. The doctor may inject a special dye which shows up on the scans and distinguishes healthy tissue from damaged tissue. Angiography - a medical imaging technique used to visualize the inside, or lumen, of blood vessels and organs of the body. This may be used to detect blood vessel pathology when risk factors, such as penetrating head trauma are involved. EEG (electroencephalography) - the device measures the electrical activity within the brain. Electrodes are placed on the patient's scalp; they pick up electrical impulses that occur in the brain. These impulses are recorded on the EEG device. An EEG can tell whether the patient is having non-convulsive seizures. Intracranial pressure monitor - a device is placed inside the head. It senses the pressure inside the skull and sends its measurements to a recording device. Brain injuries tend to result in swelling of brain tissue which may cause additional damage to the brain. What are the treatment options for traumatic brain injury (TBI)? Most concussion or mild traumatic brain injury (MTBI) symptoms will go away without treatment. In the USA approximately 1% of patients with MTBI require surgery. Click here to read more about mild traumatic brain injury. In more severe cases the patient will be hospitalized and will require intensive care. When treating traumatic brain injury, the focus of emergency care is to prevent any worsening of brain damage. The greatest risk of further brain damage is when the brain swells. The human skull is made of bone and is not very flexible; any swelling soon results in an increase of pressure. If blood vessels were damaged when the injury occurred, there is a further risk of pooled blood or clots accumulating in this small space (inside the skull where pressure is rising). The increased pressure in the brain can cause: Damage to brain tissue, just because of the pressure itself. The blood vessels to get squeezed, undermining their ability to supply the brain cells with oxygen and essential nutrients. Blood pressure - brain injuries can result in a serious drop in blood pressure, further reducing blood supply to the brain. Medications: Diuretics - a diuretic is anything that encourages the formation of urine by the kidneys; in other words, they increase urine output and reduce the amount of fluid in tissue. These are administered intravenously. Mannitol is the most commonly used diuretic for TBI patients. Some studies suggest that children may benefit from certain concentrations of saline solution. Anti-seizure medication - the risk of seizures during the first week following the traumatic injury is higher for patients with moderate to severe TBI. This medication may be administered to prevent further brain damage caused by seizures. Coma-inducing medications - comatose patients require less oxygen. Doctors may sometimes deliberately induce coma if the blood vessels are unable to supply adequate amounts of food and oxygen to the brain. Rehabilitation - a number of TBI patients with significant injury need rehabilitation. This may involve relearning how to walk, talk and carry out tasks which used to be done automatically. The aim is to help the patient gain as much physical independence as possible. Typically, therapy starts in the hospital, and later continues in a residential treatment facility, or in outpatient services. Depending on the patients' needs, they will be treated by either a physical therapist (UK: physiotherapist) or occupational therapist, or both. Surgery: Removing hematomas - a hematoma is an abnormal collection of blood (localized) which is either partially clotted or completely clotted. Often, when TBI patients arrive in hospital they are taken straight to the operating theater and have large deposits of clotted blood removed from between the skull and the brain, resulting in a reduction of pressure inside the skull, preventing further brain damage. Skull fractures - if any part of the skull is pressing into the brain it will need to be surgically repaired. In most cases skull fractures which are not pressing into the brain heal on their own. Create an opening in the skull - this is done to relieve the pressure inside the skull. This procedure is only done if other interventions have not worked. Tips that can aid recovery: Avoid activities which could cause another blow/jolt to the head. Do exactly what doctors and other healthcare professionals recommend. Do not take drugs your physician has not approved. Do not rush back to daily professional or school activities. Get plenty of rest. If you have memory problems, write things down. Only drive a car, ride a bicycle/motorbike, or use heavy equipment when the doctor says it is OK to do so. People's reflexes after a TBI may be slower. Seek help in re-learning skills that were lost. What are the possible complications of traumatic brain injury (TBI)? Seizures - these may occur during the first week after the injury occurred. Experts say that TBIs do not increase an individual's risk of developing epilepsy, unless there have been major structural brain injuries. Infections - the meninges, the membranes around the brain, can be ruptured during a TBI, allowing bacteria to get in. If the infection spreads to the nervous system there is a risk of serious complications. Nerve damage - if the base of the skull is affected, the nerves of the face can be affected, causing paralysis of facial muscles, double vision, problems with eye movement, and a loss of the sense of smell. Cognitive problems - people with moderate to severe TBI, especially severe TBI, may