Introduction:
Stewart Malcom:
I’m Stewart Malcom I’m the Neuro-rehabilitation Consultant attached to the Acquired Brain Injury (ABI) Unit.
There are two parts to this DVD. The first part deals with what happens when you come into the Accident and Emergency Department.We’d like to think that you’re going to get better and we’re not trying to scare you in anyway. The second part deals with, if needed, the Acquired Brain Injury (ABI) Services.
In the Emergency Department they’ll be a lot of fuss about you- they’re trying to rule out any particular problem that needs urgent attention, such as a brain bleed.
When they’re satisfied that you’re okay, they’ll allow you home. They’ll like you to go home with a responsible adult and this DVD is just to give you some prompts to remind you how to look after yourself.
For most of you that’s all that will happen, for a few of you, you may need our [ABI] services. Don’t be concerned about being given this DVD and thinking that it’s because we think you’ve definitely got a brain injury- it’s really just sound advice for everybody to look after themselves in the early stages.
Ultimately the doctor will decide whether you need to see the ABI people or not. And be reassured that you will get good support if you need it.
Jaycen Cruickshank:
Hi there, my names Jaycen CruickshankI’m the Director of the Emergency Department at Ballarat Health Services.
Phil Catterson:
My names Phil Catterson, I’m the Nurse Unit Manager of the Emergency Department at Ballarat Health Services.
Head Injuries-Common Causes
Jaycen Cruickshank:
People trip over and fall; people have those injuries while playing sport, from a direct blow or falling over; we see some work related things, where people are up on ladders; on the weekends, in the evenings when people are out having too much alcohol and then; there’s lots of different ways to suffer a head injury, including being assaulted or falling over; getting in your car and driving.
Types of head injuries
Jaycen Cruickshank:
When someone has a head injury there is a classification that we use- major, moderate and mild. A mild head injury is typically someone who is knocked out only briefly or is hit in the head and is actually not knocked out. And then the symptoms that’s they have afterwards are typically memory loss, headaches, nausea and confusion. They might get some dizziness and feel generally unwell and that’s distinguished from a major head injury. Major head injury patients come in unconscious often with other severe injuries as well, and that’s really a different type of injury that we deal with.
Most People Recover
Jaycen Cruickshank:
Most people that have a mild traumatic brain injury have a completely full recovery. That’s usually a quick full recovery, and sometimes it’s a bit slower. So we don’t want people to be panicked, if you want to borrow a phrase from a former Prime Minister which was something along the lines of- be alert but not alarmed.
Visiting Emergency
Jaycen Cruickshank:
A lot of people try to decide if they should go to their GP or to the Emergency Department for this sort of thing. I think that this is definitelyemergency medicine core business is to deal with injured people. So if you’ve injured your head or neck the Emergency Department has all the x-ray facilities is right within the department to be able to deal with that immediately. Normally people that have had a head injury will come through to the department, people with a minor head injury might start in the waiting room. Once we’ve ruled out a major injury and any resuscitations being needed usually the focus will be on the head and neck so assessing whether the person needs head injury observations for 4 hours to make sure nothing bad happens. Do they need a CAT scan or not, is an important decision to make. CT scans do involve a substantial radiation dose, so especially in children and younger people we really need to be mindful of the long term effects and radiation risk and so that’s why there is international published guidelines to assist us to decide how gets a scan and how doesn’t.
Phill Catterson:
Not everyone tells us the truth in regards to how things happen or why, if you want us to help you, you want us to be able to give you the best treatment we can, you must tell us what exactly has happened to you. Whether you lose your license or whether there’s a criminal investigation we can’t stop that but we also can’t treat you properly if we don’t know how that’s happened. One question that you’ll always be asked when you come into the Emergency Department is about your loss of consciousness if you’ve either had a hard enough injury that causes you to have 30 seconds to 5 minutes lack of consciousness what this tells us is that this is a significant injury and this is something we need to look at more closely.
Jaycen Cruickshank:
If someone has a blood nose, or if they get some clear fluid or blood coming out from the ear, or two black eyes, that’s called “raccoon eyes”, and that’s also suggestive of base of skull fracture. So some injuries take a while to present- so someone injures their head and they’ll walk around and look fine and then all of a sudden a few hours later they’ll suddenly start getting a severe headache and vomiting and can become unconscious and that’s called an extradural haematomaand that bleeding can be delayed but then be very fast and be a life threatening emergency. So that would be the first thing that’s always running through my mind with these patients- is making sure I’m not missing something serious.
