04/08/2013 // Concord, CA, USA // LifeCare123 // Greg A. Vigna M.D., J.D. // (press release)

(Traumatic Brain Injury News) Medical Perspective:

Families often ask why is their loved one in coma after a traumatic brain injury (TBI). A patient will be in coma if they are in a state of “unarousable unresponsiveness.”‘ When the patient opens their eyes and has a Glascow Coma Scale of eight or more, they will be out of coma. It is necessary to understand what parts of the brain must be functioning for a person to be arousable to understand the causes of coma following a traumatic brain injury. Located in the brain stem (base of the brain) is a group of structures that connect with each other by way of a network of neurons to form the ascending reticular activating system (ARAS) which is largely responsible for the allowing for and maintaining alertness. It is helpful to think of the brain stem as a major ‘highway’ of connections that is densely packed with the nerve cells fibers that resemble cables. The brain sits in the skull very much like a yolk sits in an egg. During the rapid acceleration and deceleration of the head that occurs in a traumatic brain injury the brain will quickly go forward and backwards inside the skull, very much like the yolk would if you were to shake an egg. What this rapid acceleration and deceleration causes significant shear that acts to stretch and damage some of the nerve cells that form the cables of the ascending reticular activating system (ARAS). This disruption of the ARAS is believed to be responsible for a majority of comas that occur in TBI patients and is called ‘diffuse axonal injury’. Some of these nerve cells that are stretched will irreversible die while others following the injury will be damaged and nonfunctional but capable of recovery.

Another mechanism for coma in TBI patients, which is believed to be less common, is injury to both sides of the cerebral cortex which interferes with the connections to the brain stem or a injury to one side of the cerebral cortex which puts pressure on the other side that again interferes with the connections of the cerebral cortex to the brain stem. Unilateral injuries include epidural and subdural hematomas, intracranial bleeds, and contusions to the brain.

Every patient who is in coma from a traumatic brain injury will have suffered a severe brain injury. Prognosis is directly related to the best Glascow Coma Scale (GCS) obtained within the first 24 hours. Lower the score the worse the outcome with the lowest scores (GCS 3-4) resulting in vegetative state or death in 87% of patients while the highest scores (GCS 11) result in moderate or good recovery in 87% of patients. Reactivity of pupils are also an important indicator with nonreactive pupils indicating a poor prognosis in all but 4% of patients with this finding on exam. It is very important for families and medical providers when considering the significance of GCS regarding prognosis that there are multiple medical issues that can cause coma, or decrease the mental status of the patient, and potentially decrease the best GCS within the first 24 hours. These medical issues include infection, intoxicants from liquor and drugs, IV pain medicines and sedatives, and other causes such as altered electrolytes in the blood.

From my experience of caring for patients in coma or in a persistent vegetative state there are benefits from both traditional therapy and a sensory stimulation program referred commonly as coma stimulation. Coma stimulation programs are far from standardized but generally is based on providing sensory stimulation to the five senses. It is believe to effect the ARAS to increase arousal and attention and prevent sensory deprivation which may decrease brain functioning. Patients with persistently elevated intracranial pressures should not receive this therapy, otherwise there are no contraindication to this type of therapy nor is there any adverse consequences of providing this care. Studies have failed to show any definite evidence that this therapy is effective in decreasing the duration of coma or improve outcomes. It is simply too difficult to design a valid study. Injuries to the brain are simply not uniform, and the associated injuries are too diverse to allow for a quality study to determine the effectiveness of treatment. There can be little dispute, that providing a stimulating environment to a patient in coma is far more conducive to recovery than an environment devoid of stimulation.

There are secondary benefits from providing a sensory stimulation program such as it teaches the family how to provide coma stimulation and ways for them to interact with their loved one that can foster recovery and it allows the family to have some increased control regarding the recovery of their love one. It is my opinion that it is unfortunate that this type of care is not available to most patients for a period of time following a brain injury because most insurances will no pay for it because of the lack of specific scientific evidence. It is my opinion that this is simply an example of medical economics interfering with the practice of medicine.

Life Care Planner Perspective:

A properly constructed life care plan will serve as a guide to future medical, rehabilitation, and day to day needs of a catastrophically injured patient. A life care planner’s primary role is an educator or the public and that role requires him to be objective in the evaluation of the needs of the patient, not looking at insurance issues, and provide a guide that is medically necessary and appropriate for the patient. The earlier that a life care planner is involved in a TBI patient the better. A life care planner can evaluate the available scope of services, medical expertise, and outcomes available at community based inpatient rehabilitation program (IRF) and educate the patient and the public regarding the value of referral to a TBI Systems Program.

Early involvement of a life care planner the greater chance that inappropriate referral to an ill equipped rehabilitation center. The life care planner will recommend all necessary and appropriate care for the patient not considering insurance issues. A patient who is in coma or minimally arousable will be afforded the opportunity to receive aggressive inpatient rehabilitation with a scope of service that includes standard rehabilitation in addition to coma stimulation programs. Patients who have suffered severe and moderate-severe TBI require intensive rehabilitation to confront the major cognitive, emotional issues, and physical deficits. Family education and support will also be recommended in the plan. A life care planner will recommend in a plan of treatment after rehabilitation at a TBI Model System Program which may include a local long-term acute hospital, local IRFs, skilled nursing facilities, long term residential facilities for TBI specializing in behavioral interventions and community reintegration, outpatient day programs, and sheltered versus supported community employment.

Contact Life Care Solutions Group today for post injury life care planning and legal help.

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