In the hospital

Acute care means short-term, immediate medical care. For concussions and/or mild traumatic brain injuries, acute care refers to initial testing and diagnosis and doesn’t typically require a stay in the hospital. If a friend or family member has experienced a non-traumatic brain injury (such as a stroke or brain tumour) or a severe traumatic brain injury, their time in acute care will range from a few days to a few weeks depending on the severity of the damage. Depending on the hospital size and facilities, your loved one may be in an intensive care unit or a trauma ward. They may need to be moved to a hospital with more specialized care. While this can mean more travel and stress, a patient is only transferred when necessary.

Acute care is where they will be for diagnosis, surgery, and post-surgery recovery (if surgery is needed). The focus at this stage of the brain injury is medical stability. This includes preventing further (secondary) brain injury from swelling, intracranial bleeding or oxygen deprivation. The patient will be monitored consistently with the necessary equipment and staff in order to track changes in condition and respond quickly to them. When the patient is deemed medically stable and able to be moved, they will either go home, to a rehabilitation centre, to short-term or to long-term care.

Topics in this section include:

This is a stressful time for caregivers, spouses and family. You may need to make difficult decisions based on information and support from the medical team. It’s important to ask questions when you don’t understand something and speak with the medical professionals about available supports for your loved one and yourself.

Tips for navigating acute care

It’s overwhelming to be in acute care, especially if you don’t fully understand what’s happening with your friend or family member. There are some things you can do to help navigate acute care and make sure that you, your loved one, and other family members feel supported and informed.

Ask about in-hospital support
Many hospitals have support and resource centres in their facilities to help friends and family members. Be sure to check with hospital staff if there’s a place with support services. Please remember that not every hospital will have these services or may offer them in a limited capacity.

 

Neurology nurses are a great source of information on acquired brain injury and can either answer your questions or direct you to someone within the hospital who can assist you.

Bring someone with you
Taking in new information, spending time at the hospital and being on your own through the acute care process can be stressful. It helps to have someone else in the room with you and your loved one. They can also listen to the doctors, help take notes, and you can offer each other support through an emotional time.
Develop a system to share information
Chances are you’ll have a lot of people calling, texting, and emailing you for updates about the person in acute care. While the concern and support are good, it can be overwhelming to have people constantly trying to contact you for updates.

 

It can be helpful to develop a system for sharing updates and information about diagnosis and treatment. You can set up an email list to send updates, create a phone tree, or even use a file sharing system.

Pack a hospital bag for your loved one
If they are going to be in the hospital for more than a few days, they may appreciate having their own clothes, personal items, and toiletries. Make sure to check with hospital staff to ask what is allowed.
Take care of yourself
Eating and getting proper sleep is important. You need to feel well to offer your support to others. Your loved one will be well looked after while you go home and get some rest.
Write things down
You’ll have a lot of information to process in acute care. There will be information on treatment, names of medical staff and information about brain injury you might be encountering for the first time. Writing things down on a smart device or in a notebook will help you organize information, access instructions and make it easier to relay information to other members of the family. If you don’t understand something, don’t be afraid to ask the nurse or other member of the medical staff to explain it again.

Medical staff in acute care

In acute care in the hospital, the recovery team is made up of multiple medical professionals.

Doctors
Many types of doctors may be involved in acute care following acquired brain injury including neurosurgeons, neurologists and critical care and rehabilitation medicine physicians. They are responsible for providing diagnoses, ordering tests and overseeing management of patients.
Nurses
Nurses are in charge of monitoring vital signs and keeping an eye out for medical issues. Some nurses specialize in critical care, stroke, or the care of patients with neurological disorders. The nurses are the caregivers’ and patient’s best support during this period of time. Nurses spend the most time with the patient, have excellent medical knowledge, are responsible for continuing pain management and patient comfort and are able to help streamline communication with other members of the medical team.

 

Please note: a nurse is not permitted to relay test results.

Neurosurgeon
If the patient requires surgery, they will be referred to a neurosurgeon. Surgery is needed when the brain has damaged tissue or is under pressure due to bleeding or swelling. Neurosurgeons are the ones that will be performing the actual surgery and arranging follow-up tests to monitor the results of that surgery.
Neurologist
A neurologist diagnoses and treats disorders of the nervous system – including brain injury and stroke. They will be a big part of figuring out which parts of the brain have been damaged, and next steps to take. For example, if a patient develops seizures or stoke a neurologist may be called to assist in care of these conditions.
Rehabilitation medicine physician
A rehabilitation medicine physician or physiatrist is a doctor that oversees the medical needs of patients with brain injury. A rehabilitation medicine physician may be called to assess whether a patient needs rehabilitation, what type of rehabilitation is needed (in-patient, out-patient) and what other healthcare professionals may need to be involved in the care team including physiotherapists, occupational therapists and speech language pathologists.