Consent and disclosure
Jaycen Cruickshank:
I think patients find the whole experience fairly daunting. They want to know what’s happening to them, who is looking after them and what we’re doing and why. The principle of informed consent underpins not only surgery but every decision that should be made about you in an emergency department. So you should know what’s going on and the consent is that you’ve freely given your consent to have your treatment as long as you are capable of doing so.
If anyone’s had a loss of consciousness for more than five minutes or a seizure they’re very high risk features. Part of our protocol is that all of those people will have a CAT-scan even if they have to wait until the morning to have it, so they won’t be discharged.
When someone has a mild traumatic brain injury they might not have the capacity to make a good decision on their own behalf, whether or not they have alcohol or drugs on board, those things can be difficult especially if they’ve got a brain injury. So we involve the carers and family and friends with their care. If the patients to be discharged they need to go home in the care of a competent adult who is able to bring them back if need be. And the end of the day the patient does have to take some responsibility for returning to the Emergency Department. If they’re discharged and then they’re not well, then they need to come back.
I’d like to emphasise that if we discharge you from the Emergency Department with a mild traumatic brain injury or concussion that we want you to come back if you’ve got problems. Because we can send home 100 people and half a dozen can get some ongoing symptoms and one or two of those people will have a skull fracture or something important like that. And we want you to come back to the Emergency Department if you’ve got problems.
Recovery- the first days
Stewart Malcom:
When you leave the Accident and Emergency Department you’ll be given a booklet and this DVD and this is to reinforce that there are common symptoms that in 96% of people slowly disappear over the next 2-3 weeks. It’s very likely that you’ll be very tired, you might be a bit more irritable, you might find bright lights a bit of an issue. We’d encourage you to be sensible, take the advice that’s been given in the pamphlet and in particular don’t take anything that’s going to impair your thinking such as alcohol and sleeping tablets.
A simplistic approach is that the brain is trying to repair itself and it uses a lot more energy up from the rest of the body, it takes 2-3weeks for this to sort itself out.
Jaycen Cruickshank:
If you’ve got a bad headache tomorrow you should probably be lying down for most of the day and taking it easy. We certainly avoid strenuous exercise- you don’t go for a 5km jog the next day, you go for a walk and see how things are going.
Phil Catterson:
Don’t drive for a couple of days, have a rest on that and make sure that you don’t do any stimulating games or environment as in the PlayStation, the Wii- all the lights and bells and whistles that go with those that usually, makes your brain work a lot harder and doesn’t help you. You just need to rest, relax and have a bit of time and space.
Jaycen Cruickshank:
You’ve only got one brain and once it’s injured it’s had to actually fix it up. So prevention is very important.
Recovery- Drugs and Alcohol
Phil Catterson:
Your brains still recovering from an acute event, it’s not that happy about the whole situation that’s why you’ve been to hospital, that’s why you’ve had the confusion, that’s why you’ve had the nausea, that’s why you’ve been quite unwell during that time. You’re better now but you’re only better to the point where you are functioning better but your brains still git that hang over of actually being so what we need to do is make sure that you don’t go down the drinking of alcohol or taking of drugs during that initial time.
Jaycen Cruickshank:
It’s likely to cause dehydration and make your symptoms worse. It’s also likely to put you at risk of a second injury and two injuries close together is very bad for you.
Phil Catterson:
Drugs such as your normal medications for blood pressure and medication for pain relief are ones that should still be continued. In conjunction with your doctor that has actually sent you home you should discuss that. But any drugs of illicit nature or alcohol it should just be a smart thing not to have them for 48hours post your head injury.
Jaycen Cruickshank:
Most people would expect over 2 or 3 days to get back to normal if they’ve had a mild traumatic brain injury.
Phil Catterson:
and usually recover very well, all back to normal, back to their normal job and back to everything they’ve normally done. The other percentage are the ones that we keep an eye on and will take longer term treatments to actually resolve. I guess part of the reason for getting better quickly is also if you heed the principles that we tell you and that are also suggested in the tools that you are given.
