Although none of the editors of InsideSurgery.com are involved in treating Natasha Richardson, we have noted with interest the medical reports coming out of New York concerning her traumatic brain injury sustained during a fall while skiing. Richardson is the daughter of actress Vanessa Redgrave and the wife of actor Liam Neeson.
Unfortunately, traumatic brain injuries (TBI) are depressingly common in the United States, wtih an estimated 250,000 serious head injury cases occurring yearly. Although there is almost no Level 1 evidence in the medical literature detailing the optimal care of these patients, all major trauma centers see these injuries routinely and have developed treatment protocols. Described below are some the diagnostic and treatment strategies used by trauma surgeons in treating these injuries.
First-responders are trained to stabilize and treat these patients in the field. The universally used classification system for head injuries is the Glasgow Coma Scale (GCS) which rates the patients verbal, eye-opening, and motor function on three scales. The verbal scale ranges from 1 to 5, the eye-opening scale ranges from 1 to 4, and the motor scale ranges from 1 to 6. The highest possible score is a 15 and the lowest possible score is a 3 which is a patient who is in a coma.
Severe head injuries are those with a GCS of 8 or below. Generally, patients who have a GCS of 12 or below are intubated (breathing tube is placed in their trachea) and placed on a ventilator (breathing machine) in the field.
Judging by the news reports, Ms. Richardson was awake and alert and talking immediately after the fall with a likely CGS of 15 (normal). She then deteriorated over the next several hours, complaining of not feeling well, and then a headache.
This clinical scenario where a person has a blow to head followed by a lucid or awake interval, followed by rapid and severe deterioration is characteristic of an epidural hematoma or clot. It is usually caused by a rupture in a brain artery, typically the middle meningeal artery. Epidural hematomas also occur in boxers and in patients that are struck in the head with a baseball or hockey puck.
In the setting of a rapid decline in her medical status, either the ambulance crew taking her to the hospital or the emergency medical team at the hospital would have no doubt intubated her (placed a breathing tube in her trachea) and placed her on a ventilator (breathing machine).
The medical team would also have placed a stiff styrofoam collar around her neck while keeping the neck and head stabilized. There is a high association of severe head injury with spine and spinal cord injury. The collar is placed to stabilize any potential injuries to the cervical spine (the top 7 vertebrae in the neck).
In addition to the collar placed around her neck, standard of care would require her to have been logrolled onto a stiff, plastic board to stabilize the thoracic (chest), lumbar (mid-back), and sacral spine segments. This certainly would have occurred if she lost consciousness outside of the hospital, although sometimes this step is omitted if hospital physicians who do not have formal training in trauma care treat the patient.
Initial Hospital Course
Ms. Richardson very likely received a computed tomography (CT) of the brain without contrast dye almost immediately after arriving at the hospital with her clinical history. Brain bleeding is very easy to detect on CT (it looks white) and it allows the trauma team to develop a treatment plan for the patient based on what type of injury is seen.
The four major types of hematomas that trauma surgeons and neurosurgeons evaluate on a head CT in brain trauma are subarachnoid hematoma, subdural hematoma, epidural hematoma, and intraparenchymal bleeding.
Epidural hematomas are always operated on by neurosurgeons and are a true neurosurgical emergency where seconds count. The bleeding occurs in the space between the hard bony skull and the tough, fibrous coat that surrounds the brain called the dura. Trauma surgeons often refer to epidural hematomas as the “talk and die” syndrome. Epidural hematomas can occur with only seemingly mild head trauma but can occur due to an unrecognized skull fracture to the side of the skull (temporal bone area).
If operated on sufficiently quickly, even patients in a full coma can make a full or significant recovery. The key determining factor is whether the herniation of the brain has occurred or whether the swelling is severe enough that brain cell death has occurred.
Subdural hematomas if small are sometimes watched but if moderate or large or if associated with midline shift (compression of the brain matter) or obliteration of the ventricles (open spaces deep in the brain) are taken to the operating for evacuation (removal) of the clot. Subdural hematomas can also have a period where the patient seems normal and talking with rapid deterioration, even up to one to two days later.
Only large subarachnoid and intraparenchymal bleeding associated with shifting of the brain structures or swelling is taken to the operating room and this type of bleeding is more diffuse (spread out) and does not have one defined area of clot that can be easily removed.
