In the hospital

Please note: Often individuals with a brain injury are not able to use a computer or read while they are in acute care. Accordingly, we have adjusted the language of this page.

Acute care means short-term, immediate medical care. In acute care, the patient will undergo further diagnosis, medical treatment, surgery and after surgery care (if surgery is needed). 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. When a patient has a moderate to severe traumatic brain injury, they will be taken to the intensive care unit of the hospital or the trauma wards. Intensive care and trauma wards make up the area of the hospital called acute care.

The patient will be in acute care for a few days to a few weeks depending on the severity of the injury and the process of treatment. When they are deemed medically stable and able to be moved, they will either go home, to a different part of the hospital, to a rehabilitation centre, to short-term care or to long-term care.

Topics in this section include: 

Traumatic brain injuries are commonly caused by vehicle accidents, assaults, falls and sports injuries. Many individuals who acquire a traumatic brain injury also have other emergency medical concerns. Based on emergency medical staff’s diagnosis and recommendations, the patient may need to undergo additional surgeries or treatments for conditions unrelated to brain injury – for example, broken bones, lacerations or tissue damage.

The medical team will be focused on medical stabilization of the patient, including preventing further (secondary) brain injury from swelling, intracranial bleeding or oxygen deprivation. They will be monitored consistently with the necessary equipment and staff in order to track changes in condition and respond quickly to them.

Diagnosing a brain injury

While 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 the injury.

Please note:

  • The patient may not need all of these tests
  • The hospital may not have the ability to perform some of these tests
  • Test results may not be received immediately and will be shared when 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.

Medical staff in acute care

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

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 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.

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.
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.

Questions to ask the medical team

When the patient is ready, there are several questions they or their family may want to ask the medical team.

Questions about the brain injury diagnosis
  • Does the patient have a mild, moderate, or severe brain injury?
  • What tests will you be doing and why are you doing them?
  • What does the patient have to do to complete these tests?
  • Can the patient’s family or friends stay with them while the tests are completed?
  • Are there any complications at this stage of the patient’s brain injury?
  • What part of the patient’s brain is damaged?
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?
  • Will the patient need surgery? If yes, what kind of surgery, and what will it involve?
  • How long will the patient stay in acute care?
  • What treatments will the patient need following acute care?
  • What rehabilitation centres will provide the patient with this care?
  • Who will be on the patient’s recovery team?
  • Will the patient’s family be able to visit often?
  • What kinds of support are available for people living with brain injury?

Why doctors can’t predict recovery time

Brain injuries range in severity and affect people differently. This means that doctors cannot predict an exact recovery time. Using test results, they can give the prognosis and treatment recommendations. These can change over time as recovery progresses.

Comas and persistent vegetative state

In some cases, the patient is in a coma. 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/respirator. 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 in order to give the patient time to heal. 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.

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 their position and stretch their limbs regularly to keep them from developing sores and losing their range of movement.

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 and brain injury

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.