experience some cognitive problems, including their ability to: Communicate properly - some patients may have problems with written and spoken language. Others may find their ability to process non-verbal signals is worse than before their injury occurred. Judge situations Mentally process things rapidly Multitask Pay attention Process information Reason Remember things - especially the short-term memory; remembering things before the injury occurred, but not after. Solve problems Think, organizing thoughts and ideas properly There may also be personality changes - especially during recovery and rehabilitation. The patient's impulse control may be altered, resulting in more inappropriate behavior. Personality changes are often a source of enormous stress and anxiety for family members, friends and caregivers. Problems with the senses: Tinnitus (ringing in the ears) Recognizing objects may become difficult Clumsiness, due to poor hand-eye coordination Double vision Blind spots Sensing bad smells Sensing a bitter taste Long-term depression and concussion (moderate TBI) - in a report authored by Robert C. Cantu, M.D., FACSM and published in Medicine & Science in Sports & Exercise, a study of 2,552 retired professional football players revealed that recurrent sport-related concussion appears to be related to an increased risk of clinical depression in retired professional football players. There is also a risk of Post-concussion syndrome, in which headaches and dizziness persist for weeks or months after the blow/jolt to the head. Alzheimer's disease - TBIs increase the risk of developing Alzheimer's disease later in life. Risk is linked to severity of the TBI (as well as how many TBIs the patient had). Parkinson's disease - TBIs increase the risk of eventually developing Parkinson's disease. Risk is linked to severity of the TBI (as well as how many TBIs the patient had). Coma - a deep state of unconsciousness - longer-term comatose patients may be reclassified as being in a permanent vegetative state. The patient cannot be awakened and does not respond to pain, light or sound in a normal way - the person in coma cannot react with the surrounding environment. A person in a coma does not take voluntary actions and does not have sleep-wake cycles. A percentage of patients with TBI become comatose, go into a vegetative state, and/or eventually die without ever waking up. Some wake up and have long-term problems and disabilities, while others recover some abilities and functions. (Click here to see: What is coma?) Crime in young people - in October 2012, researchers from the University of Exeter, England, found that there is an association between brain injury during childhood and crime in young people. They say there is evidence that brain trauma may make maturing brains "misfire" and disrupt the development of impulse control, social judgment and self-restraint. Preventing traumatic brain injuries (TBIs) Car seat belts: Wear a seatbelt every time you drive your car or ride as a passenger. Make sure children are buckled up using either a safety seat, booster seat, or a seat belt that is suitable for the child's size and age. When children outgrow their safety seats - usually when they weight about 40 pounds (18 kilos) - they should start using a booster seat. Children should continue using the booster seat until the lap/shoulder belts fit properly; usually when they are about 4ft 9inches (1meter 45 centimeters) tall. Drinking and driving Never drive when you are under the influence of alcohol. Helmets or specific protective headgears should always be worn when: Batting in baseball/softball or cricket (and running bases in baseball) Engaged in contact sports, such as karate, boxing, or American football Riding a horse Riding on a motorbike, snowmobile, scooter, or all-terrain vehicle (both riders and passengers) Skiing Snowboarding Using a skateboard When roller-skating or in-line skating Living areas for seniors (UK: elderly people): Grab bars should be installed next to the bathtub, shower and/or toilet Seniors should keep physically active to make sure lower body strength and balance is adequate (thus lowering the risk of falls) Make sure lighting in the house is bright enough On bathtub and shower floors use nonslip mats Remove throw rugs and other objects which may be cause tripping Stairways should ideally have handrails on both sides Living areas for children: Install window guards Place safety gates at the bottom and top of stairs if the children are young Children's play areas: The ground surface of a child's playground should be made of hardwood mulch, sand or some specific shock-absorbing material. Firearms: Firearms should be stored, unloaded, in a locked safe or cabinet. Bullets should not be stored in the same location. What are the Effects of TBI? Most people are unaware of the scope of TBI or its overwhelming nature. TBI is a common injury and may be missed initially when the medical team is focused on saving the individual’s life. Before medical knowledge and technology advanced to control breathing with respirators and decrease intracranial pressure, which is the pressure in the fluid surrounding the brain, the death rate from traumatic brain injuries was very high. Although the medical technology has advanced significantly, the effects of TBI are significant. TBI is classified into two categories: mild and severe. A brain injury can be classified as mild if loss of consciousness and/or confusion and disorientation is shorter than 30 minutes. While MRI and CAT scans are often normal, the