If you are experiencing a medical emergency, please call 911 or seek care at an emergency room.
There is no way to prepare yourself for a late-night call that a loved one has been taken to the hospital. Questions race through your mind: what happened, why, and what’s next?
You learn that your loved one has suffered a severe traumatic brain injury (sTBI) and is obtunded to the point where they have been placed on a mechanical ventilator. They’ve been taken to the neurocritical intensive care unit (Neuro ICU) where treatment has begun, and the Neuro ICU team wants to get you up to speed.
I am on the clinical side of this conversation every day in the MedStar Washington Hospital Center Neuro ICU. We are the region’s most advanced Neuro ICU, staffed by internationally recognized neurosurgeons and neuro-intensivists. As an academic medical center, we drive leading-edge neurosurgery innovations based on the latest research and our real-time expertise.
Unfortunately, there is a pencil-thin line between providing aggressive, lifesaving care and keeping a patient alive in a permanent vegetative or debilitated state. It is an existential struggle and clinical decision that leads many critical care centers to withhold aggressive treatment for severe TBI.
But if a miracle can happen, this is the place where it will.
Unlike many high-acuity trauma centers, we default to aggressive treatment if a patient has a chance for meaningful recovery. And through advanced imaging and real-time invasive multimodal monitoring that simultaneously analyzes the subtle interactions between the brain and body, we can safely take a stepwise approach, incrementally increasing treatment to potentially improve the chance of survival and function.
While we can never guarantee a specific outcome, my colleagues and I have seen enough cases to know that early withdrawal from advanced care closes the door to potentially remarkable recoveries.
This is a general overview of what happens when a loved one is brought (often) anonymously to the ICU, how we approach treatment for patients based on the severity of their TBI, and how the family is involved.
Incremental steps in neuro-critical care.
Step 1: Lifesaving mode.
Often, patients brought to the ICU for head trauma are in an unconscious state. Our neurosurgeons and trauma specialists perform rapid assessments to determine the extent of injury.
Initial treatment focuses on evaluating and stabilizing bodily injuries with immediate lifesaving procedures. Depending on the critical state of the person’s injuries, we will also quickly or simultaneously evaluate brain injuries, which include specific assessments such:
- Blood tests to check for certain proteins that indicate specific brain injuries.
- Breathing assessment, which tells us whether the brain is still managing body functions that require muscle coordination, such as swallowing and breathing. Patients with severe injuries will likely require a breathing tube.
- Examination of pupils for reactivity to light. Poor or no pupil response helps determine the severity of TBI.
- Cognitive assessment, if the patient is awake, to get a baseline for brain function.
- Imaging, such as a CT scan or MRI to visualize the areas of the brain that are affected and to get a baseline.
Patients will be continuously monitored for changes in heart rate, pulse, blood pressure, and oxygen levels. All patients will get an IV for delivery of fluids and medications and may require larger and more invasive lines.
If they do not have an ID and cannot communicate, some remain anonymous for hours or days until we can locate their family. Our social workers start searching for family members as soon as the patient is admitted and stabilized.
Once the patient is stable, we can start gathering more clarity about the severity of their TBI and concurrent traumas, such as the heart, lungs, or limbs. This is the point in which we make a data-informed judgment call about next steps in care.
Step 2: Life-sustaining measures.
This stage of care is where the incremental progression of advanced treatment begins. If the patient’s early assessments suggest a chance at recovery, we continue monitoring while continuing to provide aggressive treatment
One such test gauges the patient’s response to stressors in the physical environment. For example, we check their reaction to mild pain stimulation, such as recoiling from a pinch to the arm. These responses should be purposeful—if they’re not, we know we are dealing with a severe brain trauma that may not be treatable.
If the patient responds to stimulation and/or we identify a specific structural lesion in the brain that might cause them to be unresponsive, they may need emergency brain surgery. Our internationally recognized neurosurgeons perform procedures to:
- Reduce pressure inside the skull
- Repair a skull injury
- Remove a brain blood clot
At every point in care, we will discuss your loved one’s imaging, biophysical data, and potential prognosis with you. In the early stages of traumatic brain injury, it’s impossible to predict when a patient will awaken from a coma.