Diagnostic and informative tests for brain injuries

While your friend or family member  is in acute care, the medical team will diagnose and begin treatment for the brain injury. This involves medical tests that will help them learn more about their injury.

Please note:

  • The patient may not need all these tests
  • The hospital may not have the ability to perform some of these tests
  • Test results may not be available right away; they will be shared with you as soon as possible
  • Any questions should be shared with the doctor
Glasgow Coma Scale
The Glasgow Coma Scale helps medical professionals identify the severity of brain injuries by measuring the responsiveness of the patient. This is the first test administered after a brain injury, often by first responders or emergency room staff.

 

It’s a simple test and gives a score based on the following things:

  • Eye opening
  • Verbal response
  • Motor response

Based on the individual category scores, the patient is given a total coma score.

  • Severe: a score of 8 or less
  • Moderate: a score of 9-12
  • Mild: a score of 13-15

This is a non-invasive test. The results of the Glasgow Coma Scale test will help determine the next steps in treatment and recovery.

Rancho Los Amigos scale
The Rancho Los Amigos scale is used to help track the patient’s recovery. Every brain injury is unique- the Rancho Los Amigos scale is a guide only. Recovery time will vary from person to person.

 

There are 8 levels of recovery on the Rancho Los Amigos scale:

  • Level 1: No response
  • Level 2: Generalized response
  • Level 3: Localized response
  • Level 4: Confused – Agitated
  • Level 5: Confused – Inappropriate – Non-agitated
  • Level 6: Confused – Appropriate
  • Level 7: Automatic – Appropriate
  • Level 8: Purposeful – Appropriate

For each stage, there are a series of checkpoints the person must meet in order to move to the next stage. For more information on each of these stages, there is a helpful guide on the Rancho Los Amigos scale from Sunnybrook Hospital.

CT scan
A computed tomography (CT) scan uses X-ray machines and computers to take pictures of the inside of the body. A cranial CT scan helps doctors see the brain and potential damage. Doctors may order a CT scan if there is a suspected head injury and the patient is exhibiting symptoms such as severe headaches, vomiting, bleeding from the nose or ears, seizures, reduced vision, weakness in the facial muscles or a decrease in consciousness. CT scans do not show concussions but do show structural injury to the brain such as bleeding, bruising or stroke.  This test is non-invasive and safe but does require exposure to radiation.
EEG (electroencephalogram)
EEG stands for electroencephalogram (electro-en-ceph-a-lo-gram). It measures electrical activity in the brain. Small discs are attached to the scalp (it’s completely painless), and doctors use brain waves to help with their diagnosis. An EEG is often used in patients who experience seizures or prolonged periods of decreased consciousness following brain injury. This is a safe, non-invasive test.
MRI scan
MRI stands for magnetic resonance imaging. It uses magnetic forces, radio waves, and a computer to create 3-D images of organs, bones, and brain.

 

The patient will remove all their clothes, jewelry and any metal on their body (including clothes). They’ll be given a gown to wear. Doctors should be told if they have any metal in their body, including pins from broken bones or knee/hip replacements. If the patient has the following things in their body, they CANNOT have an MRI:

  • A cochlear implant
  • Clips for brain aneurysms
  • A pacemaker or heart defibrillator

Please note: most endovascular coils are now MRI compatible, but should be disclosed to the healthcare provider before the test.

The MRI machine is a long tube with a sliding surface on which they will lie down. The patient is required to stay still and quiet for a long period of time. If they are afraid of small spaces or have trouble staying still, doctors may offer a sedative for the test to make it as comfortable as possible. An MRI is a loud test, with lots of clanging noises. If the patient is sensitive to loud noises, this should be shared with the doctor.

During the MRI

The patient will lie down on a movable table. They will then slide into the cylinder of the MRI machine. They will be able to talk to the person administering the test at all times and must listen carefully for any instructions. Generally, an MRI will be done taking pictures after about 30-45 minutes – this could be longer depending on the number of pictures needed. An MRI is non-invasive and painless.

