Head injuries or brain damage can occur anywhere – in the workplace, in an MVA, in medical malpractice, toxic torts, a domestic fall, and environmental exposures.
Litigated head injuries generally arise from two sources:
a. blunt trauma (fall, violent blow or MVA)
b. penetrating trauma (gunshot)
2. Medical causation (stroke)
a. ischemic (a clot blocking blood flow to a major artery)
b. hemorrhagic (rupture of a major artery causes damage to the brain)
c. TIA or Transient Ischemic Attack (symptoms resolve within 24 hrs)
In all instances, brain injury is affected by blood: either blocked flow (ischemia) or bleeding that puts pressure on another area, damaging tissue. The location of the injury is the most important determinant of the severity and likelihood of recovery.
• Rate and degree of recovery after brain injury is quite variable
• The most common form of traumatic brain injury is the subdural hematoma (SDH), with a mortality rate ranging from 50 – 90%. A significant percentage of these deaths result from the pressure on the brain that develops in the days after injury. Treatment of the SDH depends upon the location and age of the lesion. Because bleeding is not static, “Early and sometimes repeated CT scanning may be required in cases of clinical or neurologic deterioration, especially in the first 72 hours after head injury, to detect delayed hematoma, hypoxic-ischemic lesions, or cerebral edema.”
• Approximately 20-30% of patients will recover full or partial brain function. However, post-operative seizures are relatively common in these patients.
• Although recovery from TIA (transient ischemic attack) occurs within 24 hours, these patients may be at a high risk for falls if they may regain mobility before being aware of their surroundings.
• Strokes arising from blood clots usually require anticoagulation therapy to prevent further clotting, but improper medication management can result in a fatal hemorrhage
• Because patients can “go bad” quickly, frequent monitoring of vital signs, ICP (intracranial pressure) measurements, lab values, pupil checks and level of awareness is crucial.
• A critical part of assessment includes changes, even by one point, in the Glasgow Coma Scale
The Glasgow Coma Scale (GCS) numerically represents the level of consciousness and is based upon a 15-point scale for estimating and categorizing the outcomes of brain injury. The patient who is unable to respond verbally or follow commands can nonetheless have a reflexive response to painful stimuli. Families do not appreciate this form of assessment, but the patient’s physical response tells a great deal about how the brain is processing this noxious stimulus. The following signs are associated with a poor prognosis:
• A Glasgow Coma Scale less than 8 in the field
• A Glasgow Coma Scale less than 5 in the ER
• Unequal/changing pupil size
• Motorcycle accident (direct head impact and no airbag)
• Problems with ventilation, further depriving the brain of oxygen
A patient with an acute and severe brain injury may be placed into a medically induced coma to protect and allow the brain to rest by slowing metabolism. Mechanical ventilation controls oxygen and carbon dioxide levels that can aid in reduction of swelling, and sedation allows an override of the patient’s breathing, which is often labored and dysfunctional.
Pain should be managed effectively because it can lead to a rise in intracranial pressure. An intubated patient is treated with short acting sedation and analgesia until time for weaning.
Claims for pain and suffering in the unconscious patient should consider:
• The victim’s awareness of impending danger prior to the head injury (an assertion of this awareness has been successfully argued even with death cases)
• Successfully communicating to a jury the difference between purposeful movements and reflex, and
• Evaluation of post-injury residuals established by Medical Cost Projection or Life Care Plan.
Putting post-injury impairment into perspective, it is very important to know the level of prior intellectual and emotional functioning. This information is sought by defense counsel in quantifying financial responsibility, and is equally important to plaintiff’s counsel in supporting a reasonable demand.
Alice Adams is a veteran RN who has cared for many acute head injury patients. She has been a legal nurse consultant since 2006 and lives in Atlanta, GA. She evaluated the injury cases in the 2007 Bluffton University Baseball team’s tragic accident and fatalities, and is very active compiling Medical Cost Projections and providing medical analysis for >40 attorneys and law firm.