Fever and Infection
Infections are very common after a brain injury. Usually the first evidence is a fever. The most common locations of infections are the lungs (pneumonia) and the bladder. That is why when a patient has a fever, the physician will often order tests of the urine, known as a urinalysis and culture, as well as an x-ray of the chest. Once the location of the infection is discovered, antibiotics are used for treatment.
Conditions other than infections can cause fevers. These include blood clots and heterotopic bone, which are discussed later. Sometimes the fever can be a result of the brain injury itself and not the result of an infection. This happens when the part of the brain that controls body temperature is damaged. These conditions require other types of treatment.
Blood Clots (Deep Venous Thrombosis - DVT)
DVT refers to clots that form in the legs or arms, not the brain. These clots are very common; they occur in approximately 40 percent of patients with brain injuries. Clots are serious because they can break off from the blood vessels of the leg and travel to the lungs causing damage or even death. Signs of a DVT may include swelling, redness, or pain in the area of the clot.
Patients with brain injury are watched closely for DVT and are sometimes given blood thinning medicines to reduce their risk. If the physician suspects that a blood clot has formed, a Doppler or blood flow test may be indicated. If a clot in the lung is suspected, a CT scan may be ordered. If a blood clot is discovered, a strong blood thinner or filters placed in the veins can be used for treatment.
The risk of seizures depends on the type of injury. In people with a closed head injury, about five percent will develop seizures. In those with a penetrating injury, the percentage can approach 50 percent. A seizure occurs when a part of the brain becomes active on its own. The symptoms of the seizure depend on which area of the brain that is involved. For instance, if the area of the brain that controls movement of the arm is affected, the seizure would involve twitching or shaking of that arm. Not all seizures involve movement. They can also cause an abnormal sensation in the body or a change in mental function. Usually, however, seizure in people with brain injuries can cause a loss of consciousness and shaking of the whole body.
Physicians sometimes decide to use anti-seizure (anticonvulsant or anti-epileptic) medicines for preventive purposes. This decision is based on issues such as the risk of someone having a seizure and the possible side effects of the medication. Sometimes, an EEG test may be used to help make the decision.
If a patient has already had one or more seizures, especially if occurring one week after the injury, anti-epileptic medicines are often used. Most likely, these medications will be needed for six months to one year.
This condition occurs when there is a build up of fluid in the hollow spaces of the brain (ventricles). The extra fluid can squeeze the rest of the brain and cause symptoms. The symptoms are not very specific, however. Often, the first signs may be a subtle change in a patient’s level of arousal or a slowing of recovery. Of course many other factors can cause these changes. The physician may order a CT scan if hydrocephalus is suspected.
If the CT scan shows hydrocephalus, then a decision will be made in consultation with the neurosurgeon about the type of hydrocephalus and if it would improve with the placement of a shunt. Hydrocephalus is thought to occur in about five percent of people with brain injuries. The percentage is higher in those people with severe brain injuries.
This refers to formation of extra bone in the body and occurs in about 10-20 percent of people with brain injury. The extra bone most often forms in the large joints of the body such as the hip or the shoulder. It can cause pain, swelling, inflammation and tightening of the joint. No one yet knows for certain why this happens.
If heterotopic ossification is suspected, x-rays or a bone scan may be order to help with the diagnosis. Treatment for heterotopic ossification can include range of motion exercises, bracing or splinting, medications, or even surgery.
Fractures and Nerve Injuries
Because most people with brain injuries have been involved in trauma, for instance an automobile collision, they are likely to have other injuries as well. Approximately 30 percent of people with brain injuries have fractures and the same number have injuries to the nerves of the arms and legs. Sometimes these injuries are not discovered until the person is in rehabilitation for several reasons. During the initial hospitalization, the focus is on life threatening conditions. Other problems are not yet a priority. Also, many fractures and nerve injuries are extremely difficult to diagnose when someone is comatose or minimally conscious because the primary symptoms of these injuries are pain and difficulty moving. As a person becomes more alert, however, the team may order additional tests, such as x-rays or an EMG, to assist with diagnosis.
High Blood Pressure (Hypertension)
Some patients (less than ten percent) will have high blood pressure after a brain injury. This is usually because of damage to the part of the brain that controls blood pressure. Patients with high blood pressure are treated with medications called anti-hypertensives.
This is one of the most common problems faced by people with brain injuries. Certain muscles of the body become tight or hypertonic because they cannot fully relax. For instance, the elbow can be bent almost completely, so that the hand is almost at the shoulder. If one tried to straighten the elbow out, it would be extremely difficult because of the tightness. Spasticity prevents use of the body part and is painful. It can also interfere with the ability of a helper to assist with dressing or other care.
Therapies play a crucial role in the treatment of spasticity through interventions including range of motion and stretching exercises, splinting or bracing, and serial casting. Medicines may also be used to relax the muscles. Other options are nerve block, baclofen pump, botulinum toxin injections, and surgery.
Problems with respiratory care including tracheostomies; feeding and nutrition including feeding tubes; swallowing problems including aspiration; bowel and bladder management; and skin breakdown are other effects of brain injury.
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