Questions to ask the acute care medical team

There are questions you’ll want to ask the acute care medical team while your friend or family member is in acute care. Please note that it may be too early for definitive answers to some of these questions. If you don’t understand the answers provided, ask for more explanation.

Questions about the brain injury diagnosis
  • Does my loved one have a mild, moderate, or severe brain injury?
  • What tests will you be doing and why are you doing them?
  • Can I be in the room when these tests are being done?
  • Are there any complications at this stage of the brain injury?
  • What changes in my loved one can I expect at this stage?
  • What can I do to make my loved one feel more comfortable?
Questions about brain injury treatment
  • What treatments should the patient have for this type of brain injury and what are the risks and benefits of treatment?
  • What will the treatments do/how will they help?
  • Will they need surgery?
  • How long will my loved one stay in acute care?
  • What treatments will they need following acute care?
  • What rehabilitation centres will provide this care?
  • Who will be on the recovery team?
  • What kinds of support are available for people living with brain injury?
  • Are there out of pocket costs for treatment?
  • Are there long-term care facilities? What are the wait times?

Why recovery time can’t be predicted

The doctors may not be able to predict the length of time your friend or family member is in acute care, or how their recovery will progress. Every brain injury is different: there is no definitive timeline for recovery. Recovery is dependent on factors such as the severity of the injury, the commitment of the person to rehabilitation, and time. It’s important to remember that recovery is different than ‘cured’: a brain injury is permanent, which means a person will never fully be the same as they were before the injury.

Comas and persistent vegetative state

Your friend or family member may be in a coma or vegetative state. A coma means they are deeply unconscious with little to no responses to stimuli and no sleep-wake cycle. They may even be on a ventilator. Persistent vegetative state is when someone is in a comatose state for a long period. Comas and persistent vegetative states are generally caused by the following things:

  • Head trauma
  • Swelling in the brain
  • Bleeding in the brain
  • Stroke
  • Oxygen deprivation

In some cases, a coma will be medically induced to give the patient time to heal. You may have to make decisions about next steps while your loved one is in a coma or a persistent vegetative state such as discussing surgery options with the acute care medical team. Your loved one may also need a respirator to breathe. As brain function improves, they may open their eyes, follow sleep-wake cycles, follow commands, respond to people, and speak. It’s common for the person to be confused and disoriented. You may find that they have trouble paying attention and learning or that they seem agitated or restless. They may not sleep well.

Doctors will use the Glasgow Coma Scale and the Rancho Los Amigos test to track progress. The doctor may use a respirator to help the patient breathe or perform surgery to help prevent further damage to the brain or body. Nurses will also change the patient’s position and stretch their limbs regularly to keep them from developing sores and losing their range of movement.

Some days will be better than others. For example, the person may follow a command (like squeezing your finger), then not do it again for a while. Try not to become too anxious about the ups and downs—they are normal. You can help by keeping the person’s space calm and quiet. Examples include limiting the number of people in the room, turning off the TV, or turning down the lights.

Be sure to speak with the healthcare team if you have questions or concerns.

https://youtu.be/U2K8UqC3AXI
Dr. John Connolly spoke with Brain Injury Canada about the decades of research into coma and vegetative state, and how his research has proved that the brain can be active even with no visual signs.

Can comatose patients hear?

Many people want to know if their loved ones who are in a coma or persistent vegetative state can hear. There has been a lot of research done on identifying the brain’s awareness and responses when someone isn’t able to react in a typical conscious way. While this research helps identify the proper diagnosis for someone with a brain injury who isn’t conscious, it also suggests that language is a big part of consciousness. People in comas have shown increased brain activity when they hear the voices of people they know. They may not be able to identify what is said, but in many cases their brains do react if people speak to them.

Pain management

The patient may be experiencing acute pain, especially if they were in a traumatic accident. Acute pain occurs immediately after the injury but isn’t long-term.

Acute pain can come from almost anything associated with both physical injuries and brain injuries – and many survivors of traumatic brain injury are experiencing comorbidities such as broken bones or additional organ damage. For example, a person who was in a motor vehicle accident could experience painful headaches, muscle and tissue damage, or severe abdominal pain all at the same time. While acute pain is normal immediate and able to be identified, that is not always the case. Not all pain can be seen by imaging tests or be easily explained by doctors. For example, back pain is incredibly real to the patient, but the imaging of the spine all looks normal . It’s complex and difficult for many people to explain their pain and what is causing it while they are experiencing it. The doctors in charge of the patient’s care will work with the patient to identify and manage acute pain as effectively as possible.

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