individual has cognitive problems such as headache, difficulty thinking, memory problems, attention deficits, mood swings and frustration. These injuries are commonly overlooked. Even though this type of TBI is called “mild”, the effect on the family and the injured person can be devastating. Follow this link for more information on Mild TBI. Severe brain injury is associated with loss of consciousness for more than 30 minutes and memory loss after the injury or penetrating skull injury longer than 24 hours. The deficits range from impairment of higher level cognitive functions to comatose states. Survivors may have limited function of arms or legs, abnormal speech or language, loss of thinking ability or emotional problems. The range of injuries and degree of recovery is very variable and varies on an individual basis. Follow this link for more information on Severe TBI. The effects of TBI can be profound. Individuals with severe injuries can be left in long-term unresponsive states. For many people with severe TBI, long-term rehabilitation is often necessary to maximize function and independence. Even with mild TBI, the consequences to a person’s life can be dramatic. Change in brain function can have a dramatic impact on family, job, social and community interaction. What types of TBI are there? Any injury to the head may cause traumatic brain injury (TBI). There are two major types of TBI: Penetrating Injuries: In these injuries, a foreign object (e.g., a bullet) enters the brain and causes damage to specific brain parts. This focal, or localized, damage occurs along the route the object has traveled in the brain. Symptoms vary depending on the part of the brain that is damaged. Closed Head Injuries: Closed head injuries result from a blow to the head as occurs, for example, in a car accident when the head strikes the windshield or dashboard. These injuries cause two types of brain damage: Primary brain damage, which is damage that is complete at the time of impact, may include: ¦skull fracture: breaking of the bony skull ¦contusions/bruises: often occur right under the location of impact or at points where the force of the blow has driven the brain against the bony ridges inside the skull ¦hematomas/blood clots: occur between the skull and the brain or inside the brain itself ¦lacerations: tearing of the frontal (front) and temporal (on the side) lobes or blood vessels of the brain (the force of the blow causes the brain to rotate across the hard ridges of the skull, causing the tears) ¦nerve damage (diffuse axonal injury): arises from a cutting, or shearing, force from the blow that damages nerve cells in the brain's connecting nerve fibers Secondary brain damage, which is damage that evolves over time after the trauma, may include: ¦brain swelling (edema) ¦increased pressure inside of the skull (intracranial pressure) ¦epilepsy ¦intracranial infection ¦fever ¦hematoma ¦low or high blood pressure ¦low sodium ¦anemia ¦too much or too little carbon dioxide ¦abnormal blood coagulation ¦cardiac changes ¦lung changes ¦nutritional changes What physical problems occur after TBI? Physical problems may include hearing loss, tinnitus (ringing or buzzing in the ears), headaches, seizures, dizziness, nausea, vomiting, blurred vision, decreased smell or taste, and reduced strength and coordination in the body, arms, and legs. What communication problems occur after TBI? People with a brain injury often have cognitive (thinking) and communication problems that significantly impair their ability to live independently. These problems vary depending on how widespread brain damage is and the location of the injury. Brain injury survivors may have trouble finding the words they need to express an idea or explain themselves through speaking and/or writing. It may be an effort for them to understand both written and spoken messages, as if they were trying to comprehend a foreign language. They may have difficulty with spelling, writing, and reading, as well. The person may have trouble with social communication, including: ¦taking turns in conversation ¦maintaining a topic of conversation ¦using an appropriate tone of voice ¦interpreting the subtleties of conversation (e.g., the difference between sarcasm and a serious statement) ¦responding to facial expressions and body language ¦keeping up with others in a fast-paced conversation Individuals may seem overemotional (overreacting) or "flat" (without emotional affect). Most frustrating to families and friends, a person may have little to no awareness of just how inappropriate he or she is acting. In general, communication can be very frustrating and unsuccessful. In addition to all of the above, muscles of the lips and tongue may be weaker or less coordinated after TBI. The person may have trouble speaking clearly. The person may not be able to speak loudly enough to be heard in conversation. Muscles may be so weak that the person is unable to speak at all. Weak muscles may also limit the ability to chew and swallow effectively. What cognitive problems occur after TBI? Cognitive difficulties are very common in people with TBI. Cognition (thinking skills) includes an awareness of one's surroundings, attention to tasks, memory, reasoning, problem solving, and executive functioning (e.g., goal setting, planning, initiating, self-awareness, self-monitoring and evaluation). Problems vary depending on the location and severity of the injury to the brain and may include the following: ¦Trouble concentrating when there are distractions (e.g., carrying on a conversation in a