Understanding Coma

Rancho Los Amigos Scale The Medical Team Neuro-imaging Rehabilitation and Recovery UNDERSTANDING COMA Your child, husband, wife or friend is rushed to the emergency room and has suffered a serious traumatic brain injury. You wait for days by their bedside, hoping and praying that they will just open their eyes and recognize you. But, they lie in bed in a sleep-like state for days. Evidence of wakefulness comes gradually first with a response to painful stimulus. Moaning and groaning and withdrawing a limb are the first responses. Next, the command to blink the eyes is obeyed. Yet, there may still be confusion, agitation, fatigue and even agitation. It may take considerable time before the patient in this prolonged period of unconsciousness following a brain injury begins to consciously process information. Coma can be caused by injury to the brain stem where the normal central nervous system nerve pathways are interrupted causing a loss of consciousness. This could be caused by a direct blow to the brain stem such as when a head hits the back of a headrest. It may also be caused when the brain is violently rotated on its axis (brain stem) by gravitational forces or it may be caused by pressure on the brain stem from edema and bleeding. Doctors in the emergency room measure the acute severity of a coma with the Glascow Coma Score. Progression of the patient's responsiveness and cognition, is measured with the Ranchos Los Amigos Scale. Use of these tools is helpful in preparing for rehabilitation and future life care planning. While these tools do not predict speed of recovery or ultimate level of recovery they do provide insight into the anticipated progression of recovery. Top of page RANCHOS LOS AMIGOS SCALE I. No Response Patient appears to be in a deep sleep and is unresponsive to stimuli II. Generalized Response Patient reacts inconsistently and non purposefully to stimuli in a non specific manner. Reflexes are limited and often the same, regardless of stimuli presented. III. Localized Response Patient responses are specific but inconsistent, and are directly related to the type of stimulus presented, such as turning head toward a sound or focusing on a presented object. He may follow simple commands in an inconsistent and delayed manner. IV. Confused-Agitated Patient is in a heightened state of activity and severely confused, disoriented, and unaware of present events. His behavior is frequently bizarre and inappropriate to his Immediate environment. He is unable to perform self-care. If not physically disabled, he may perform automatic motor activities such as sitting, reaching, and walking as part of his agitated state, but not necessarily as a purposeful act. V. Confused-Inappropriate, Non-Agitated Patient appears alert and responds to simple commands. More complex commands, however, produce responses that are non purposeful and random. The patient may show some agitated behavior it is in response to external stimuli rather that internal confusion. The patient is highly distractible and generally has difficulty in learning new information. He can manage self-care activities with assistance. His memory is impaired and verbalization is often inappropriate. VI. Confused-appropriate Patient shows goal directed behavior, but relies on cuing for direction. He can relearn old skills such as activities of daily living, but memory problems interfere with new learning. He has a beginning awareness of self and others. VII. Automatic-Appropriate Patient goes through daily routine automatically, but is robot like with appropriate behavior and minimal confusion. He has shallow recall of activities, and superficial awareness of, but lack of insight to, his condition. He requires at least minimal supervision because judgment, problem solving, and planning skills are impaired. VIII. Purposeful-Appropriate Patient is alert and oriented, and is able to recall and integrate past and recent events. He can learn new activities and continue in home and living skills, though deficits in stress tolerance, judgement, abstract, social, emotional, and intellectual capacities may persist. Top of page THE MEDICAL TEAM The following is a partial list of the brain injury team professionals that you might find in the hospital or rehabilitation center. 1. Neurosurgeon: Physician who is trained to diagnose and treat brain or central nervous system injuries and disorders and perform surgery on the brain or within the central nervous system as needed. He evaluates the need for surgical intervention. 2. Neurologist: Physician who is trained to diagnose and treat brain or central nervous system disorders. He should request neuropsychological testing by a neuropsychologist to assess brain dysfunction. 3. Physiatrist: Physician who is trained to evaluate and treat cognitive and physical dysfunction as a result of traumatic brain injury. They are especially concerned with helping the patient overcome disability as a result of brain injury through rehabilitation and are a critical part of the acute care brain injury team by preventing contractures and controlling spasticity. 4. Neuropsychologist: Ph.D. trained psychologist usually with a clinical background and extra training in neurology who evaluates brain dysfunction through a variety of psychological tests and observation. He also is helpful in planning appropriate cognitive rehabilitation and vocational rehabilitation. 1. Physical Therapist: Trained to help the patient regain bodily function. 2. Occupational Therapist: Trained to help the patient with activities of daily living and regaining maximum independence. 3. Speech Therapist: Trained to help the patient regain speech and language function. 