If surgery is recommended, the patient likely will remain sedated and still require a period of time to recover. If monitoring and our team’s experience suggests the patient has a chance to survive, the next incremental step is multi-modal deep brain monitoring.
Step 3: Multi-modal deep brain monitoring.
The brain can be injured both visibly and in subtle ways. The brain requires autoregulation. It tries to maintain its own homeostasis separately from the regulation of other body functions. So, after an accident or severe injury, the brain is more susceptible to physical stressors throughout the body. For example, rising and falling blood pressure can cause further damage that cannot be measured through imaging alone.
Using multi-modal brain monitoring, we can watch the brain and body for signs of stress and guide the patient’s care in real time. This approach involves surgically placing sensors or a catheter in the brain to:
- Continuously monitor intracranial pressure and oxygen levels
- Divert fluid from the brain to reduce swelling
- Monitor how the brain is reacting to changes made by the heart and blood pressure
Patients typically stay in the hospital for several days or weeks if they have severe brain injury that requires brain monitoring. They will remain in a medication-induced coma to rest the body and calm the brain. During this time, the patient will have a breathing tube connected to a ventilator. Patients may also need anti-seizure medications, diuretics to reduce fluid buildup in the brain and body, and will receive procedures that will allow for monitoring and administration of medications to maintain the body.
During this time, our social work team will work closely with you to start planning for next steps in your loved one’s care. You will have a lot of questions, and we will provide you with information and options to make the best choices for your family.
Communicating with the Neuro ICU team.
Talking with your loved one’s care and case management team can feel overwhelming, frustrating, and scary. It’s natural for friends and family members to want to know how things are progressing. We recommend appointing a family spokesperson to communicate with the doctors and nurses about your loved one’s care.
There are many unknowns with TBI, and every patient’s outcome is different—here are some situations to prepare for when you talk with the Neuro ICU team:
- Uncertainty: Outcomes after a TBI are different for every patient. It is likely that your loved one will stay in the neuro ICU for several weeks if they have a chance at recovery. While we cannot guarantee a specific outcome, we will be transparent and forthcoming with information throughout your loved one’s care.
- Seeing and discussing brain imaging: Visuals of your loved one’s brain are an important tool in helping us manage their care and seeing those images can be alarming. In some cases, imaging looks terrifying but the patient can recover. In others, the imaging looks normal but the prognosis is poor due to injuries elsewhere. We will explain the patient’s holistic findings to help you understand our treatment recommendations.
- Planning for recovery or end-of-life arrangements: You may be asked to make difficult decisions about your loved one’s care, particularly if they did not have an advanced directive. Our compassionate providing teams, nurses, palliative care, and case management team help families navigate the rollercoaster of emotions that TBI causes. These teams provide emotional support as well as connections to resources to help with unexpected challenges.
When patients survive a severe brain injury, it can feel miraculous. However, in most cases, recovery is a long road. The brain, although largely thought to be static, can also be surprisingly malleable and able to compensate for deficits over time.
Sometimes and with the aid of physical therapy, this can mean a remarkable recovery. But often, it means recovery along with new and potentially chronic symptoms, particularly if several areas of the body were injured. Long term, your loved one may struggle with symptoms such as:
- Cognitive limitations
- Mood changes or behavioral health disorders
- Nerve or musculoskeletal pain
- Paralysis or physical limitations
Medication, cognitive therapy, specialized brain injury services, and physical, occupational, and speech therapy, may help relieve or resolve some symptoms. Those that remain may be lifelong, and patients and families must come together to manage those issues. Your case worker can help connect you with supportive resources as your loved one’s needs change over time.
Getting the call that a loved one was severely injured is an emotionally traumatic experience. The hours to weeks that follow compound that stress. We encourage families to ask questions and raise concerns throughout your loved one’s Neuro ICU stay—we have your family’s best interests at heart and we will give you the most up-to-date information at every step.
Although we cannot guarantee a specific outcome, we will take every appropriate opportunity to save your loved one’s life and preserve their chance for a positive quality of life, while respecting your wishes.