Common Symptoms
Jaycen Cruickshank:
The most common symptoms that people might experience are headaches and some nausea and some memory loss. Substantial memory loss requires medical assessment. So if you can’t remember a large period before or after the injury then that requires medical expertise to determine is that important? Sometimes the memory loss just comes back slowly. The other symptomspeople get are dizziness, difficultly concentrating; they can get mood swings and emotional instability. Those symptoms might make life difficult at home or at work or driving and so on. So that’s why they need to betaken seriously. There’s people walking around that still get headaches months later. They should be taking regular pain relief to make them feel better. It’s important that they don’t get dehydrated sothey keep their fluids up. If they’ve got nausea we’ve got medication that we can prescribe them. And then we need to advise them about rest and appropriate return to duties.
Seizures
Jaycen Cruickshank:
If someone goes home the advice they are given is to return for further care includes if they have severe headache, prolonged vomiting, drowsiness and seizures. So any seizure warrants calling an ambulance and bring the person back to the emergency department.
Phil Catterson:
What do we do at home when we have someone who has a seizure in front of us, cause it’s quite scary to know what to do, always the first thing to do is A, B, C. And that’s the airway breathing circulation and so we should roll them onto their right side and have it so that they can access, the coma position and make sure that they’re breathing. Okay, so make sure there is no implements around them that they can hurt themselves with, ring 000 and say I have an emergency here I have a person who is having a seizure and we need to get to a hospital.
Medication
Jaycen Cruickshank:
So if you’re sent home from the Emergency Department with pain relief it’s really important that you understand what tablets that your meant to be taking, what’s in them how much and how often. And there can be quite a lot of different companies make the same drugs with very similar sounding names. So it’s really important you check what you are meant to take. Anyone who is on blood-thinning treatment who has had a head injury raises a big red flag for us to look out for bleeding inside the brain. So it’s important for patients to remember to tell us if they’re on medicines just as it is their allergies.
Dizziness
Stewart Malcom:
There are some specific symptoms that can be resolved quite well if given advice early. For example dizziness, now we know that’s usually due to the inner ear being rattled a bit, we know that will settle by itself most times with appropriate rest and things like not moving your head suddenly, not standing up suddenly. We’re not particularly keen that you take medication for it because that organ adapts very quickly and it slows down that adaptation. If that symptom persists then there are particular tests that we can organise, usually through physiotherapists to help us sort out the problem.
Carers
Jaycen Cruickshank:
It’s really unwise to go home on your own. The medical staff need to assess the level of risk. That level of risk is never zero but it’s also important that we don’t over exaggerate that risk. As we discharge people with a head injury advice form and that’s signed by a competent adult if not by themselves.There’s no point telling a patient to return to the Emergency Department if they become unconscious.
Carers- what we look for?
Phil Catterson:
Often the care is quiet worried about what we do now, what happens, what do we look for, what are the signs? That’s important to be able to give them some tools to be able to do that and know when they go home what am I going worrying, what am I going to look, what am I going to be worried about? I don’t know all this stuff that you’ve just done.
Jaycen Cruickshank:
Carers might notice things that are not normal for a patient who has a mild traumatic brain injury. And often they will actually tell us hey he looks fine butthey’re are not their usual self- I’ve noticed that they are sleeping more than usual and very tired which is out of ordinary for them. I’ve noticed that they are really irritable and cranky, that they are having mood swings, they might be paranoid which are really out of character for them, and off their food and so on. So when carers notice that people are not right they are usually very good judges that something is not right and it’s important that they take action then, try and get that person to see a doctor and that they convey those messages to the medical staff that are looking after the patient. And it’s those subtle things that will help us raise our vigilance for looking out for something serious and it’s also those things that will prompt the emergency staff to involve our experts at the Acquired Brain Injury Clinic and get a referral to the people who are very well placed at following these people up. Because what they do that the emergency department doctors are not expert at is but they assess thatbrain function in much more detail and they’ll notice something that we might not have picked up. And I think quite often they are symptoms that the carers might have notice, that the emergency doctor who is looking for the big life threatening things has missed. Sometimes people a week to ten days later are getting symptoms which is due to a subdural hematomawhich is some bleeding again between the brain and the skull at a slightly different place to the other sort of bleed. And that’s actually very fixable by a Neurosurgeon. If I see someone who is unwell a week after their head injury that’s the first thing I think of.