4. Case manager: Can be helpful in coordinating rehabilitation and future care. Top of page NEUROIMAGING Diagnoses of traumatic brain injury can be made by clinical evaluation of indirect evidence of pressure on the brain through monitoring loss of consciousness, drowsiness, vomiting, confusion, unequal pupil dilation, lessened reflexes, etc. Diagnoses can also be made by neuropsychological testing of brain dysfunction. Physicians routinely use neuroimaging though as a means of looking at the brain and surrounding structures to detect brain injury. CT scan is helpful in looking at the skull for evidence of linear or depressed skull fractures. CT is less clear or sharp than an x-ray when viewing the skull, but, it is superior in it's ability to detect brain bleeding, swelling, enlargement of ventricles, tumor growth and brain compression due to excess pressure. While CT is useful in the emergency room it is limited in detecting mild brain injury involving diffuse axonal shear injury. CT done in the emergency room may also miss a slowly developing intra-cranial leak 2 to 3 days after the initial trauma. MRI is the non-emergency technique that has higher clarity of fine brain matter detail. This is an excellent tool for viewing brain injuries and lesions that are gross or focal, however, it cannot show diffuse cellular brain "shear" injury. PET and SPECT can show functional disturbances of normal brain metabolism that do not show up on traditional structural imaging. Few hospitals however, have the latter mentioned types of equipment and a patient may have to be sent out of state for such a scan. Sometimes brain injuries do not show up on any type of neuroimaging technology because the damage was microscopic. The neurolawyer must have a good knowledge of the neuroimaging technology available and the reasons why brain injury are not always documented by such technology. Top of page RECOVERY AND REHABILITATION The road to recovery is a long and hard process. A good neurolawyer can help you not only preserve early evidence and document your case, but they can advocate for you to get the best treatment available, find sources of funding for that treatment and coordinate your care for the duration. The severity of a brain injury is often difficult to determine immediately following a head trauma. Generally speaking, full recovery is not expected where coma is prolonged, serious physical injury occurred, GCS is poor and Ranchos Los Amigos Scale score remains low. However, each injury is unique and many variables exist, such as whether the injury is focal or diffuse, whether the brain stem is injured and whether anoxia occurred. It may take several months or even a year to understand the severity of the injury and the residual deficits and disabilities. There is medical literature that suggests recovery can continue throughout a person's life despite intermittent plateaus. Brain injury rehabilitation programs do positively enhance the rate of recovery and the eventual recovery gained. Usually the most rapid recovery occurs in the first six months after a person progresses from a coma to a conscious state. By the end of the first year a patient generally undergoes a plateau in their recovery, however, this slow down in progress does not indicate that gains in function will not occur. The neurolawyer can play a vital role in advocating for her client to obtain appropriate rehabilitation, to help find funding sources, to coordinate medical treatment with providers who know brain injury and to make sure that documentation of the nature and extent of a person's injury is thorough. Roberta Robinson has prior experience as a hospital medical social worker, which facilitates her role as an advocate for her client's in their rehabilitation experience. Her experience as past president of the Oklahoma Brain Injury Association has enabled her to personally visit many different types of rehabilitation facilities. Finally, her role as chairman of several medical conferences has helped her to meet many physicians and specialist across the country in brain injury medicine and rehabilitation. Various options exist for rehabilitation. It is recommended that before committing to any treatment options, the patient should thoroughly explore all available options in their region. The state brain injury association is a good resource as is an experienced neurolawyer. The following is a brief list of the types of medical care a patient might encounter. 1. Acute Hospital Care: Medical stabilization of one's condition. 2. Acute Inpatient Rehabilitation: a. Early therapeutic intervention which encourages self participation and weans one from medical dependency. b. Coma stimulation which encourages consistent responses and weans off of sedating medicines. c. Early functional and cognitive retraining and physical restoration. d. Examples are weaning a patient off the ventilator, feeding tube, etc. 3. Post-acute Inpatient Rehabilitation: a. Rehabilitation which focuses on community, educational, vocational and social reintegration and continued independent function. 4. Daytreatment: a. Hourly, half day and full day programs which address specific needs. 5. Group Home/Residential Living a. Supported living with supervision 6. Support Group: a. Local chapters of a state brain injury association 7. Vocational Rehabilitation: a. State agencies and private facilities that provide vocational evaluation, Retraining and job coaching for work re-entry. Many of these programs provide specialized care for certain clients such as behavioral management for aggressive client's, pediatric care focusing on educational re-entry, ventilator care and weaning, coma stimulation, substance abuse counseling and programs tailored for mild brain injury cognitive rehab. Please remember, few programs are capable of meeting every client's needs. Make sure that the program your Doctor refers you to is best for you! Top of page