When will he wake up? Will he die? Will he return to normal? What will he be like? Will he be able to walk? Talk? Recognize me? When? How long?
We have been asked and have answered these questions many times. The cause for concern is very real after traumatic brain injury. After all, the brain is NOT like a bone that heals readily. Once brain tissue dies, it is gone forever. That’s why an injured patient’s loved ones deserve utmost sympathy, patience and understanding.
Lucky are those who suffer mild concussions, are fully awake after a brief period, and are sent home after some observation. Lucky are those who wake up after surgery and start recognizing people instantly. But for many severely injured brains, the road to recovery is long and uncertain. No, it is not like the movies, where actors wake up from a coma and resume life like nothing happened. It takes weeks, months, even years for “recovery” to happen. This entry focuses on the first few days after severe brain injury — the critical phase.
What to Expect
After determining the extent of brain injury, many patients need immediate surgery to evacuate blood, clots, dead tissue and unwanted debris that may harm the brain. To save as much brain tissue as possible, any surgery needs to happen as soon as possible. Remember, brain tissue starts to die 4 – 6 minutes without oxygen.
After brain surgery, patients usually stay in an Intensive Care Unit (ICU), with a highly trained team, for critical monitoring. How long they stay there depends on their progress.
Families should be aware that many complications can happen after brain surgery. For severe injuries, it’s rarely a smooth road. So it’s best to take it one day at a time.
The Irony of “wait and see”
What will he be like? Will there be permanent damage? These questions are dependent on the extent of brain tissue damage. Learn the basics here. But most likely, immediately after the injury, doctors reply with “we’ll have to wait and see”…
Frustrating. But unfortunately, it’s true. We do not yet know exactly how much of the brain tissue had died, how much of it only got cut off of oxygen and can still heal, and how much of it is temporarily compromised because of swelling.
After any injury (like a broken arm or cut skin), there’s bound to be swelling. Brain swelling is called cerebral edema, and can be fatal if not treated promptly. Brain swelling can increase the pressure inside an enclosed skull (intracranial pressure) and compress on other brain structures, causing more tissue death. It is only after the swelling has gone down that we can start to appreciate the “extent of damage.”
Early Goals after Traumatic Brain Injury
- keep intracranial pressure (ICP) down
- reduce brain swelling (cerebral edema)
- give the brain as much oxygen it needs to heal
And if you think about it, they all go hand in hand. By reducing swelling, we keep the brain pressure down, which in turn allows space for the blood vessels to supply oxygen-rich blood to the brain.
The doctors will try their best to make this happen. Complications after traumatic brain injury almost always involve any of these three issues. The docs will give medications to keep the swelling down. They may install devices to measure intracranial pressure and brain tissue oxygenation. These may look scary at first. Patients may get repeated scans to make sure the brain is in good shape. And if necessary, the docs will bring the patient back to surgery to achieve these goals.
When will he wake up? And how can he wake up when they’re sedating him?
Aha! “Waking up” from the coma. Another common question. Some patients wake up immediately. Others take longer. Some don’t wake up at all. It all depends on the location/extent of the injury and the amount of swelling involved. It’s generally thought that those who wake up sooner tend to have better recovery.
So why are you sedating him?
Remember the 3 goals? Often, after surgery, patients are agitated. Sometimes they have seizures. Their intracranial pressures are too high. Their brain, now in a state of imbalance, has become hyperactive. All these can cause increased oxygen demand in the brain. And since our goal is to give it more than adequate oxygen to prevent death and promote healing, we need to rest the brain. We need to make the patient sleep. And give them pain medication. Hence, sedation.
Every so often, the doctors and nurses will turn off the sedation to examine a patient as see what he can do. Does he open his eyes? Does he follow commands? Does he move his arms and legs?
Ultimately, when the brain is ready (controlled edema, normal pressures, enough oxygen), the sedation can be weaned off. Then we’ll be able to better see what he can be like. But until then, until he’s stabilized, patience…
What will he be like after all this is over?
Rehabilitation is long. Common practice say it takes a year to see what a patient will be like in terms of disability. But some patients take longer, and continue to improve in functionality over the years. While some parts of the brain die permanently, studies show remaining parts may learn to take over some of their function. The doctors will be able to give more information over time, after the critical phase is over.
Let’s reserve that discussion for another post.