noisy restaurant or working on a few tasks at once). ¦Slower processing or "taking in" of new information. Longer messages may have to be "chunked," or broken down into smaller pieces. The person may have to repeat/rehearse messages to make sure he or she has processed the crucial information. Communication partners may have to slow down their rate of speech. ¦Problems with recent memory. New learning can be difficult. Long-term memory for events and things that occurred before the injury, however, is generally unaffected (e.g., the person will remember names of friends and family). ¦Executive functioning problems. The person may have trouble starting tasks and setting goals to complete them. Planning and organizing a task is an effort, and it is difficult to self-evaluate work. Individuals often seem disorganized and need the assistance of families and friends. They also may have difficulty solving problems, and they may react impulsively (without thinking first) to situations. How is TBI diagnosed? The speech-language pathologist (SLP) works with the person and his or her family/caregivers as part of a team that may also include: ¦doctors ¦nurses ¦neuropsychologists ¦occupational therapists ¦physical therapists ¦social workers ¦employers ¦teachers The team works together to evaluate the person and develop an appropriate treatment plan. The SLP completes a formal evaluation of speech and language skills. An oral motor evaluation checks the strength and coordination of the muscles that control speech. Understanding and use of grammar (syntax) and vocabulary (semantics), as well as reading and writing, are evaluated. Social communication skills (pragmatic language) are evaluated with formal tests and the role-playing of various communication scenarios. The person may be asked to discuss stories and the points of view of various characters. Does he or she understand how the characters are feeling, and why they are reacting a certain way? Can he or she explain how different characters' actions affect what happens in the story? The person may be asked to interpret/explain jokes, sarcastic comments, or absurdities in stories/pictures (e.g., what is strange about a person using an umbrella on a sunny day?). The SLP will assess cognitive-communication skills. Is the person aware of his or her surroundings? Does the person know his or her name, the date, where he or she is, what happened to him or her (orientation)? Recent memory skills are assessed, such as whether the main details in a short story are retained. Executive functioning is evaluated. The SLP assesses the patient's ability to plan, organize, and attend to details (e.g., completing all of the steps for brushing teeth). The SLP may read an incomplete story and ask for a logical beginning, middle, or conclusion. The person may be asked to provide solutions to problems (reasoning and problem solving; e.g., "What would you do if you locked your keys in your car? How can this problem be avoided in the future?"). For more information about when to refer someone for a cognitive-communication evaluation, see Cognitive-Communication Referral Guidelines for Adults. If problems are observed, the SLP will evaluate swallowing and make recommendations regarding management and treatment. The focus of this evaluation will be to ensure that the individual is able to swallow safely and receive adequate nutrition. Additional swallowing tests may be recommended as a result of this evaluation. If necessary, the SLP may also evaluate the benefit of a communication aid or device to express basic needs and ideas. Glasgow Coma Scale The Glasgow Coma Scale (GCS) defines the severity of a TBI within 48 hours of injury. Eye opening Spontaneous = 4 To speech = 3 To painful stimulation = 2 No response = 1 Motor response Follows commands = 6 Makes localizing movements to pain = 5 Makes withdrawal movements to pain = 4 Flexor (decorticate) posturing to pain = 3 Extensor (decerebrate) posturing to pain = 2 No response = 1 Verbal response Oriented to person, place, and date = 5 Converses but is disoriented = 4 Says inappropriate words = 3 Says incomprehensible sounds = 2 No response = 1 The severity of TBI according to the GCS score (within 48 h) is as follows: •Severe TBI = 3-8 •Moderate TBI = 9-12 •Mild TBI = 13-15 Ranchos Los Amigos Scale of Cognitive Functioning The severity of deficit in cognitive functioning can be defined by the Ranchos Los Amigos Scale. •level I = No response •level II = Generalized response •level III = Localized response •level IV = Confused-agitated •level V = Confused-inappropriate •level VI = Confused-appropriate •level VII = Automatic-appropriate •level VIII = Purposeful-appropriate TBI defined by the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine The Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine defines mild head injury as "a traumatically induced physiologic disruption of brain function, as manifested by one of the following: •Any period of loss of consciousness (LOC), •Any loss of memory for events immediately before or after the accident, •Any alteration in mental state at the time of the accident, •Focal neurologic deficits, which may or may not be transient." The other criteria for defining mild TBI include the following: •GCS score greater than 12 •No abnormalities on computed tomography (CT) scan •No operative lesions •Length of hospital stay less than 48 hours The following criteria define moderate TBI: •Length of stay at least 48 hours •GCS score of 9-12 or higher •Operative intracranial lesion •Abnormal CT scan findings |