Regardless of the type of bleeding, the goal of surgery in a traumatic brain injury is to stop bleeding and to release the pressure on the brain due to the inability of the hard, fixed skull to expand in the setting of brain swelling. It is common in severe brain injury for the neurosurgeons to do a craniectomy (not replace the piece of skull removed to get to the brain).
Once a patient with head trauma is taken to the operating room or the decision has been made not to operate, the patient always is admitted to an intensive care unit. Most large trauma centers have dedicated neuro intensive care units. The only care dictated by the medical literature is that patients with traumatic brain injury should never be given steroids in an attempt to control the swelling.
However, there is a general consensus among trauma surgeons, neurointensivists, and neurosurgeons on how to manage these patients. The goal is to prevent secondary injury to the brain tissue by reducing edema (swelling) in the brain and by delivering oxygen.
There are several key physiological parameters that are tracked on the ICU monitors. The goal is to keep the intracranial pressure (ICP) less than 20 mmHG and the cerebral perfusion pressure (CPP) greater than 60 mmHG. The CPP is calculated by taking the mean arterial pressure (MAP) and subtracting the ICP.
All severely injured brain patients should have some intracranial pressure monitoring to record the intracranial pressure. There are several types of monitors availabe, the most advanced being the Licox monitor. The Licox monitor measures partial pressure of brain oxygen (i.e., allows a reading of how much oxygen is getting to the brain tissue) and is extremely helpful in guiding therapy.
Other monitors inserted into the brain allow for recording of the ICP and also have the ability to allow fluid to be removed from the brain when the pressure builds up.
If mechanically removing fluid from the brain is not option because of catheter type, there are drugs that can be given to attempt to reduce the swelling.
Chief among these is mannitol, which is given intermittently to force fluid out of the brain and can also be given emergently to treat spikes in ICP. Administration of mannitol causes an intense diuresis (causes large urine production) and electrolyte (e.g., potassium and calcium) abnormalities.
ICU specialists also try to increase the sodium level of the blood and commonly use 3% hypertonic saline (i.e., a concentrated salt solution) to try to pull fluid out of the brain and brain cells.
Although sometimes misunderstood by patients’ families, in the United States, patients that are brain dead are legally dead, regardless of whether their heart is still beating and the presence of spinal reflexes.
There are two general ways to determine brain death and laws and protocols vary from state to state. Clinical brain death can be done by bedside clinicians. This occurs when the patient has lost all signs of life (e.g., gag reflex, cough reflex). It is usually done by two separate physicians at least 6 hours apart in a patient who is not paralyzed by drugs and who has a close to normal body temperature. One common clinical brain death test is the apnea test, which measures the patients drive to breath when deprived of oxygen.
Brain death can also be determined by radiographic tests such as the brain flow study. This test is done in the radiology suite by radiologists. A specific type of tracer dye that is tagged to blood cells is injected into the patient. The patient then is viewed under a monitor to see if any of the tagged cells have moved to the brain area. If there is no tracer detected, there has been no blood flow to the brain and the patient is brain dead.
End of Life Issues
There are significant end of life decisions that must be made by patients’ families, including the decision to consider organ donation. This discussion is almost always intiated by a representative of the organ procurement organizations (OPO) that has jurisidiction for that hospital.
Most states have laws requiring hospitals to notifiy the OPO when a severely injured patient is admitted, even if there is a likely chance of recovery. In cases less certain of survival, the representative of the OPO actually comes to the hospital and reviews the chart and progress of care as the patient moves toward brain death, while avoiding interfering or changing the care plan in any way.
The one exception is that before brain death is established many treating physicians will allow the panel of blood tests to be run that is required for organ donation and that can take up to 12 hours (HIV, hepatitis) for results.
Young, isolated severe traumatic brain injury patients who have a rapid progression to brain death are often excellent organ donors who are able to donate up to seven organs – heart, two lungs, liver, two kidneys, pancreas – as well as corneas and tissue. Approximately 50% of people on waiting lists in the United States die before they receive their transplant.
Please click here for an update on the death of Natasha Richardson and observations on her baffling course of treatment.
Please click here for an update on how wearing a helmet might have saved Natasha Richardson’s life